In order to be good trauma therapist, it is crucial to understand dissociative phenomena. Having no memory for the first 12 years of your life can be very disturbing. While we don’t know each other it sounds like you may suffer from dissociative amnesia. These kinds of events only happen when you have suffered through multiple traumas.
But you can’t get to them directly by using the active trauma processing phases of EMDR. These are eight phases that make up EMDR treatment. Phases three through six, named Assessment, Desensitization, Installation, Body Scan, are used judiciously by the therapist to help the client release the pain of traumatic memories that they have the ability to retrieve. Dissociative amnesia by definition means that there are traumas that are not able to be retrieved initially. Much work needs to be done in phases one and two before active trauma work can begin. EMDR is not a method for memory retrieval. It seems to me, by your report, that you therapist did not spend enough time in the first two phases of EMDR.
Phase 1 called history taking and evaluation is designed to facilitate the recognition of conscious traumatic memories that are put on a treatment plan so that you in the clinician can determine what memories you wish to reprocess (meaning release the pain from). Having such a long amnestic time period is a red flag to any seasoned trauma therapist of any stripe.
Phase 2 of EMDR is designed to help the person develop all needed coping and self soothing strategies so that the person is ready to reprocess old traumatic material. Phase 2 can last for a session or two, or up to a year or two. One of the issues that Dr. Shapiro mentions is that a firm therapeutic relationship must be established in order to do trauma work. This doesn’t mean that you like it therapist, or therapist likes you. It means that the two of you have set goals, discussed the tasks each one of you needs to be active in, and by agreeing to both tasks and goals of therapeutic bond begins to develop. One issue that it sounds like you therapist missed was the issue of creating safety for you before starting the active phases of trauma work.
Part of safety means talking things out until memories do start to surface, and/or taking the necessary steps in dealing with someone with a dissociative disorder. There are many strategies, I’ll just mention one. There is a technique called Frasier’s Dissociative Table Technique. This procedure is used to help someone with a dissociative disorder recognize that they have different parts (as we all do). Optimally All of our parts work together, only in this case there are parts that are protecting you from things that have happened during your first 12 years of life. Without creating safety by using those protective parts as allies to help the wounded child part no good work can be done.
It seems to me that EMDR is not the problem. It seems that you’re therapist did not understand how to deal with you dissociative problem. As a result EMDR was misused and you suffered as a result. I’m sorry for your pain. If you ever do decide to try working with the trauma therapist again let me know what part of the country you are in and I will help you find someone who is competent in trauma and memory, as well as any number of different kinds of trauma therapies. While I do think EMDR practiced by someone who understands dissociation is your best bet, somatic experiencing, sensorimotor therapy, internal family systems, structural dissociation therapy, cognitive behavioral therapy, are all reputable forms of treatment. Please remember this above all, it’s the quality of the therapeutic relationship as well as the clinical judgment of the seasoned clinician that will make the difference in any form of therapy.
That is why when I train people in EMDR I spend a good deal of time helping them understand how the therapeutic relationship affects the work in all eight phases. I also spend a good deal of time lecturing on have trauma affects memory, how different kinds of attachment problems may need modifications in the standard methodology, and have different kinds of dissociative disorders need to have a much different approach when thinking through, and using EMDR methodology.
AIP and the Intersubjective Matrix: Implications for Practice and Training in EMDR
Mark Dworkin CSW, LCSW
EMDR Institute Facilitator
EMDRIA Approved Consultant
251 Mercury St.
East Meadow, NY 11554
Fax: 516-579- 0771
AIP and the Intersubjective Matrix: Implications for Practice and Training in EMDR
Abstract: Developmental and interpersonal neurobiology and attachment research add the intersubjective dimension to AIP and memory networks both adaptive and dysfunctional. This dimension begins through early interactional patterns between caretaker and infant, and has been linked to the patterns of interaction between client and clinician. The mirror neuron system, elaborates the intersubjectivity of these networks. AIP, guides EMDR practice, and sets the groundwork with a memory network/information processing framework which allows an elaboration of this intersubjective matrix. This elaborated framework suggests the need to expand instructions to clinicians to include their activated memory networks as intrinsic to the intersubjective matrix in EMDR. An explication of these issues within this framework can allow clinicians a greater understanding of their role in the therapeutic process, and suggests ways clinicians can best self monitor and make needed adjustments to expedite their clients’ progress.
Key Words: Adaptive Information Processing, Intersubjective, Mirror Neurons
Adaptive Information Processing and the Intersubjective Matrix: An Elaboration of AIP with Suggestions for Practice and Training
Is it possible to “stay out of the way,” as is taught in EMDR trainings while “the train is moving down the tracks?” The answers from interpersonal neurobiology, including research on mirror neurons, are obviously no. The clinician may be able to inhibit compassionate verbal reflections of empathic attunement while implementing the protocols and procedures of EMDR; however, to suggest that our very presence, our unspoken thoughts and feelings, our non-verbal behavior can be kept out of the way ignores this research and the contributions from attachment and intersubjectivity. As it is taught and sometimes practiced, EMDR appears to be a one-person psychology. That is the issue of continual relatedness, or “how my memory networks affect your memory networks, which affect my memory networks” has barely been dealt with, and it is author’s EMDR definition of intersubjectivity.
The term “intersubjective matrix,” as defined by Daniel Stern, is used in this article to elaborate interactions of adaptive and dysfunctional memory networks between clinician and client. This intersubjective matrix is encoded in memory networks through all significant life experiences. While not explicitly spelled out in Shapiro’s explanation about AIP and memory networks, it is implicit in her writings and teachings (Shapiro 2007). The attachment researcher Lyons-Ruth (1998) terms this part of the memory network “implicit relational knowing.” Implicit relational knowing is, in AIP terms, a non-conscious part of a memory network that holds interpersonal experiences and sets expectations of how to be with others. In his discussion of attachment theory, Siegel (1999) states a similar point of view, defining mental models as “a fundamental way in which implicit memory allows the mind to create generalizations and summaries of past experiences. These models are then used to bias present cognition for more rapid analysis of an ongoing perception, and also help the mind anticipate what events are likely to happen next” (p. 71-72).
The addition of interactions of memory networks between client and clinician with the protocols and procedures of EMDR, whether adaptive or dysfunctional, elaborates the basic tenents of AIP. Adaptive to adaptive connection activates the resonance circuit of the social brain (Cozolino, 2006; Siegel, 2007), causing mental state resonance (Siegel, 1999) which is an attunement of states of mind between client and clinician. This attunement of states is non-verbal and allows the client to feel safe and understood deeply (Siegel, 1999, p. 69-70). This attunement of states of mind is the basis for collaborative contingent communication between caretaker and infant; client and clinician (Siegel 1999). When this co-constructed state is stable, the protocols and procedures of EMDR Reprocessing can be applied, and the chances for productive reprocessing of trauma to an adaptive conclusion are enhanced.
AIP posits that there “appears to be neurological balance in a distinct physiological system that allows information to be processed to an ‘adaptive resolution… Essentially, what is useful is learned and stored with the appropriate affect” (Shapiro, 2001, p. 30). Pathology is results of unprocessed experiences, stored in their own neural networks, unable to link up naturally with anything more adaptive. (Shapiro 2001, Solomon & Shapiro, 2008). Implicit in the definition of AIP is that at least two people are involved in the beginnings of what will become a human being’s self-organizing abilities. Self organization is only a function of adaptive communal living (i.e. the family). Infants are incapable of developing adaptive memory without a caretaker who attends to them sufficiently. According to Bowlby, inherent in human beings is an attachment behavior system (Cassidy and Shaver 1999). Dr. Shapiro gives interpersonal examples of how dysfunctional memory networks may develop, but limits what she describes to how experiences in living between people can impact AIP (Shapiro, 2001, 2007a). What is missing in AIP’s definition is the explicit and inherent two person system. The purpose of this paper is to propose an elaboration in the definition of AIP, to an explicit two person model and to discuss its implications for the practice of EMDR and the training of new EMDR participants.
EMDR came into existence as a result of Dr. Shapiro’s research first published in the Journal of Traumatic Stress Studies, (Shapiro1998a) and the Journal of Behavior Therapy and Experimental Psychiatry, (Shapiro 1998b). At that time, EMDR’s underlying conceptualization was “Accelerated Information Processing.” It remained that way through the publication of the first edition of Eye movement desensitization and reprocessing: Basic Principles, Protocols, and Procedures (Shapiro, 1995). In her second edition, the term “accelerated” was changed to “adaptive.” She states, “This model is offered as a working hypothesis only and is subject to modification based on further laboratory and clinical observation” (Shapiro, 2001, p. 30). She also notes that the term “memory networks” is used instead of “neuro networks” to include “cognitive/emotional strata” (Shapiro, 2001, p 30). Many studies have proven EMDR’s efficacy. Indeed any controversy EMDR’s effectiveness ended when Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, 2nd edition (Foa, Keane, Friedman, & Cohen, 2009) was published, and an “A” rating was given to it by its critics.
Lyons-Ruth (1998) introduces the concept of implicit relational knowing. Siegel (1999) discusses mental models. These concepts both share an understanding that humans relate to the other from past experiences encoded in memory. Traumatized patients could experience “therapists are dangerous,” since they may have been hurt by others who they trusted in their past. Insecure attachment relationships occur as a result of being hurt by the other. This “knowing” has implications for how a traumatized client may have attachment problems with the clinician: “I would view intersubjectivity as a parameter of human mental functioning that cannot be deactivated. The human brain cannot develop and sustain itself without relatedness, which is a continuously active condition of mental life” (Lyons-Ruth, 2005, p. 7).
Working with traumatized clients often holds the possibility for difficult interactions that may result in ruptures of attunement. In intersubjective terms, a “rupture of attunement” is defined as a “now moment,” or an affectively charged interaction between client and clinician (Stern, 2004, p. 245). The intersubjective concept of “moments of meeting” is defined as “something that happens in the present moment that potentially resolves the crisis created by this now moment and alters the intersubjective field” (Stern, 2004, p. 244). This moment of meeting is the relational repair of the rupture of the therapeutic alliance.
