Applications of Client Self Administered Bilateral Stimulation in the Treatment of Trauma
Pauline Fullam B.Sc. M.A. P.G.D.C. (EMDR Level I and II)
October 2003
Abtract: This article looks at some of the situations where client self-administered bi-lateral stimulation has facilitated EMDR by increasing the client’s sense of control during therapy.

Three conditions where this may be appropriate are discussed and partial presentations of two cases, Allen and Anna, in which the general approach has been used, are given. The second case, relating to client belief in childhood sexual abuse has, in addition to the above, some relevance to the debate relating to false memory syndrome.
For some time now I have, in a small number of cases, been unhappy with the minimal degree of control that some client’s may experience in the standard operating format of EMDR in relation to the effects of bi-lateral stimulation.

There are generally three conditions where this is so:
  1. Where the facts indicate that a client is relatively stabilised at the point of therapy but where the degree and stability of current coping remains in question against a considerable historical background of relationship difficulties.


  2. Where the extent of the need for client control and autonomy is likely to work against the therapeutic need to let go and “do nothing” beyond “watch the old video”.


  3. Where the extent and nature of the traumatic material to be processed indicates a likelihood of excessive inter-activation between memory networks to the degree that the individual is likely to be assailed by a firework display of brief flashes from different experiences that feels overwhelming. Such a situation would, at the outset of treatment, make focusing on any one area very difficult.
To counter possible difficulties from any of the above, I have, at times, substituted client administered knee taps instead of therapist applied bi-lateral stimulation.

The following partial presentation of two cases gives some examples of this approach in practice and some of the results I have found.
Case I: Allen – a Post-Mortem Trauma
Perhaps my earliest instance of introducing self administered knee taps in therapy was with an experienced policeman in his early forties, self referred through his occupational health unit following the post mortem of a very young baby. This reactivated a dozen or more traumas, all but two, work based. At first presentation there was no evidence of adult dissociation. Dissociation had been extensive in childhood, associated with emotionally absent parents. However, though very “present” in that first session, Allen did reveal that he was drinking more than normal because of a range of trauma symptoms which included flashbacks of the baby’s face held in the pathologist’s hands. He glimpsed the scene unexpectedly through a window after he had left the room following the pathologist’s intention of removing the eyes and placing them on the counter for examination. He described the image of the baby’s face as looking “like a mask”, and the underlying tissue on the head as an “anatomical illustration – horrible!” (SUD level = 10).

My client, who I will call Allen, had been unaware of any difficulty following the post mortem. He was alerted by comments from friend’s and colleagues that he had “been acting strangely, and saying stuff”. He had however been aware of severe sleep disturbance, agitation , irritability and an inability to trust his own judgement. As a result, he had taken the initiative in getting himself signed off work as a precaution against the possibility of losing control. As an additional safety precaution Allen had decided to suspend his much loved hobby of diving until he was “sorted”. He had taken the sport up as a way of countering a childhood experience in which he had nearly drowned. He had, in the same way, and with the assistance of a friend, successfully confronted his fear of snakes. The one phobia he did not know how to eliminate was the thought of anyone doing anything to his eyes. He described the phobia as very strong and stemming from the time when, as a young boy, he fought to prevent his mother daily from administering eye drops to avoid him having to go into hospital for an operation.(SUD level = 0.)

He spoke of how the “tape kept playing” from “hundreds of fatalities” where he had taken statements from families left after the death.

Alan was clearly very aware of his own process and actively engaged in the management of his mood and behaviour as an habitual coping skill developed as a result of the experience of a disturbed childhood with an extra punitive father who was constantly critical. The fear he felt on hearing from others of his own disturbed behaviour spurred him to seek help as he foresaw that the problem in this case was not one he could solve on his own.

By the first working session Allen had had no alcohol for some days following our discussion over the obstruction this would pose to successful therapy. During that session we attempted to begin desensitisation of the experience of the post mortem, which was where Allen chose to begin. This was, in one sense, partially obstructed by his shame and frustration at having to withdraw from the scene. In view of the childhood dissociation, and following a remark by Allen that he had been unable “to let go enough” when he had attempted to rid himself through hypnosis of the need to smoke, I decided to pendulate frequently between the safe place and the negative cognition: “It was like a mask” (SUD = 10) relating to the baby’s face. I was aware that the underlying central negative cognition was something like - “ I’ve failed” or “I can’t cope”, but I used the cognition that the client felt was most appropriate.
Memory reactivation worked rather too well and we had a cascade of brief flashes of snapshots from myriad material whipping through “like a firework display” which left Allen recoiling in his seat, and showing signs of dissociation and later mild confusion. After grounding him, I closed down the attempt at EMDR with a discussion of how we might proceed.

