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Abbreviated Protocols: The Case of
Mary
December 2004 Chief Editor’s Note: Thanks again
to John Campbell-Beattie for another interesting case example, this time illustrating
the application of an abbreviated EMDR protocol. - SEB
I had been working with Parnell’s (1999) shortened protocols in a primary
health care setting where time and the number of sessions were limited. Although
the challenges are steep, they are surmountable when incorporating flexibility
to the standard protocol.According to Parnell, the visual image and the body sensation are the two key and minimal elements necessary for effective processing, once a collaborative and careful assessment has been accomplished. Successful processing can be achieved when the following aspects of the protocol are highlighted:
Mary, in her mid to late 30’s, was referred with symptoms of depression and an inability to cope with the rigours of life. She said that the worst aspect of her condition was that she felt out of control. “In what way”, I enquired, but she was non-specific - ‘just not in control’. She reported no body symptoms, but there was an image that she did not wish to disclose. This was the source of her misery. The image disturbance was “medium”, reported at 7 on the 1 – 10 SUDS scale. I asked, “What do you want to do with this image?”, and she replied, “get rid of it.” I explained the EMDR process and that the matter, at first, should not be a large trauma, as she might feel worse for a short period or other unexpected images or material might emerge. She agreed to continue. The abbreviated session
I commenced with about 30 saccades (her eyes tracking my finger) and the response
was that she felt “worse”. A further 25 and she felt “better”.
After another 30 she reported only being able to see a face, and SUDS of 3. A
further set of 26, and the image was “fuzzy”. After 31 saccades she
reported, “that’s strange – it’s all gone - strange.”
Next, a set of 26 resulted in a SUD of 0, and a reinforcing set of 25 was completed
at the conclusion of which Mary reported being “scared”. I commenced
a vertical set of 23 with the intention of calming her as I realised that time
had expired and I had other patients to see. At this point she disclosed being
raped 17 years previously.Now at the end of the session, exploring this trauma further was impossible. I took the SUD rating at 9, introduced the safe place procedure (essential!), and was able to make arrangements to see Mary again within the next 2 hours. The session had worked to provide an atmosphere of safety and confidence, within which the primary trauma could be dealt with later on. When Mary returned that day, what unfolded what was a horrific sequence of events. When in her mid teens, she had been raped and strangled, putting her life at serious risk. To compound matters, an almost identical attack occurred the following day. There was more to surface. Following the attacks by these two strangers she had concerns about venereal infection and HIV, and she was terrified of the potential consequences. She had no close support and a few weeks later discovered that she was pregnant - it could only have been one of the two offenders. Young, vulnerable and inexperienced in the ways of the world, she wrestled with the trauma, the stigma of rape, the possibility of contracting a fatal disease and her enforced pregnancy without the benefit of any wise counsel. She terminated the pregnancy clinically but went through that process suffering indignity and humiliation, and not having disclosed the origin of the pregnancy. Fortunately, subsequent processing cleared all matters. Mary’s story is heart rending, emphasizing that the therapist should always be vigilant to the ‘iceberg syndrome’. When a relatively minor issue is presented, it is wise to be prepared for the unexpected. This was the matter in Mary’s case, and the immediate follow-up was essential. If early follow-up is not possible, then optional support must be instigated, including telephone contact with the therapist and other emergency contact information. At the time I felt badly about closing an incomplete session, but on rare occasions this happens and the immediacy of follow-up I believe to fundamental to therapist/patient integrity and welfare. Using shortened protocols in a time-limited situation ultimately leads to inevitable worry on the therapist’s part – “Was this an appropriate session - did I get it right?” I have concluded that a therapist should use whatever tools are considered appropriate to resolving the client’s problem, while also taking into account the context of the sessions (e.g., time-limited) and the observed vulnerabilities and strengths of the patient. I carefully specify the treatment proposal and obtain informed client consent to proceed, keeping in mind that the treatment approach is the medium to achieve the end result. The therapist should be competent in the therapy used and not proceed where ones level of experience or training is outmatched. Clearly, some presenting issues are inappropriate for treatment in a time limited focused setting and these are deferred for full applications. Nevertheless, I have found the Parnell protocols to be most suitable to these shorter sessions. Background
John Campbell-Beattie is a European accredited EMDR consultant & practitioner,
and psychotherapist practicing in Plymouth, England. He can be contacted at: campbellbeattie@supanet.com References
Parnell, L. (1999). EMDR in the treatment of adults
abused as children. NY:W.W.Norton & Co.
©2004 The EMDR Practitioner - All Rights Reserved Worldwide
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