It is now time to open a discussion on the role of interpersonal and developmental neurobiology in elaborating AIP. This elaboration explicitly includes the role relationships play in AIP, including the recent developments in the mirror neuron research. Siegel (1999) states that “Relationship experiences have a dominant influence on the brain because circuits responsible for social perception are the same as or tightly linked to those that integrate the important functions controlling the creation of meaning, the regulation of bodily states, the modulation of emotion, the organization of memory, and the capacity for interpersonal communication” (p 21). Corticolimbic connections between the more mature brain of the caretaker and the developing brain of the infant during early period of postnatal development have been demonstrated in the development of affect regulation as a result of positive attachment experiences (Schore, 1994). Similarly, less than optimal attachment experiences can result in problems of affect regulation (Lyons-Ruth, 2006; Schore, 1994; Wallin, 2007). Porges (2003) elaborated a model of how positive social engagement may decrease sympathetic arousal, mediated through the ventral vagal components of the parasympathetic nervous system. Courtois and Ford compare the developmental trajectories of the learning brain, open to novelty, and the post traumatic stress brain’s trajectory focused on harm avoidance (Courtois and Ford 2009).
Within the EMDR community Leeds (2009) states that “an examination of the attachment literature in the context of the AIP model suggests that patterns of attachment shaped in early caregiver experiences influence all later adaptive and maladaptive coping responses” (p. 67), and Wesselman, (2007) makes positive comparisons between an AIP framework and attachment issues from childhood.
Researchers discovered that mirror neurons play a crucial role in social connectivity (Gallese 2009, Iacoboni 2008, Rizzolatti and Sinigaglia 2006). These neurons activate motor neurons when attuned to an intention of another. This motor neuron activation creates an inner experience of the “other,” called embodied simulation. Gallese states that “through embodied simulation we experience our connectedness to others.” (Gallese, 2009, p. 524). This is the neural basis for empathy, defined as a matching of inner and outer experience, is developed as a result of mirror neuron activation. Through empathy we “know” the experience of the other through our internal experiences of them (Damasio 2003, Rizolatti and Sinigaglia 2006; Wicker et. al 2003).
The mirror neuron system activates the resonance circuitry of the “social brain” of both parties (Cozolino, 2006; Siegel, 2007). According to Siegel (2007) this neural circuit is the basis for mental state resonance. “As two individuals’ states are brought into alignment, a form of what we can call mental state resonance can occur, in which each person’s state both influences and is influenced by that of the other.” (Siegel 1999). This is a state of mind where the client feels felt by the clinician, and is the mutual state of mind when productive reprocessing of traumatic memories occurs (Dworkin 2005). The resonance circuitry of the social brain “has been shown not only to encode intention (memory networks), but also to be fundamentally involved in human empathy, and also in emotional resonance, “the outcome of attunement of minds” (Siegel, 2007, p. 165-166). Compaq
According to Lyons-Ruth (2005), “Therefore, there is now a convergence of developmental, behavioral, biological, and evolutionary arguments for enlarging our model of the attachment motivational system to include positive components of the infant-caregiver relationship, components that also serve to down-regulate fearful arousal in early life” (p. 6).
The research on attachment has strong implications on the practice and training of EMDR clinicians. Infant researchers and intersubjective psychoanalysts also agree that patterns of early attachment influence how one interacts with others through their lifetime. (Lyons-Ruth, 2006; Stern, 2004). These early attachment patterns may be repeated in the EMDR client-clinician encounter.
Shapiro has instructed the clinician to “optimally interactive,” (Shapiro 2007a p 76) with the client during EMDR. Any problems in doing so have only been incorporated into training and practice through Resource Development and Installation (R/D/I.) Leeds (1996) discusses “countertransference” in EMDR with attachment disordered clients and candidly admits his activated dysfunctional memory networks. His difficulties with an attachment disordered client led him to develop “EMDR resource installation” (p 268), as another way to promote healing. He was influenced by Barach (1991), reorienting his clinical focus to stabilize clients with early attachment problems. In EMDR methodology attachment issues are dealt with R/D/I and researched successfully by Korn and Leeds 2002. R/D/I strategies have been spelt out by Leeds, in Shapiro 2001, (p 434-440). While these strategies are useful and now incorporated into EMDR methodology, the attachment difficulties between client and clinician remain unaddressed through R/D/I methodology. Gelinas (2003) has addressed the need to take more time to form an effective alliance with the attachment disordered clients who suffers from complex PTSD. Dworkin (2005) elaborated these issues as well. For example when an EMDR clinician attempts to obtain too much detail about specific traumas in the history taking phase, before establishing a good enough therapeutic alliance, the traumatized client may interpret this behavior as a desire on the clinician’s part to use this information in a hurtful manner (harm avoidance Coutois and Ford 2009).
The formation of a strong enough therapeutic (or collaborative) alliance has been stated as necessary in EMDR methodology (Shapiro 2001), but not the problems of rupture and relational repair of the bond (Norcross 2002). In their chapter on repairing alliance ruptures, Safran, Muran, Samstag, and Stevens (2002) highlight Bordin’s (1979) transtheoretical conceptualization of the collaborative working alliance as having shared goals, differentiated tasks, and therapeutic bonding. For the sake of convenience, the term “therapeutic alliance” will be used to represent both concepts. Alliance ruptures have been shown to strengthen the therapeutic bond when there is relational repair (Safran et al., 2002). A significant conclusion of their research is that patients have negative feelings about their relationship with the therapist and that they fear alienating the therapist and that therapists need to be mindful of these ruptures and take the initiative in exploring what has occurred and that poorer outcomes can be expected when these issues are not dealt with (Safran et al., 2002).
From Neurobiological Research, Attachment and Intersubjectivity to EMDR Practice
Developmental and interpersonal neurobiology, attachment and mirror neuron research demonstrate that the clinician’s memory networks are always interacting with the client’s; hence, EMDR protocols and procedures cannot be set apart from the memory networks of client and clinician. Research on the therapeutic bond dictates the necessity of dealing with ruptures of attunement with relational repairs.
Shapiro (2001) stresses that EMDR is not a “cookie cutter” approach but must be tailored to each client (p 381); she stresses the need for continued study and consultation after finishing the Basic Training in EMDR, and that clinician factors affect the application of EMDR methodology (p 381).However when she states that some of the procedures in EMDR may be too disturbing to clinicians who might have difficulty “staying out of the way” during reprocessing, she cites “previous training, (p 381), and not the activation of the clinician’s dysfunctional memory networks. In other writing she acknowledges “countertransference” and credits this author with methods of dealing with it (Shapiro 2007a p 76). While gratifying to be recognized it is the desire of this author to have the intersubjective matrix an explicit part of Basic Training in EMDR.
Now, through the research of neuroscience, clinical judgment in EMDR can be expanded to include understanding attachment processes between client and clinician, identifying attunement and resonance as necessary to continue the progression of preparing and reprocessing traumatic experiences, and intervening in this intersubjective matrix when ruptures to attunement and resonance occur.
This author has defined transference and countertransference in information processing terms as “the activation of state dependent memories (or dysfunctional memory networks) in the client or clinician, or both, that have been activated by the client, intentionally or not” (Dworkin, 2005, p. 126). The clinician’s attachment patterns; intersubjective consciousness (which include the bi-directional re-entry loops between client and clinician communications) (Stern, 2004, p. 243); memory networks; and information processing system differ from those of his client’s. Each makes ongoing appraisals of the other. An appraisal is an evaluation about an interaction between self and other, based upon mental models, (Siegel, 1999, p. 124-125) of the other’s intentions. When these appraisals of the intentional attunement of the other become activated, what may become embodied in either party, or both, may be the dysfunctional activations of unprocessed trauma causing misattunements, or now moments, requiring moments of meeting to repair the relational rupture.
Rupture and Repair To the Therapeutic Alliance
One question this author raises in mirror neuron research involves the interpretation of the intentional attunement of the other. When dysfunctional memory network activations occur what may become embodied is the activation of thoughts, feelings and sensations of old memories “transferred” to the alliance. A simple example of a rupture may occur when the clinician holds up his hand to demonstrate eye movements (EM’s). While the intent may be a teaching point, the client, who may have been physically abused by a man, might flinch at the sight of a male therapist raising his hand. It may implicitly activate his mirror neuron system with the incorrect interpretation of intentional attunement of dysfunctional memories of being beaten. The clinician needs to use his somatic awareness when this occurs, and immediately evaluate what has occurred. Often this type of rupture is minor, with both parties being sensitized to the intersubjective nature of their experience.
When more considerable ruptures occur significant complexities arise causing an intersubjective block to the progression of evaluation, history taking, preparation, and reprocessing. These will be described through case examples in phases one, two, four, and seven. The EMDR clinician should take the adequate amount of time, not only to test the client’s affect tolerance abilities, but also to develop, and check the level of the therapeutic alliance during many of the phases of EMDR psychotherapy. There needs to be a firmly established alliance that will carry through, and be tested, before, during, and after the active trauma reprocessing phases (Dworkin, 2005, Gelinas 2003, Safran et al 2002). This alliance will be tested and will change during the course of treatment. (Safran et al 2002, p. 245).
“Now Moments” and “Moments of Meeting” in History Taking
Client and clinician are neurobiologically connected in a two-person, subject-to-subject, ongoing bidirectional, nonlinear experience. An example during the History Taking phase may be found on page 22 of the March 2009 EMDR Approach to Psychotherapy: Part One of the Two Part Basic Training Manual, “Developing Appropriate Negative Beliefs (Cognitions NC).”
“Gary” requested EMDR psychotherapy to help relieve the beliefs and feelings associated with being inadequate due to the present day trigger. He is a 28-year-old male patient who is single and working as a teacher for special needs children. He recently received a poor evaluation by a supervisor and became quite anxious, believing that he would lose his job for being stupid. The EMDR clinician evaluated the client’s whole clinical picture and began to develop a Targeting Sequence Plan. Starting with the present day trigger, the client reported that the image he sees is of his supervisor frowning. The current instructions next call for obtaining a negative cognition: “When you think about of (repeat description… supervisor’s frown…) what negative belief do you have about yourself?” The clinician received this reply, “I feel ashamed of myself.” The clinician then responded, “What does that say about you as a person?” The client said, “I hate myself.” Now the clinician started to become a little frustrated and said, following the EMDR Institute Part One manualized instructions, “What negative belief goes with that emotion (of hating yourself)?” (p 22). “Well, I have hated myself since I’ve been a child.” The frustration (and failure memory networks of the clinician now became more pronounced) and the clinician replied (with a little irritation starting to creep into his voice), “not what you believed about yourself then, what do you believe about yourself now?” The clinician’s frustration continues to increase and he said, with irritation in his voice, “Gary, when you see your supervisor’s frown, in your worst moment, what negative belief you have about yourself when you think of that event?” Gary’s visual and auditory mirror neurons sensed the clinician’s irritability, and his failure memory networks became activated by the clinician’s frustration. His appraisal of the clinician’s irritability is correct, but it activated a subservient memory network and he responded, “I’m doing this all wrong now, aren’t I?”