When Allen returned the following week he decided that he wished to shift the first target to an episode where his father, who he had feared, had been abusive. In order to give him maximum control and maintain close reference with safe ground I asked him to tap his own knees during desensitisation using the negative cognition - “ I’m helpless” (SUD = 8/9). In addition, for the first 10 minutes or so of the session, I got Allen to pendulate periodically between the cognition and the safe place. He very quickly settled down, and the material was processed swiftly, reducing the SUD rating to 1 as he processed through to the point where he had finally been able to “stand up to” his father (VOC = 7) - “I dealt with him”.

Over 6 subsequent sessions the main clusters of traumatic incidents were successfully desensitised, where earlier sessions employed self administered knee taps at the beginning of the session, with Allen happy to allow me to come in and take over once we were in process.

The post mortem which had been the trigger to reactivation remained firmly blocked to processing in any form until I encouraged Allen to formulate protective rules for future self management. He worked out that he would leave any proceedings when stress reached a moderate level, and bring a distraction (e.g. a notebook) to make notes or even doodle, as his role did not require him to note details of proceedings. In this way the removal of threat was effected and processing proceeded smoothly.

Finally, we came to the “big one”, that is, “the eyes”. That is certainly how it felt for both of us. This image had already surfaced in different forms throughout our work. Allen was by this time very confident in the technique. Nonetheless, he remained uncertain about whether it would have any deep effect on the memory which still made him shudder - that is, of having eye drops forcibly placed in his eyes over many weeks. In this session, following safe place installation, (we were on our second, having “worn out the first”) I discussed with Allen his level of fear. He was more agitated than I had seen him before, but firm in the conviction that he needed to face his fear as he had always done in the past. In this case he saw it “as a working necessity”. He felt, though, that if this did not work it would possibly reduce his confidence in the effectiveness of the work we had done. His concern was that the memories “might come back”. At this point I got him to “hunt” the memory of the post mortem and the associated negative cognition “I can’t cope”. It held firm, of course. He seemed to relax a little and I was able to go on to discuss the memory of the eye drops in its wider context of his mother’s wish to avoid him having an operation.

We searched a little for a negative cognition but as the “feeling” from the eye drop memory was so strong (SUD = 10) I decided to work with that, following reinstallation of safe place. The sense of where we both wanted to go was strong and in this context it felt inappropriate to remain with the normal method of finding an explicit positive cognition. Instead, I asked Allen to focus solely on the feeling from the memory as if habituating. After 90 seconds or so, I asked him to concentrate on taping both his knees. There followed the usual sequence of monitoring changes and self-administered tapping. There was an almost immediate reduction of distress down to a SUD of 6. This was closely followed by sequences that threw up random associated images; for example, eyelids hooked back in an eye operation, a tube in the corner of an eye and women applying mascara. There were “shivers” and a general indication of aversion. However, distress levels remained moderate but steady at about SUD 5.

On instinct, I took this a stage further, asking Allen to put an internal commentary to the images he was seeing whilst maintaining his own sense of control through intervening self-tapping. This appeared to work well and he opted to externalise the commentary; speaking of “adverts for eyelashes, a photo of an eye”. And later, much more uncomfortably, he became “a person having an eye operation”. Knee tapping and intervening commentary of images reduced the distress swiftly and significantly. This was followed by his wry comment - “ a little knowledge is a dangerous thing. - But I’d be asleep”, remembering an operation early in his career where a pin was inserted in his ankle and he “knew nothing about it”.

The next spontaneous image, a woman killed by a piece of glass through the centre of her eye, brought only minimal response as he remembered it came from a novel. I asked Allen to return to the original scene in the bedroom and his mother’s struggle to insert the eye drops. Allen exclaimed, “two things had sprung out at him”. The first - “Can I let someone touch my eye?”, and the other - “No one allows anyone at their eye! It’s valid! Why am I allowing myself to wind myself up with this?”.