This previous dialogue is an example of a rupture of attunement. At this moment the clinician’s visual and auditory neurons now became activated empathically to his client’s activated failure memory networks. He recognized that his irritation was the result of his own failure networks, and his adaptive memory networks containing compassion became activated and he responded, “I know that this question is difficult for you to answer the way I want you to; is it possible that my responses to you made you feel like you were failing again?” Gary shrugs his shoulders and nods. “So maybe the questions, or the way I was asking them, made you experience your negative beliefs now. Let’s see if we could try this again a little differently. Would that be okay?” Both experienced relief in this moment, and they repaired this rupture. Implicitly, the clinician is letting the client (and himself) know that misattunements can be resolved creatively through a moment of meeting; hence, misattunements do not equal failure and “I am here for you”). This is a “moment of meeting” that repairs the rupture of attunement. A moment of meeting cannot be manualized. It is the creative solution that the clinician develops to find the solution to this rupture. In this case the clinician was able to use Gary’s words, “I’m doing this all wrong” as a way to find a negative cognition, “I’m a failure.” It is the interaction of activated adaptive and dysfunctional memory networks, with mirror activations, appraisals, interpretations of intentional attunement occurring in each party, and self-corrections happening as each reflected as to what their part in the process might have been. The standard EMDR instruction to “strive for optimal attunement,” may be better modified to suggest that the clinician mindfully notice how his subjectivity (memory networks) starts and continues to influence the client’s subjectivity (memory networks.)
Overtly, the clinician was following the standard instruction to elicit a negative belief during the Targeting Sequence Plan. However, while Gary was trying to following the instruction, in parallel process it exposes his implicit relational knowing to the clinician “in the moment” that “people think I’m stupid (and therefore I’m ashamed of myself)…” “‘Moments of meeting’ involves a response that is well-fitted to the particular crisis. It cannot be a general technical response…” (Stern, 2004, p. 244). The instructions, “When you think about yourself, …what negative belief do you have about yourself as a person;… what does that say about you as a person; what negative belief goes with that emotion…?” etc, are all general technical responses, and therefore do not meet criterion for a moment of meeting.
This “now moment” puts Gary’s and the clinician’s alliance in jeopardy, and “a well fitted response” (moment of meeting) was needed to solve the intersubjective crisis. (“So maybe the questions, or the way I was asking them, made you experience your negative beliefs now. Let’s see if we could try this again a little differently. Would that be okay?” At first they both enacted the exact problems Gary and the clinician both experienced, only this time it happened “in the moment.” The EMDR clinician needed to become aware of this repetition, with awareness of his dysfunctional memory network activations; otherwise, Gary’s implicit relational knowing would have been reinforced. Another failed dyadic experience would occur because the clinician was not taught to pay attention to his own implicit relational knowing (“people treat me like I don’t matter and don’t listen to me”). And his negative cognition, “I am unimportant,” is actually a defense against a similar implicit relational knowing of Gary’s. Clinician needs to be taught, right from the beginning of basic training in EMDR, that these occurrences are possible, not absolute, and a moment of meeting that is well fitted to the situation is required. This moment of meeting re-engaged Gary in a problem-solving attempt.
“Now Moments” and “Moments of Meeting” during the Preparation Phase
It is important to remember that there is a difference between a state shift, as evident in phases one and two, and a trait shift that occurs as a result of successful reprocessing during phase four. Activations of dysfunctional memory networks can re-occur and the client and clinician are vulnerable to these activations. Gary continued to act subserviently while trying to develop a “Safe Place” unsuccessfully. The clinician, remembering Gary’s difficulties in developing an appropriate negative cognition in the history taking phase, initially experienced compassion towards Gary since he was “obviously” is trying. However, as Gary continued to be unable to experience safety, regardless of the clinician’s creative efforts to give Gary different choices, the clinician again experienced himself becoming frustrated; his frustration was evident in his tone of voice, facial features, etc. Gary’s mirror neurons accurately reflected the clinician’s frustration, but his embodied experience was again an appraisal of his being at fault, and failing again. He experienced an embodiment of anxiety related to failure memory networks, but he did not want admit this reaction for fear of “hurting the alliance.” The clinician had demonstrated kindness and flexibility, and Gary feared that he would anger the clinician with his inability. While he continued to try to comply with the instructions he withdrew into a dysfunctional belief of “I’m incompetent.” This withdrawal was not acknowledged by the clinician, who had a somatic reaction of going numb. This numbing was based upon an activation of his dysfunctional memory network of being helpless (which was actually Gary’s problem with developing safety. If the clinician was able to use this somatic reaction appropriately, it might have given him a clue to Gary’s difficulties.)
When the clinician’s mirror neuron activation causes him to have an embodied experience of activated dysfunctional memory networks, the work functions of treatment do not progress. The clinician needs to learn to compartmentalize (Dworkin 2005) this activation, and then deal with this “now moment” with a “moment of meeting.” In Gary’s case, the clinician was able to finally attune to the Gary’s difficulties.
“Now Moments” and “Moments of Meeting” during the Desensitization Phase
These “now moments” can be observed during the desensitization phase of EMDR clinical practice when the client reports that “nothing” has occurred after two consecutive sets of EM’s. While many “instructive” procedures facilitate blocked processing, the clinician needs to pay careful attention to the verbal or non-verbal intersubjective experiences that may be occurring when reprocessing trauma becomes blocked. The adaptive and dysfunctional memory networks of both client and clinician, both with mirror neuron activations and somatic reactions (whether somatic activations, or somatic numbing), can guide the clinician in making these clinical judgments.
Robert was a 36 year old, single, social worker, who contacted this author for EMDR reprocessing. He had been traumatized by a harsh romantic breakup and believed that he was defective because of this rejection. Other treatment methods were not useful in helping him resolve his dysfunctional failure and rejection memory networks, and he decided that he would “try” EMDR. His implicit relational knowing was that older men show kindness and compassion. He reported a good relationship with his father; a fair relationship with his mother (“she’s a bit too emotional for my taste, just like most women”), and he had a strong social support network. The author and the client made a good beginning alliance; during history-taking, Robert said that there were few childhood “issues”; he scored low on his DES-T and completed all procedures of the Preparation phase. While the author’s dysfunctional subservient memory networks were activated he did not pay attention to his somatic reactions informing him that there were more childhood issues than he was aware of. It seemed as though Robert and the author had achieved mental state resonance, and he had the requisite coping abilities to begin the active phases of EMDR.
He reprocessed some childhood issues of rejection during athletic competitions with little distress. During one of these reprocessing sessions he began to remember a dissociated memory of being a little child and finding out that his mother, who was not present to watch him play Little League, had an extramarital affair with his father’s best friend. After finishing his childhood athletic competition traumas, the trauma of seeing his father in pain was next.
P – “I see my father crying and I go over to comfort him.”
NC – “I am a failure.”
PC – “I did the best I could.”
VoC – 3
E – Sadness and guilt
SUDS – 8
Body – Heartache and pain in his stomach
At the end of two sets of EMs he said that no new information had come up for him. Longer sets, direction changes, instructions for under-accessing a target memory, and cognitive interweaves such as “If this had happened to your best friend as a little boy, what would you tell him?” were used. No “standard instruction” seemed to fit. A “now moment.” Occurred and this author had an experience of not being able to think clearly. This is an intersubjective example of a now moment that is non verbal (as many of them are). The author quickly reflected on this dilemma and wondered if his mirror neuron system was sensing non-conscious dysfunctional memory networks from Robert that may have been activating dysfunctional unprocessed memories of the clinician’s when he felt helpless and could not figure out what to do.
The author first compartmentalized his anxiety in not being able to think clearly, and then decided to share his inner experience of clouded thinking as a “moment of meeting.” (The author’s implicit relational knowing was that he is safe to reveal his process). When informed of this experience, Robert exclaimed, “That’s it! That’s what I experienced. I had forgotten all about it. I couldn’t think clearly and I blanked out.” The author suggested that this intersubjective moment of what had just happened be reprocessed, and another dissociated memory network of Robert’s became activated. He remembered an experience of being six years old, in his first school play, and forgetting his lines. His mother, who was in the audience, began to cry, activating shame in Robert and causing him to urinate in his pants, increasing his feelings of humiliation to unbearable levels. He experienced an elongated period of intense emotional releases with dual attention and verbal support from this author, whose adaptive memory networks of compassion were activated. After this period of release Robert recognized that he had been choosing women to date who would be critical of him. In a non conscious manner, he realized that his identification with his father’s pain propelled him to continually repeat this pattern. This author did not make any suggestions that would make Robert think this way. Once this intersubjective block was discovered and reprocessed Robert was able to adaptively reprocess his dysfunctional memory networks which related to a merged sense of himself with his father. It took three 90-minute sessions to reprocess the rest of his past problems with women, the romantic breakup that had sent Robert into therapy, his present day referents (dating women with similar characteristics to his mother), and his future template of finding a more appropriate partner, whom he eventually married. This author receives holiday greeting cards every year; Robert is married and has two children. Again, the purpose of this paper is not to discard any part of AIP; it is to elaborate it so that it now is seen and taught as a two person model, informing the work of EMDR psychotherapy.
“Now Moments” and “Moments of Meeting” during Incomplete Closure
During an incomplete closure, a now moment occurred. While debriefing the client who had been in EMDR psychotherapy for seven months, client and clinician were discussing how she had experienced positive affect for the first time about a person who had rejected her. Her trauma remained unfinished, and the clinician’s dysfunctional memory network activation of feeling rejected caused him to make the mistake of suggesting that the client list a number of positive attributes and experiences the client had with this person. The clinician’s conscious judgment was that the client had begun to tolerate positive affect, and thought that he was supporting this progression. He was unaware of his dissociated anger network. His suggestion was met with intense negative affect by the client. She had an activation of her rejection networks and correctly experienced this suggestion as a dismissal of her remaining pain. (Activated by her auditory mirror neuron interpretation of the clinician’s non conscious intent to have finish and “get over it!” This was his problem that he later worked out by using the Clinician Self Awareness Questionnaire (Dworkin 2005, 2009). It was also experienced as an order which was not the clinician’s conscious intent. But as the clinician reflected on his dysfunctional memory activations of being angry, he recognized that his covert impatience towards the client was an activation of how he had experienced the client’s complaining about how long this process took. This awareness opened up his awareness regarding his mother’s impatience towards him.
The clinician recognized that he had made an error and discussed this error at the beginning of the next session, during re-evaluation . He further said that he had wanted the client to make as much progress as possible in the shortest time, but that he could recognize that while his conscious intent was to move the process along, that he was pushing the client, and that he had an activation that he had worked on. He then reported to the client that he was pushing her in a direction that made her feel too vulnerable, and “commanded” like her parents had done to her as a child.
The client felt moved by the clinician’s sharing. The intersubjective field was reshaped with more dual awareness and safety. They were able, after the re-evaluation phase, to revisit that “now moment” and “moment of meeting” as a place to start reprocessing her rejection traumas. In a short time she was able to release the pain of her implicit subservience and recognize that she had a right to say no. (This example is a variant of what this author has previously written about, and is called the relational interweave (Dworkin, 2005).
The client’s mirror neurons had become activated because of the implicit intentionality of the clinician’s demand to get better more quickly. Her embodied simulation of this implicit intention was the activation of both painful submission to authority and her rageful refusal to ever submit again. As she reprocessed these activations during the next session, she was able to also recognize that she had been repeating this pattern with a man who loved her (but also had his own issues to work out). Her functionality improved significantly and she was able, calmly an assertively, to confront her present partner and request (strongly and assertively) that he self-reflect on his issues. She reported that he received her request in a very different manner and decided to seek his own EMDR treatment. In essence, her mirror neuron activation began an intersubjective process that included adaptive and dysfunctional memory networks of both parties interacting in a manner that when recognized promoted a great deal of healing. This example demonstrates that the clinician’s memory networks are always interacting with the client’s; hence, EMDR protocols and procedures cannot be set apart from the non-linear, bi-directional interactions of client and clinician.
In every phase of EMDR, instructions are given to the clinician regarding how to perform EMDR procedures based upon the AIP model. While useful, such instructions do not include the possibility that the clinician’s dysfunctional memory networks may be interacting with the dysfunctional memory networks of the client’s. As demonstrated in the case examples during phases 1, 2, 4, and 7, the clinician has adaptive and dysfunctional memory networks that interact with the client’s memory networks. The procedural elements of developing a negative cognition, or Safe/Calm Place; accessing and stimulating dysfunctionally stored information; containing and stabilizing dysfunctional information; facilitating blocked processing; and closing down incomplete sessions have intersubjective risks and opportunities for creating a stronger therapeutic alliance so that the client may feel safe enough to reprocess deeper and more painful dysfunctional memories (Safran et al 2002). Addressing blocks to preparing clients, facilitating adaptive information processing, and closing down incomplete sessions is more complex than just following these instructions. A fuller instruction might be added to include, “and just notice mindfully how your attunement is affected, both adaptively and dysfunctionally by your memory network activations and interactions as well as your client’s.”
Awareness of the clinician’s dysfunctional memory network activations, in intersubjective interaction with the client’s memory networks; the ability to recognize what to do once noticed, enhance EMDR practice. But without their inclusion in the AIP model too many unacknowledged problems arise.
Instructional behaviors are necessary but not sufficient. They give the clinician a “roadmap” to follow with all the tasks required of him and his client. For instance, during intense emotional releases in the desensitization phase, “The client relies on the clinician to provide emotional stability and a sense of safety during the abreaction” (Shapiro, 2001, p. 174 Clinicians whose memory networks become dysfunctionally activated during intense emotional releases may have beliefs that they are “harming” the client by continuing bilateral stimulation, when the client seems to be adaptively remaining in dual attention but has not reached the next plateau of adaptive information processing. This may be a function of a dysfunctional memory network of the clinician, and not just the result of other training the clinician has experienced with different orientations.
In a different situation, a clinician who may have been “harmed” but unaware of that memory network activation may continue reprocessing with their client way past their client’s tolerance. The clinician may have “learned” that it was safer to harm than be harmed, but this information may not be available to the clinician’s self awareness. The client’s subservient memory network may continue allowing reprocessing to continue in spite of being taught the stop signal in phase two. Then the clinician’s sadistic memory network activations, as an overcompensation to have being harmed may be activated. In this case the clinician may continue harming the client until the client dissociates.
The reader may interpret the clinician’s dysfunctional memory networks as “countertransference” that needs to be dealt with so that the clinician does not interfere with the client’s reprocessing. The intersubjective matrix is far more complex. Current instructional guidance aids critical thinking, but ignores the possibility that part of the blocks in reprocessing may be caused by implicit non-linear interactions between both parties. The clinician is intrinsically part of the process whether he verbalizes anything or not. Both are in nonlinear continuous intersubjective feedback loops (intersubjective consciousness Stern, 2004, p. 243).
Instructions to clinicians to be mindful of their somatic reactions as well enlarges the focus of attention for both client and clinician memory network activations. The example of the author becoming unable to think straight while reprocessing a memory with Robert illustrates this point. When dysfunctional memory networks of the clinician are activated, intersubjective strategies are needed to continue productive reprocessing. This elaboration starts with broadening the theoretical underpinnings of EMDR by making explicit the intersubjective nature of AIP.
The Clinician Self Awareness Questionnaire (Dworkin, 2005; Dworkin 2009) is a tool clinicians find useful to those ends. However, nothing takes the place of competent EMDR psychotherapy for the clinician when he sees dysfunctional memory network activations repeating, and implicitly interrupting, the work.
Self-reflection implies that the clinician is capable of maintaining dual awareness. This process may be validating for the EMDR clinician. When the clinician finds moments when dual awareness diminishes, he should immediately use a compartmentalization strategy to regain his self-reflective abilities. If it were not for the adaptive memory networks of the clinician in concert with the application of EMDR procedures, many dysfunctional memory networks of the client would not be reprocessed. When the clinician observes patterns of dysfunctional memory network activation that block reprocessing (in consultation with a colleague), he would be well advised to reprocess these memory networks that block mental state resonance.
Detailed intersubjective strategies that this author has briefly described are outside the architecture of this paper. These strategies, if not implemented with effectively, will be blocks to adaptive information processing. These dysfunctional activations of the clinician can be used productively. The processes of compartmentalization and self-reflection, using AIP as its theoretical basis, are one strategy. They are the beginning of a series of processes that have implications for furthering the practice of EMDR psychotherapy. Using these “dysfunctional memory network activations” productively to continue adaptive information processing is a superior way of viewing them as just “pathology that needs to be reprocessed by the clinician so that he can get back to practicing EMDR being “optimally interactive.” (Shapiro 2007a p 76). The implication is that these activations have no merit. It is useful for all EMDR clinicians to continue to work on reprocessing their dysfunctional memory networks, but using them productively to create “moments of meeting” makes them more than “interruptions” that pathologize the EMDR clinician. Another limitation of this paper is its lack of recognition that unprocessed memories all have dissociative elements, or dissociative disorders. While much has been written on this subject (Forgash and Copley eds 2008) it has been in ego state language. If AIP is the theoretical underpinning to EMDR, dissociation, in all of its forms should be elaborated in the same language.
These strategies, along with this elaborated conceptualization of AIP, have implications for training EMDR clinicians. It is this author’s opinion that it is well past time to restructure the formats of EMDR Basic Training. The current course of two three-day workshops, with no real accountability, is problematic. Further suggestions for detailed improvements are also outside the realm of this paper and will have to wait. For now, the most important change that can be made within the same structure is to teach AIP as the non-linear, bi-directional interactions of client and clinician memory networks and to teach clinicians how to recognize “now moments” and create “moments of meeting.” It is also crucial to have EMDR clinicians understand how AIP is the theoretical basis for EMDR, and for them to understand and demonstrate this understanding by the end of the Basic Part One and Part Two Trainings. Too few “fully trained” EMDR clinicians continue their education and become “Therapists Certified in EMDR” by the EMDR International Association.
Standards for training new EMDR clinicians in the United States are the responsibilities of the EMDR International Association. Slight modifications of explaining AIP might include giving explicit explanations that the formation of memory networks, from infancy, is dyadic, and therefore communal in its origins. It would be useful to have a stronger emphasis that AIP includes the encoding of the dyadic experiences that form the basis for further relating; The attachment literature and research has demonstrated this over and over again. The images, attitudes, perceptions, emotions, sensations, cognitions, and beliefs that comprise memory networks include implicit relational knowing (Lyons-Ruth 1998). They are the sum total of adaptive (autobiographical intersubjective) experiences, and dysfunctional (implicitly encoded intersubjective) experiences become dysfunctional memory networks. Either adaptive or dysfunctional memory networks may become activated in the present due to the process of association, which will then activate memory networks in “the other” (clinician); this can easily be taught in the standard way in the training. Examples could be included in the client clinician matrix during each phase. The trainer, through intersubjective example during question and answer, could demonstrate that every human being has a combination of adaptive and dysfunctional memory networks.
The manual could include a section that encourages the participant to write one or two adaptive and dysfunctional memories networks that still affect his current day functioning (this would not need to shared). Another part of the manual could have the participant write down an example of an adaptive or dysfunctional memory network activation he experiences during each part of the training. This intersubjective elaboration, which seems to elude many EMDR clinicians, may become tangible and affectively encoded in the participant’s brain (thanks to George Abbott, Ph.D., HAP Trainer, for this idea).
During each phase of EMDR, adaptive memory networks of both client and clinician set the stage for mental state resonance (Siegel 1999). When dysfunctional memory networks of the client affect the dysfunctional memory networks of the clinician, mental state resonance is breached, and learning (which is the function of adaptive information processing (Shapiro 2001) becomes inhibited. Then the suggestion could be given that the clinician and client together search for what caused the misattunement; this could enhance the clinician’s understanding that the success of EMDR depends on both a collaborative working alliance and the attention to mindfulness of both parties. Fidelity to the protocols and procedures yields the most robust results (Maxfield & Hyer, 2002), and the participant should be mindful of the effect on the psychotherapy process should he modify them. These recommendations are meant to augment, not replace, what has been researched to be useful.