Then “out of the blue” came the sudden memory of an experiment at school to cut up a bull’s eye. The teacher had said that no one had to do it if they did not want to. Allen had forgotten his knife and was afraid the “others” would think he was a coward. This memory generated minimal distress, and was followed closely by the memory of how, on a diving expedition he had taken the initiative of saying that the weather was unsafe for the dive, against the instinct to conform to the group plan. He had felt uncomfortable because he was less experienced than some of the others. However, on the contrary, everyone had been relieved and glad he had taken the lead. That judgement was based, he said, upon his childhood experience of nearly drowning (SUD = 3). This flowed into the final statement at close of session that “fear of eye-poke is natural, protective and instinctive”. At this point the SUD level referenced to the original “feeling” and image of struggle had reduced to 3.

The following week, the SUD level associated with the struggle over the eye drops had increased to 4. Allen was again aware of marginal avoidance, which he saw as a “flaw” in his ability to do his job properly in the event of being called upon to attend an “eye harvest”. In the course of the standard EMDR protocol, with a negative cognition of “I’m helpless ”, and a positive cognition of “I’m all right”, and during cognitive interweave, he suddenly exclaimed: “but it would be interesting. I would be learning!”. The close of session found him “very comfortable” but with the feeling that, given the early nature of the memory, it would need more time to “work through” on his own. The SUD level remained at 1-2 over the closing sessions, and was maintained at that level on an 8 week check up.

Allen returned to work successfully two weeks after close of therapy.
Case II: Anna - A Belief in Childhood Sexual Abuse
A woman in her mid thirties, separated and with two children, presented following the breakdown of an affair. She had been sent home from work after she had begun cutting her head. Anna (not her real name) described how, throughout her childhood, her sister had been favoured over herself. She felt constantly undervalued and unable to have any real and meaningful relationships with her immediate family beyond her grandfather who she loved dearly and who was the only one “to cuddle me”. At the age of 15 she had overdosed and ended up in hospital. Thereafter, she sought relief from distress by cutting herself. This pattern was well established by the time she came to see me for 8 sessions under an EAP scheme.

In the first session Anna mentioned that she had a deep-seated belief for as long as she could remember that she had been sexually abused when very young. She had no actual memories of the abuse and held only a vivid and recurring image of herself, viewed from above, as a four year old, curled up in a fetal position on a bed and feeling very tense. The image, recurring as it did, served to reinforce the belief in the abuse. Her belief in the truth of that memory was of the order of 80%. In this connection she told me the “evidence” for the belief came from a memory of being placed in her uncle’s bed to sleep overnight by her grandmother - being joined later in the night by the uncle who she disliked intensely and had always avoided. She was “sure” that in the course of the night that “something must have happened”. Her wish was “to get rid of the feeling” that came with the image.

It seemed possible, given the very firm self-image as a victim of child sexual abuse that she offered, that here was the key and the template to her later relationship difficulties. Anna wished to know what had happened on that night. At this point I offered some insights into the fluid nature of memory (Bartlett 1932; Belli and Loftus 1995,), and the reasons why recall is often faulty and cannot be taken as proof of fact (Mollon 1996; Johnson et al.1988; Holmes 2001). The implications for her in terms of family were also discussed.

There was evidence of a low level of periodic dissociation in adulthood as a “coping” mechanism following its extensive use in childhood. Initially we did some work on understanding the role that both cutting and dissociation served for her and their effects both on day-to-day control as well as the therapeutic difficulties they presented.

Anna came back a fortnight later, having used the grounding techniques discussed and practised in session. She reported that in spite of a stressful period at home with one of her two children, she was able to remain present and not dissociate. She reported feeling more able to cope with the situation and pleased with herself. In addition, she had reduced her alcohol intake to very minimal levels and had taken no alcohol within 48 hours of our session, as I had requested. She had been very tempted to cut herself at a point of difficulty with her ex-boyfriend but had taken the longer view and resisted.

I was impressed with Anna’s strength of purpose. There were convincing indications that, in spite of ongoing relationship difficulties, she was stabilised enough to attempt some gentle unstructured probing, to see whether we could expose the original template experience, and how it underpinned her recurring difficulties.

I was concerned that if sexual abuse had occurred, reactivation of the associated memory network might cause Anna to feel overwhelmed (Mollon, 1996) leading to destabilisation through altered self schemas (Horowitz ,1988). This concern was balanced by Anna’s determination to “discover” what had occurred on that night paired with a realistic awareness of the distress this might bring.

In the end I went with my instinct. I felt strongly that EMDR could be tried at a relatively minimal level, working solely with the image and encouraging Anna to be in charge of her own bilateral stimulation. This took the form of self administered knee taps. It seemed to me that if she was in charge she would be unlikely to continue if the memory complex became too intense or in anyway beyond control. Giving her charge of the process was also designed to increase her ease with the procedure and enhance her sense of trust with a view to freeing up the system.