During the practicum experience, the clinician could be encouraged to think about a client he (SUDS, 5) has experienced some dysfunctional memory network activation with, and then use this memory activation as the present day referent, developing a targeting sequence plan from that point. This experiential learning would enhance the participant’s sense of what he may need to reflect about not only during the training but also back in his office.
This author urges EMDRIA to incorporate, as a condition of completing basic EMDR training, the expectation that each participant complete a number of sessions as a client, outside of the practicum.
Mirror neuron research shows that humans respond with intentional attunement and embodied simulation to affect charged actions of the significant other. Unfortunately, while attachment, developmental neurobiology, intersubjectivity and mirror neuron research are part of AIP, they are not detailed in AIP. It’s time that the EMDR world wakes up during its second generation to include what is already an intrinsic part of many therapies are interacting in bi-directional, non-linear ways. This elaboration of AIP is simply taking what Dr. Shapiro implied (personal communication 2009); however, the implications of this explicit elaboration will have far-reaching effects on the practice and training of EMDR for future generations.
Hopefully this paper will accelerate the conversation of their rightful place in treatment and training.
Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research, & Practice, 16, 252-260.
Bromberg, P. (1998). Standing in the spaces: essays on clinical processes, trauma, and dissociation. New York, NY: Analytic Press
Bromberg, P. (2006). Awakening the dreamer: clinical journeys. New York, NY: Analytic Press.
Cassidy, J. & Shaver, P.R. (1999) Handbook on attachment. Theory, research, and clinical applications. New York Guilford
Chefez, R., (ed) Dissociative disorders: An expanding window into the psychobiology of the mind. Psychiatric Clinics of North America,29, (1) p 63-86
Cozolino, L., (2002) The neuroscience of psychotherapy: Building and rebuilding the human
brain NY Norton
Cozolino L., (2006) The neuroscience of human relationships: Attachment and the developing
Social brain. New York: Norton
Courtois, C., and Ford J.D., Treating Complex Traumatic Stress Disorders: An evidence based guide. New York Guilford.
Dworkin, M. (2005). EMDR and the relational imperative; the therapeutic relationship in EMDR treatment. New York: Routledge.
Dworkin, M. (2009) The Clinician Awareness Questionnaire. In Luber, M., EMDR scripted protocols: Basic and special situations, New York: Springer
Foa, E.B., Keane. T.M., Friedman, M.J., Cohen, J. A. (Eds). (2009). Effective treatments for ptsd: Practice guidelines from the international society for traumatic stress studies. New York, Guilford.
Forgash, C., and Copeley, M., (eds) (2008), Healing the heart of trauma and dissociation with emdr and ego state therapy. New York, Springer
Ford, J. D., (2009) Neurobiological and developmental research: Clinical implications, in Courtois, C., and Ford J.D., Treating Complex Traumatic Stress Disorders: An evidence based guide. New York Guilford.
Gallese, V. (2009) Mirror neurons, embodied simulation, and the neural basis for social identification. Psychoanalytic Dialogues, 19, 519-536.
Gallese, V. (2005). Intentional attunement: mirror neurons and the neural underpinnings of interpersonal relations, JAPA, 55, 131-176.
Gelinas, G. (2003). Integrating EMDR into phase oriented treatment of trauma. J. of Trauma and Dissociation, 4, 91-135.
Iacoboni, M. (2008). Mirroring people: the new science of how we connect with others. New York: Farrar, Strauss, and Giroux.
Korn, D. L., & Leeds, A. M. (2002). Preliminary evidence of efficacy for EMDR resource development and installation in the stabilization phase of treatment of complex posttraumatic stress disorder. J. Clinical Psychol., 58(12), 1465–1487.
Leeds, A. (2009). A guide to the standard EMDR protocols for clinicians, supervisors, and consultants. New York, NY: Springer Publishing Co
Leeds, A., (1996) Lifting the burden of shame: Using emdr resource installation to resolve a therapeutic impasse; in Manfield, P., (1996) Extending emdr. New York: Norton p 256-282.
Luber, M. (2009). Eye movement desensitization and reprocessing scripted protocols: basic and special situations. New York, NY: Springer Publishing.
Lyons-Ruth, K. (1998). Implicit relational knowing: its role in development and psychoanalytic treatment. Infant Mental Heath J. 19(3), 282-289.
Lyons-Ruth, K. (2005). The interface between attachment and intersubjectivity: perspective from the longitudinal study of disorganized attachment. Psychoanalytic Inquiry, 26:595-616.
Lyons-Ruth, K., Dutra, L., Schuder, M.R., & Bianchi, Ilaria, (2006) From infant attachment disorganization to adult dissociation: Relational adaptations or traumatic experiences? In Chefez, R., (ed) Dissociative disorders: An expanding window into the psychobiology of the mind. Psychiatric Clinics of North America, 29, (1) p 63-86
Manfield, P., (1996) Extending emdr. New York: Norton
Marich, J., (2009) “EMDR in the addiction continuing care process.” J. of EMDR Practice and Research, 3, (2) 98-108
Maxfield, L. & Hyer, L. (2002). The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD. J. Clinical Psychol., 58(1), 23–41.
Norcross, J., (2002) Psychotherapy relationships that work. New York, Oxford
Paulson S., (1995) “Eye movement desensitization and reprocessing: precautious use in the dissociative disorders,” Dissociation 8, p 32-44
Porges, S., (2003) “The polyvagal theory: phylogenetic contributions to social behavior.” Physiology and Behavior, 79, 503-513
Rizzolatti, G. & Sinigaglia, C. (2006). Mirrors in the brain. Oxford: Oxford University Press.
Safran, J.D., Muran, J. C., Samstag, L. W, Stevens, C., (2002) Repairing alliance ruptures; in Norcross J.C.,(ed.) Psychotherapy relationships that work; Therapist contributions and responsiveness to patients. New York Oxford
Schore, A. (1994). Affect regulation and origin of the self. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.
Schore, A. (2003a). Affect dysregulation and disorders of the self. New York, NY: Norton.
Schore, A. (2003b). Affect dysregulation and repair of the self. New York, NY: Norton.
Shapiro, F. (1989a). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies, 2, 199-223.
Shapiro, F. (1989b). Eye movement desensitization. A new treatment for post traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211-217.
Shapiro, F., (1995) Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (1st ed.) NY: Guilford
Shapiro F. (2001). Eye movement desensitization and reprocessing, Basic principles, protocols and procedures (2nd ed.). New York, NY: Guilford.
Shapiro, F. (2007a). EMDR, Adaptive Information Processing, and Case Conceptualization. J. of EMDR Practice and Research. 1(2), 68-87.
Shapiro, F., Kaslow, F., & Maxfield, M., (eds) (2007b) Emdr and family therapy processes New York Wiley
Shapiro, F., (2009) The emdr approach to psychotherapy: Part 1 of the two part basic training. Watsonville CA: EMDR Institute
Shapiro, F., (2009) The emdr approach to psychotherapy: Part 2 of the two part basic training. Watsonville CA: EMDR Institute
Siegel, D.J. (1999). The developing mind. New York, NY: Guilford
Siegel, D.J. (2007). The mindful brain. New York, NY: Norton
Solomon, R. & Shapiro, F. (2008). EMDR and the adaptive information processing model: potential mechanisms of change. J. of EMDR Practice and Research, 2(4), 315-325
Stern, D. N., (2004) The present moment in psychotherapy and everyday life. New York Norton
van der Hart, O., Nijenhuis, E., and Steele, K., The haunted self. New York Norton
Wesselman, D., Treating attachment issues through emdr and a family systems approach. In Shapiro, F., Kaslow, F., and Maxfield, M., Emdr and family therapy processes New York Wiley.
Wicker, B., Keysers, C., Plailly, J., Royet, J.P., Gallese, V., and Rizzolatti, G.,(2003) Both of us disgusted in my insula: the common neural basis of seeing and
feeling disgust. Neuron, 2003, 40, 655-664.
Complex PTSD (CPTSD) and Dissociation – An Unrecognized Problem in Psychotherapy
In order to understand this complicated phenomenon we call dissociation (and specifically “pathological dissociation” it is necessary to understand where and why it develops. This condition is part of a syndrome called Complex PTSD. Before we can really understand where it fits in, I need to describe the differences in people who present in a therapist’s office with PTSD. By the way, PTSD is in my humble opinion (and many others) as a dissociative phenomenon, and should not be classified as an anxiety disorder.
Many times potential clients will start treatment with me saying that the last 5 therapists they had were nice people, but not quite helpful. Often these people suffer from Post Traumatic Stress Disorder of a different kind, called Complex PTSD (or CPTSD).
Let me explain some differences between PTSD and Complex PTSD (CPTSD). When the World Trade Center was hit on 9/11 2001, there were scores of people calling me in crisis. Some had been there, or had been close by; some had lost loved ones. By and large, these people were pretty well put together before this national tragedy. Many came from secure homes as children; most were married and had productive jobs.
These people are usually high functioning in their lives. Yet, after experiencing an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. Their response involved intense fear, helplessness or horror. (DSM 4 – TR 2000). They were quite “freaked out,” as we say in the vernacular.
Mental health professionals will easily recognize the aforementioned as the “A” criterion for PTSD. They will also suffer from intrusive and distressing recollections of the event, sometimes flashbacks, nightmares, and psychological and physical reactivity to anything that reminds them of their traumatic experience. Then there are a whole symptom complex of avoidant and hyperarousal symptoms.
Sounds pretty dire, doesn’t it? Well, these people can heal from this traumatic event without too much of a problem. I treated many of them with Eye Movement Desensitization and Reprocessing or EMDR. Treatment was usually pretty brief, and almost always successful.
EMDR is an “evidence based form of trauma psychotherapy that has been accepted worldwide as being highly effective in these cases. It has been researched by many mental health professionals and has consistently given the highest ratings by various organizations including the International Society for Traumatic Stress Studies, or (ISTSS); the Department of Defense and Veterans Affairs, to name a few reputable organizations.
That’s all well and good, but these problems pale by comparison when we talk about CPTSD. This form of trauma usually starts in early childhood and is characterized by harmful and persistent emotional, physical and sexual abuse. Courtois and Ford 2010) have edited one of the definitive text books on the subject. In chapter two Julian Ford describes the differences in brain development of children who have grown up in secure vs. abusive households.
In a secure and loving household children neurologically develop a “learning brain,” while those who have grown up in abusive households develop a “survival brain.”
“The learning brain is engaged in exploration (i.e., the acquisition of new knowledge and neuronal/synaptic (a end point of a brain cell called a neuron) connections… The survival brain seeks to anticipate, prevent, or protect against the damage caused by actual dangers, driven and reinforced by a search to identify threats, and an attempt to mobilize and conserve bodily resources in the service of this vigilance and defensive adjustments to maintain bodily functioning (Ford, Chapter 2 p. 32).
How is Pathological Dissociation a Part of CPTSD?
In order to begin to understand this phenomenon it is useful to first understand the syndrome of CPTSD. It characterized by:
•Affect Dysregulation (not being able to regulate one’s emotions)
•Alterations of Consciousness (The code name for pathological dissociation)
•Somatization (the development of many physical problems that multiple physicians cannot find an organic origin to)
•Loss of Systems of Meaning.
As stated, dissociation is related to the Alterations of Consciousness – While some think that this means only the “absence of,” it could also indicate the “presence of” (as in the “A” criterion of PTSD. Still with me?)
Identifying features of a dissociative disorder may go unrecognized. Why is that? I believe that the problem starts with many clinicians lacking the proper education in being able to identify dissociative phenomenon.
It’s important to realize that dissociation is on a continuum from something we all do, such as daydreaming, and other forms of absorption, to the more pathological disorders of dissociative amnesia, all the way to Dissociative Identity Disorder, or what lay people still call multiple personality disorder (yes, it exists, though there are some in the mental health field who claim that this is a made up problem, concocted by clinician and client. Let’s first look at this continuum.
The Adaptive to Maladaptive Continuum:
Here are some common forms that most of us experience.
•Forms of Forgetting,
Cross Cultural Perspectives need to be taken into account – such as altered states of consciousness; non possession trance, or shamanic rituals, soul journeys, spirit channeling. They all need to be taken into account in order to understand what part of dissociation is part of a culture, such as some primitive rituals in South America, Africa, and other countries, and what is pathological.
Here is where we start to find forms of pathological dissociation:
•Shock/Peritraumatic Dissociation (dissociation at the time of a trauma)
•ASD (or Acute Stress Disorder)/PTSD/CPTSD
•Depersonalization and Derealization
•Dissociative Identity Disorder
The Taxon/Epidemiological Model of Dissociation:
•Dissociation Classified by Symptoms of:
•DDNOS (Dissociative Disorders Not Otherwise Specified)
•DID (Dissociative Identity Disorder)
Elizabeth Howell in her excellent book, The Dissociative Mind, defines pathological dissociation as – “a separation of mental and experiential contents that would normally be connected.” (Howell 2005).
The BASK Model of Dissociation (Braun 1998) breaks down dissociation as a fragmentation of:
- B = Behavior
- A = Affect (or emotions)
- S = Sensations (whether present or absent)
- K = Knowledge
•According to Frank Putnam of NIMH (1997), “there is a failure of integration of ideas, information, affects and experience.”
All definitions bring a wealth of information to the table.
In the most general form, pathological dissociation has also been characterized as:
•Psychologically defensive, or organismic and automatic response to imminent danger (remember the survival brain I quoted Ford on earlier in this article?)
•The concept can be used as a verb when describing dissociative processes, such as when a person looks at themselves while experiencing themselves as not in their body.
It can be used as a noun, as in Dissociative Amnesia when someone cannot remember considerable blocks of time, while NOT under the influence of mind altering drugs or alcohol. I’ve had clients who tell me that they can not remember anything before the age of 12 (and they are only 32).
One of the problems with the concept is that there are so many definitions and disputes that the concept is in danger of losing its meaning.
•van der Kolk and Fisler (1996) describe PTSD (a type of dissociative experience), as involving “a unique combination of learned conditioning, problems modulating arousal, and shattered meaning propositions (as in a case where a priest sexually abuses an alter boy; there is often a loss of a religious system of meaning).
•Shalev (1995) proposed that this complexity is best understood as the co-occurence of several interlocking pathogenic processes:
•- an alteration of neurobiological processes involving stimulus discrimination.
• -the acquisition of a conditioned fear response to trauma related stimuli.
• altered schemata and social apprehension.
People who suffer from dissociative disorders are in a terrible bind.
•Because the roots of their relational traumas lie deep within their early childhood experiences, they often manifest strong dependency needs combined with a deep distrust of other people.
The way they perceive others is categorically different from other people.
Let me give you an easy example:
•When you see friends at a conference whom you haven’t seen for a year, often you will give them a hug. You or they won’t ask for one; you just “know” that it is fine.
•This example is part of what Lyons-Ruth (1998) calls “Implied Relational Knowing.” (IRK)
•Now take a patient from your population who has complex PTSD starting in infancy or early childhood.
•What is their “IRK”?
•”"People will hurt me; even the ones who seem to be nice at the beginning” (think of grooming behaviors of pedophiles).
•These patients will have a hard time trusting, and it will take a while to develop a therapeutic alliance. They will test their therapist to prove over and over again that he/she is worthy of their trust, and will actively search for signs that they are being fooled again.
•Many times these poor souls will be caught between their dependency needs, and their fear of harm.
van der Hart et. al have written beautifully about this dilemma in their text, The Haunted Self, (2006) in their chapter “Overcoming the Phobia of Attachment and Attachment Loss to the Therapist;” and Kathy Steele et. al(2001,) “Dependency in the treatment of complex ptsd and dissociative disorders,
•Davies and Frawley (1994) when the write about the idealized omnipotent rescuer and the entitled child.
•This dilemma was noted by Pierre Janet, a contemporary of Sigmund Freud’s.
•He was clear that there was a special need for the patient to feel safe with the therapist.
•He considered this alliance indispensible for any therapy to succeed with dissociative disordered patients.
•However, he recognized that forming this bond was fraught with difficulty.
•He observed that the patient was prone to idealization of the therapist.
•This idealization if not carefully managed could develop into an intense “somnambulistic passion.” (van der Hart, Brown, and van der Kolk 1989).
•While he called this idealization “rapport” we would call it transference today.
•Both Freud and Janet considered transference both a necessity and a resistance for a cure
•While Freud was better known for the concept of transference and repression, it was actually Janet who originated this idea.
Here are some other facts:
•There is a higher prevalence of undiagnosed dissociative disorders in clinical populations.
•There is a high cost to the patient, therapist and society for not adequately finishing the first phase of Janet’s phase oriented approach (which has also been known as the Consensual Model of Trauma Treatment).
•The first phase is stabilization, symptom oriented treatment and preparation for trauma work.
•If a therapist moved too quickly into the second phase which Janet called the liquidation of traumatic memories, too many negative outcomes could result.
•During the first phase it is necessary to stablize affect dysregulation. (A point made by Dr. Alan Schore 1994, 2003a, 2003b).
Treatment of dissociative disorders:
•It is crucial to be able to tell when a patient was not ready to even talk in depth about their traumatic histories
•To try to encourage this, as a means of shortening treatment, is a way of ensuring re-traumatization.
•When a patient seems to be having trouble telling a coherent narrative, the therapist needs to let the patient know that they can take as much time as needed, and that the therapist would be happy to teach stabilization and symptom relief strategies to the patient first.
•There are many signs and symptoms that the therapist needs to be aware of even before administering the Dissociative Experience Scale (DES).
•A history of years of unsuccessful therapy (Kluft 1985; Putnam et. al. 1986).
•The client comes to treatment with a number of varying diagnoses; none which have been successfully treated.
•The patient may have a history many in patient hospitalizations with multiple diagnoses over the years.
•The client reports intrusive thoughts, flashbacks, and nightmares.
•They may evidence periods of “spacing out” and forgetting what they were saying during an evaluation.
•The patient may report not feeling like themselves (perhaps they see themselves as bigger or smaller).
•They may report that surroundings that are known to them look somehow “different.” or;
•They may report looking in the mirror and not recognizing themselves. (de-realization)
•They may report having experiences of floating alongside their bodies (depersonalization).
•They may report that their daily environment seems dreamlike as if they were walking in a fog.
•They may report have memory lapses, i.e not recalling how they got to the shopping mall.
•Finding items at home that seem unfamiliar to them; not being able to remember ever buying them.
•In tertiary dissociation (DID) the client may report hearing strange voices coming frominside their heads.
•Experiencing “made feelings” i.e. feelings that come out of the blue, without having a logical way of explaining them.
•Having “made” thoughts and behaviors that they cannot identify as their own.
•Ross et. al. reports that DID patients have more first rank Schneiderian symptoms than schizophrenics.
•The DID patient, in contrast to the schizophrenic will usually demonstrate a full range of affect, whereas the schizophrenic patient will suffer from a blunted affect.
•Putnam (1989) reports that DID patients will evidence a preponderance of somatic symptoms, and will report:
•Intractable headaches not relieved by over the counter analgesics.
•Physical complaints that cannot be accounted for by competent physical examinations and tests. (These may be “somatic memories”)
•Sleep disturbances (Lowenstein 1991) are common with nightmares and sleep walking reported.
•Many DID patients may present with what they believe to be depression.
•Frequently there is a history of suicide ideation, or suicide attempts.
•These vast array of symptoms which must be asked about during an evaluation make it imperative to complete a DES on all patients where any of these symptoms are suspected.
If many of these symptoms appear familiar to you, it is best to call a therapist trained in diagnosing and treating pathological dissociation. An organization that supports the evolution of research and clinical practice of dissociative disorders is the International Society for the Study of Trauma and Dissociation (or ISSTD).
What you can do before and during the treatment of dissociation. I am indebted to a fine psychotherapist, Dr. Patti Levin for the following suggestions:
HELPFUL COPING STRATEGIES: If a person comes in for an evaluation and they do not have basic coping skills, here are a partial list of things they need to do before the reprocessing phases:
- mobilize support system — reach out and connect with others, especially those who may have shared the stressful event
- talk about the traumatic experience
- hard exercise like jogging, aerobics, bicycling, walking
- relaxation exercise like yoga, stretching, massage
- prayer and/or meditation
- hot baths
- music and art
- maintain balanced diet and sleep cycle as much as possible
- avoid overusing stimulants like caffeine, sugar, nicotine
- committment to something personally meaningful and important every day
- hug those you love: hugging releases endogenous opioids, the body’s natural pain-killer — now you know why it can feel so good!