In the absence of her ability to find a “safe place”, I did the white light installation, which worked well and swiftly. Anna then brought up the image of her 4-year-old self curled up on the bed. The associated SUD level was 8. The chosen positive cognition was - “I’m indifferent. It just happened.” As with therapist led work, Anna was asked to monitor changes in physical sensation and emotions as she worked, intermittently in sets, tapping her own knees. I regulated the periods of tapping as I would normally do while keeping a close eye on her physical reactions.

I was waiting for signs of abreaction at an early stage that, for safety’s sake, might lead me to stop the intervention. There were none. The session worked swiftly with little verbal feedback. There was much facial contortion and twitching of the upper body. At one point Anna scrunched up slightly but without evident distress. I had a sense of non-verbal struggle but no sense of deep distress. This being so, I let the initial tapping sequence continue for about two and a half minutes before calling a check to see what was happening.

It emerged that rather than “interfering” with her, Anna’s uncle had heard her crying and had tried to wake her. She was distraught and beyond comfort. In his efforts to calm her (“He was probably just trying to shut me up”) he tried to cuddle her. Anna was unused to cuddles as comfort (except from her grandfather), never having been cuddled by her mother, and failed to understand the significance of the action.

This development was clearly a complete surprise to Anna. It cut across her original and long held trauma belief. The remains of the processing centred round the struggle to let the interpretation of the image go. Using cognitive interweave she explored this and the current difficulties she experienced in her parenting of her own children. Her relief was palpable that she “had not been sexually abused”.

Given the enormity of the change in belief she had sustained (SUD = 2, VOC = 7), I wondered briefly if I should caution Anna about possible reactive depression. As I was due to see her only three days later, I felt it better not to get into an explanation of the effects of change in case it obstructed the process we had just initiated.

Three days later, Anna failed to attend session. I immediately feared that I had misjudged the management of that part of the session, and wrote a therapeutic letter explaining the possible effects of sudden change upon mood in this context. Anna replied a week later, ringing me to apologise, but her son had been ill and she had forgotten to cancel. She told me that she had not had any period of feeling down, and that on the contrary she felt enormous and continuing relief that she had not been abused. She said she felt more in control and able to cope in general. We made an appointment to meet again.

When I next saw Anna, the change was remarkable. She no longer looked tired or depressed. She was dressed differently and had a new hairstyle. She said she thought differently about herself, aware of and willing to do more work around her childhood and marriage. However, she still did not like her uncle. In spite of the impulse to cut, which arose in situations of stress, she had not cut over the month since our session. The impulse was less intense, and remained so at the close of our eight sessions.

My feeling is that the self administered knee tapping allowed my client enough personal control to have the confidence to regulate her own process, so allowing us to run the sequence safely. Against the presenting material I feared a very different outcome. The actual outcome, so unexpected, will be a source of delight to me for some time.
Background
Pauline Fullam has a first degree in Psychology from Leicester University (1971), an M.A. by research from Liverpool University (1992) and a Post Graduate Diploma in Counselling from Liverpool John Moores University, where she worked for a year as a staff student counsellor. She moved into private practice, and was quickly drawn into working with a large G.P. unit in Litherland, a deprived area of Liverpool. In 1995 she joined the skills team at J.M.U. and for 5 years was a tutor and sessional lecturer on the Post Graduate Counselling Diploma. At the same time she continued working in Independant Practice and Primary Health Care. Since 2001 the main focus of her work has been Trauma Therapy , predominantly with both Merseyside Police and Lancashire Constabulary. Fascination with the mechanisms asssociated with approach and avoidance / salience and suppression underpin much of her work both practical and theoretical.

References
Belli, R.F., Loftus ,E.F. The pliability of autobiographical memory: Misinformation and the false memory problem. In D. C. Rubin (Ed.), Remembering our past: Studies in autobiographical memory (pp 157-179). Cambridge: University Press.

Bartlett, F. C. (1932). Remembering. Cambridge: University Press.

Holmes , J. (2001). The search for the secure base: Attachment theory and psychotherapy. Brunner-Routledge

Horowitz, M.J. (1988). Introduction to psychodynamics: A new synthesis. London: Routledge.

Johnson,M. K. , Foley, M.A., Suengas, A.G., Ray,C.L. (1988). Phenomenal characteristics of memories for perceived and imagined autobiographical events. Journal of Experimental Psychology, 117, 371 - 376.
©2003 The EMDR Practitioner - All Rights Reserved Worldwide