- eat warm turkey, boiled onions, baked potatoes, cream-based soups — these warm foods are tryptophane activators which help you feel tired but good (like after Thanksgiving dinner)
- pro-active response toward personal/community safety: organize or do something socially active
- write about your experience — in detail, just for yourself or to share with others
People are usually surprised that reactions to trauma last longer than expected. It may take weeks, months, and in some cases, years, to regain equalibrium. Many people will get through this period on their own, with the help and support of family and friends. But too often friends and family push to “get over it” before you’re ready, or encourage feeling sorry for or trying to understand the perpetrator. Remind them that such responses are not helpful for recovery right now. Many people find that individual, group, or family counseling is helpful. Either way, the key word is ATTACHMENT — ask for help, support, understanding, and opportunities to talk.
The Chinese character for crisis is a combination of two words — danger and opportunity. Hardly anyone would choose to be traumatized as a vehicle for growth. Yet our experience shows that people are incredibly resilient, and the worst traumas and crises can become enabling, empowering transformations.
While these are excellent suggestions, I strongly urge anyone who believes that they may be suffering from a dissociative disorder to contact a competent trauma therapist trained in treating these conditions.
Braun, Bennett G.,”The BASK Model of Dissociation”, Dissociation Vol I, No. 1, March 1988.
Courtois, C., and Ford, J., eds. (2010) Treating complex traumatic stress disorders: An evidence based guide. NY: Guilford
Davies, J., and Frawley, (1994) Treatment of survivors of childhood sexual abuse NY Guilford
Diagnostic and Statistical Manual of Mental Disorders (DSM – IV- TR) Fourth Edition (2000) Arlington VA: American Psychiatric Association
Howell, E., (2005) The dissociative mind, NJ The Analytic Press
Foa, E., Keane, T. M., Friedman, M., J., Cohen, J., A., (2009) Effective treatments for ptsd: Practice guidelines from the International Society for Traumatic Stress Studies. NY: Guilford
Kluft, R. (1985) Childhood antecedents of multiple personality. Arlington VA:
American Psychiatric Association.
Levin, P., (2000) Helpful Strategies for Patients With PTSD and Dissociation. Boston, (self published)
Lyons-Ruth, K., (1998) “Implicit relational knowing: Its role in development and psychoanalytic treatment” Infant Mental Heath J. V 19(3) 282-289
Putnam, F. W. (1997).Dissociation in Children and Adolescents New York: The Guilford Press.
Putnam, F. W., Guroff J, Silberman E, et al. (1986). The clinical phenomenology of MPD: review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293.
Schore, A., (1994) Affect regulation and origin of the self, Lawrence Erlbaum Associates Inc., Hillsdale NJ
Schore, A., (2003) Affect dysregulation and disorders of the self, Norton, NY
Schore, A., (2003) Affect dysregulation and repair of the self. Norton NY
Shapiro F, (2001) Eye movement desensitization and reprocessing, Basic principles, protocols and procedures. New York: Guilford
Steele, K., et. al., (2001) Dependency in the treatment of complex posttraumatic stress disorder and dissociative disorders, J. of Trauma and Dissociation, 2 (4), pgs 79-166
van der Hart, Brown, P. & Van der Kolk, B.A. (1989). Pierre Janet’s treatment of
posttraumatic stress. Journal of Traumatic Stress, 2(4), 379-396
van der Hart, O., Steele, K., Ninjenhuis, E., (2006) The haunted self. NY Guilford
van der Kolk, B., and Fisler, R., Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study. Journal of Traumatic Stress, 1995, 8(4), 505-525
This case history gives the essence of the EMDR reprocessing (which is what EMDR is best known for. It is not intended as a teaching tool, or a way to have yourself try to practice EMDR without going through the Basic Training in EMDR Psychotherapy. It is intended to give the reader who may be somewhat familiar with EMDR a sense of the power of this form of psychotherapeutic treatment.
Before this case history, Greg and I had a number of History Taking Sessions (Phase One) and Preparation Sessions (Phases 2).
The following is a shortened version of Greg’s history, and part of a treatment session where Greg is able to make a significant change in his life.
How EMDR Can Help Mend a Broken Heart Presenting Problem: Generalized Anxiety Disorder
Greg is a 30 year old, single, Jewish social worker who lives in an apartment in a suburb of New York City. He presents with an anxiety disorder. He had two romantic break ups and believes that he is a failure at love and that he can never please a woman. He also doubts that he would be able to find a suitable wife. He reported a good relationship with his father; but no relationship with his mother. His parents have been divorced for several years. He has an older sister who he rarely speaks to. He has a strong social support network, consisting mostly of his male friends he played sports with, and male and female colleagues.
He informed me during history taking that there were a few childhood “issues” that might be related to his present day anxiety. Present day Target Scene: His fiancée telling him that she was breaking up with him. NC: I’m unlovable PC: I’m lovable VOC 3 Emotions: Anxiety, panic, sadness, anger SUD 7 Body: Chest pounding, butterflies in his stomach, and loose bowel movements On direct questioning he told me of the first time he felt this anxiety: He was 11 and playing shortstop on his little league team. He was the star of the team and “the apple of his father’s eye.” His father was the coach. His mother never came to the games. His friend Billy, who played third base, told him that he saw his mother with Greg’s father getting into Billy’s father’s car earlier that day. Billy’s mother was crippled and rarely went out. Greg remembers feeling upset when Billy told him that and he made two errors that day. His father was upset and yelled at him. Picture – My father yelling at me after the game. NC (Initially Greg said “There is something wrong with me” which when I asked him what that say about him he responded, “I’m unlovable”) PC I am lovable VOC 2 Emotions: Sadness, guilt, anxiety Body: Rapid heart rate, cramps in his stomach, and daily headaches that his doctor could not find a cause for. .
Processing on the “Touchstone Memory” Greg: I hated that he yelled at me Go with that: Greg: At least I had one parent I thought loved me: Go with that: Greg: My parents never did anything together, and I always thought if I could please my mother maybe she’d love me and my dad. Go with that: Greg: Wait a minute, I just thought of something I haven’t thought about in many years. My mother was very musical, and she made me play the clarinet. I hated it, but I did it for her. When I was 8 she came to my class music recital. I was very excited. When it was over I walked up to her and I thought she would say something nice, but she told me that she heard me playing many wrong notes. Holy s—- I was just 8 years old. I wasn’t Beethoven. There was no pleasing her. I’m pissed. Go with that: Greg: Now that I think about it, I’ve been dating women who are always critical or disappointed in me. Marsha (his ex-fiancee) told me that I’ll never make enough money for her to live the life she wants to. F— that. I’m good at what I do. It’s like when I was playing shortstop. I was really good; and I liked doing it.
Insights: He always dated women who would put him down. He was trying to please them in an attempt to get his mother’s love. He would do things they wanted because that was what he thought would make them love him, even if he didn’t like what he was doing (like going to her friends’ barbeques where all the other husbands made a lot more money than he did, and played golf at a private golf club every weekend; Greg didn’t like golf; wasn’t good at it; didn’t have the money for it, but tried to join this club and play with these guys he didn’t like because Marsha wanted him to.) His mother never thought that his father was good enough for her, and she had an extra marital affair. This was his mother’s problem. She was an unhappy woman because Greg’s father was a teacher and didn’t make a lot of money either. “I like what I do and don’t need to make a fortune of money, but I needs to date different women.
Greg started to date a nursery school teacher shortly after this session. They dated for nine months; got engaged and married. They’ve been happily married for 6 years now, and they have a 4 year old son. Greg sends me a Christmas card with the family picture every year, along with a short note thanking me for helping him find love.
This phase begins at the following session after any active trauma reprocessing. The clinician looks over the clients journal, noting any progress, and then both the client and clinician work together to process the next memory that is decided upon.
A crucial part of the reevaluation phase is to determine what progress the client is making from session to session. They may not be aware at first, but may tell you conversationally that something just doesn’t bother them as much. Also look for nightmares and perhaps other kinds of challenging experiences the person had during the week because that may indicate more dysfunctional memories coming up for the client implicitly.
Thank you for reading my blog series, I hope you’ve found this information helpful and interesting. If you are a licensed mental health professional, please look into taking my EMDR Training coming up this fall. More information is on this website, and I hope to see you there. Take care!
The phase occurs with much time to spare at the end of the therapy session, whether active trauma processing is complete or not. The client is then instructed in journaling and other exercises that will hep enhance the progress made in the session. The client should also be made aware of the clinician’s availability if he or she needs extra assistance in between sessions.
During the closure phase it’s crucial to spend 15 minutes to debrief the person from their experience. When the experience is incomplete, I find it help full to ask four questions:
- What was the most important part of the experience?
- What has been the most challenging part of the experience?
- What one lesson did you learn?
- What one action (or thought) are you willing to take to honor this experience?
The last phase of EMDR is coming up next, so please come back to read it.
This phase functions as another checkpoint to assess the completion of trauma processing with all its associational channels. With their target memory in mind, the client is instructed by the clinician to scan their bodies from head to toe to self assess for any residual trauma or associational links. When a sensation is notes, the client is to open his or her eyes and process that sensation. It is possible that old trauma links can be experienced on a sensory motor level. This informs the clinician that further trauma processing is necessary for the client. It is also possible that pleasant sensations will arise. In this case, sets of EM’s can enhance the “installed” lessons.
What I have seen during the body scan is that even tiny somatic activations can be evidence of traumatic experiences that have not been reprocessed. Also, sometimes when the activation is positive it may mean that more adaptive information processing is going on, and we need to support that.
Once the trauma is desensitized to a zero by the previous phase, the PC and VOC are assessed again. Unless the clinician assesses that there is more trauma present, the clinician installs the positive cognition until it reaches a seven at least twice. (On a side note, the term installation is a bit jarring; Instead I have come to call it “Linking to the Adaptive Perspective”).
In my experience during the installation phase, there is a really good check and balance that happens. If the target memory and the positive belief do not seem to be fully installed, it may be evidence of additional traumatic material that may have not been reprocessed.
Phase 4: Desensitization
This is the phase of active trauma processing for the events and associations with the events. It is the clients brain the does the healing through bilateral stimulation and dual attention. It is the clinicians job to “stay out of the way” as long as “the train is moving down the tracks”. Only when productive processing stops, an active intervention by the clinician is necessary. Dr. Shapiro named The Cognitive interweave, and it’s function is to link more adaptive neural networks to the dysfunctional networks which block the processing. This allows the clinician to reactivate the clients information processing abilities to continue to resolve the painful memory networks.
I’m always amazed at the variety of associations and responses that I see in clients during bilateral stimulation. Sometimes profound effects occur without much release of emotion whereas sometimes a person may release much emotion but may not change in their daily life. It is important to use my best clinical judgement in order to determine how to adjust this phase to each particular person.
Glad to have you continue on to read about the next phase!
Phase 3: Assessment
This phase is the beginning of active trauma work. The client and clinician carefully choose a memory to work on, and this target must be focused on clearly. As the picture and negative cognition of the memory are described, a trauma activation sequence begins. There are many accounts of client activation into “State Dependent Memory” which means that the learning that took place in that memory or “state” is better remember when the client is in a similar situation or “state”. This can occur during the first parts of this phase, proceeded by PC and VOC, followed by the triggered emotions, their intensity, and body location.
When a person is able to think of an image or a negative belief, the feelings and sensations that they start to have in association with their trauma are being activated. This is necessary so that we can desensitize the trauma. The client needs to pay attention to these sensations throughout this phase. Also, use a positive cognition during the procedural steps because thats the installation of hope.
Phase 4 coming soon, so remember to check back. Thank you!
Thanks for coming back for phase 2!
Phase 2: Preparation
The function of this phase is to test for Affect Tolerance, Body Awareness, as well as test out coping strategies such as the Safe Place exercise. The Safe Place exercise is an 8 phase process to ensure that a person in capable of shifting into a more comfortable state when they’re slightly upset. In testing all of these different aspects, the clinician tries to gauge the person’s ability to self soothe. It is also during this stage that the degree of dissociation of the client is assessed.
It is also possible that there will be a person whose level of function may require a bit more evaluation to prepare for the trauma processing that will begin in the next few phases. On the other hand, findings show that people with Complex PTSD may benefit from not having any extra preparation.
Another important part of this phase is to explain the future phases to the client, to make sure that they understand what to expect. The responsibilities and functions of all participants involved should be clearly explained. I think that EMDR is a co-participatory method, and clients should be actively aware of this throughout the process.
I had an interesting experience with a client during this preparatory phase 2 with the safe place exercise. I was treating a young woman, and when I installed her safe place with bilateral stimulation within the first 4 phases of the exercise, she started to get tearful. Her safe place, a lake by her summer camp, also held a memory of when her boyfriend broke up with her. We needed to change her safe place so there would be no negative associations.
Please check back soon for another blog about phase 3.
EMDR is a multimodal, multi phasic methodology of treatment specific to the reprocessing of traumatic stress. The idea of EMDR therapy is to awaken and reactivate the brain to heal from the traumatic experience. The aim is to release the stress of the event, allow the person to better function in the world, and to empower the person to live more happily and productively.
EMDR has 8 specific phases, each with it’s own important function.
Phase 1: Client History Taking and Treatment Planning- The function of this phase is to assess:
1 – symptoms of dysfunction as a result of the client’s trauma.
2 – the individual’s ability to function in the world.
3 – the client’s useful and dysfunctional manners to assess their strengthens and weaknesses.
4 – specific aspects of a the client’s life and mind including negative beliefs, goals, ego strengths, gaps in ego strength, physical health, as well his or her gender and cultural identity.
It is necessary to have an account of all of these things in order to make a thorough evaluation of the person’s unique issues. The Trauma Case Conceptualization Questionnaire allows the clinician to have a much wider and clearer picture of the person being treated.
A challenge that sometimes comes along with this phase is when I have a new client who can’t articulate their narrative coherently. This alerts me that they may have a sense of disorganization and that I may need to teach them coping strategies and self soothing strategies first, even though they’re tested for in the second phase.
The first phase is just one of 8 steps in the EMDR therapeutic process, so please check back for the following phases in future blogs.
As stated in the first blog in this series, PTSD is not the only type of disorder that can result from an extremely traumatic occurrence in a person’s life. Acute Stress Disorder is another. Essential features of this disorder are anxiety and dissociation.
With symptoms identical to PTSD, Acute Stress Disorder is very similar to PTSD. The defining factor is that with ASD, symptoms usually resolve within 4 weeks. (Have you ever been really upset for an entire week, and maybe thought you were depressed, but you started to feel like yourself again soon after? This is a relatable example that also illustrates the difference between PTSD and ASD). After those 4 weeks, the diagnosis may change to PTSD, or these symptoms may continue on in a sub-acute phase. This implies that symptoms are still present at times, but are not present enough to be considered a full-blown psychiatric syndrome.
The sub-acute phase may contain symptoms of:
- intrusive thoughts
- hyper arousal
These symptoms can last anywhere from a few days after the traumatic experience, to a lifetime.
When a trauma occurs in a person’s life that he or she is unable to process, the ability to cope radically diminishes. When the pain of that experience can not be tolerated, dysfunctional thinking patterns may emerge, which can potentially turn into dysfunctional behaviors, such as overeating. This is why EMDR therapy, and it’s 8 stages which will be discussed next in this blog series, is a great tool to help people who have experienced an awful event.
In this blog series, I am going to go into great detail about EMDR in terms of what it is, who could benefit from it, and the different stages of therapeutic process. In this first blog, I’d like to write about trauma. EMDR can greatly benefit traumatized patients and awaken memories that will allow them to move past those awful experiences, ensuring them a happier life.
Trauma is any event or occurrence that the brain cannot metabolize, preventing people from being able to learn from their experience. Instead, they continue to have negative feelings, and poor beliefs about themselves. Reminders of that event will cause additional pain not including the initial pain that the event caused, making them feel worse. This can often lead to depression, anxiety or substance abuse.
There are many different types of trauma that can exist in numerous forms. Do you think you’ve ever experienced a traumatic event? Trauma is not limited to a formal diagnosis of PTSD, and not everyone who experiences an abnormally awful event will develop PTSD, but perhaps the definition of post-traumatic stress disorder (PTSD) could be helpful. PTSD is the result of exposure to an situation that may involve direct personal experience, or witnessing an event that is not within the realm of expectable daily experience. This can range from physical, sexual and emotional abuse to experiences of war, terrorism, or natural disaster. No matter the experience that triggered it, PTSD is a formal diagnosis including symptoms of:
- Intrusive thoughts such as nightmares and flashbacks
- Avoidance behavior such as psychological amnesia and not wanting to think about accident or participate in previously pleasurable activities
- Hyperarousal such as difficulty falling asleep, irritability, and problems with concentration.
Another condition that people may develop after a traumatic exposure is Acute Stress Disorder. Please read my next blog which will go into much more detail about this other trauma disorder.
THE CLINICIAN SELF AWARENESS QUESTIONNAIRE IN EMDR v.5
Mark Dworkin CSW, LCSW
EMDR Institute Facilitator
EMDRIA Approved Consultant and Instructor
Private Practice , East Meadow NY
Purpose: To assist in raising awareness of what may be triggering you; to assess what may be coming from you and what may be coming from the client; to develop EMDR Relational Strategies . Sometimes problems may occur in Phase One when a client shares information that evokes negative arousal; or Phase Two when the client has trouble understanding the elements of preparation or “wants to get going” processing trauma prematurely; or Phase 3 when there is a problem structuring the Assessment piece. Sometimes client information may not evoke negative arousal until Phase 4 when the client is actively processing. Often times our triggers are from old memories. These memory(s) may be explicit; at other times implicit (somatosensory). Noticing these moments in yourself may aid you in continuing productive processing.
Instructions – Whenever an EMDR treatment session becomes problematic; consider this self-administered instrument when reflecting on this session.
How many times have you seen this client? _____ Gender M___ F___ Marital Status M D S W
Gender and ages_______________________________________________________
Occupation (of client)______________________
1) Is this the first time you have felt triggered by this client? Y__ N__
2) If “No”, is this the same issue that has triggered you previously with this client? Y__ N__
3) Do you get triggered by the same issue with other clients? Y__ N__
4) Have you ever been traumatized? Y__ N__ Could your old trauma be triggered? Y__ N__
5) Do you believe that you are struggling with Compassion Fatigue/Vicarious Traumatization/Secondary Traumatic Stress Y__ N__
6) Describe the Presenting Problem (or Present Day Referents)
7) What old trauma(s) are related to Question 6?
8) Describe what is triggering you with this client NOW. How are you triggered?
9) Why do you believe that you are being triggered NOW?
10) What makes this client unusually challenging for you NOW?
11) – What is it about this client’s “style of struggle” with their problem (i.e. externalizing, intellectualizing, substance abusing) that may trigger you NOW. Why NOW? (Describe)
12) – Describe this client’s “presentation style”(avoidant, aggressive, straightforward, shameful, guilt ridden, etc.)
13) What triggers you about their “style of struggle”, and their “presentation style”?
14) When you think of the problem you are experiencing with this client what picture comes to your mind NOW?
15) When you see this picture in your mind, what negative cognition do you get about yourself NOW?
16) When you link the picture with the negative cognition what unpleasant sensations do you experience right NOW? Where in your body do you experience these sensations?
17) When you picture the client in your mind’s eye, who does this client remind you of? (Check as many as fit)
a) Mom __
b) Dad __
c) Sibling __ (Which)________________
f) Relative____ (Which)_______________________
What old memories emerge? (Hint- Use Floatback Technique)
18) What negative cognitions go along with these old memories? When you link the picture of the most disturbing part of the memory with this negative cognition what feelings and sensations arise in you RIGHT NOW? Where do you feel these sensations in your body?
Feelings and Sensations________________________________
19) Does your client notice your getting triggered? Y__ N__; if yes, how?
20) What does your client do with their reactions to your reactions? (To do this, reconstruct a piece of process that became problematic between the two of you).
21) After examining this piece of process how would you NOW reconceptualize this treatment problem?
22) What relational strategy(s) can you develop NOW to overcome this problem?
(When this questionnaire is part of a workshop or study group you may have the option of processing this issue to possible closure, including debriefing. Consider using Zangwill’s Floatback Technique when stuck in the present without old memories available).
Present Day Referent (in the treatment moment):_____________________________________________
23) Based on your experiential work, how do you NOW reconceptualize this problem. How does this answer differ from question #21?
24) What relational strategy might you consider NOW to help work this problem out?