Case Presentation: "Swimming/Fish
Phobia"
A single session case using an abbreviated EMDR protocol
John Campbell-Beattie
May 2002
I have been using a short EMDR session along the same protocol lines as Parnell
(1999), being less pedantic about the ordered protocol set-up.
While the patient tells me about self and their issues, I consider the necessary
approach. In this case the value of EMDR, and a focus on what is needed
for it to work best. Working within a 40 minute time limit window some direct
questioning is usually necessary to focus the patient’s attention.
1. I exclude the positive cognition and VOC until it is needed later.
2. I may occasionally exclude the Negative cognition, particularly if it is difficult
to formulate, or exclude the SUD rating, but this is rare.
3. I focus on the presenting issue, encouraging the patient to formulate an image,
(identifying the worst aspect if they can), obtain a SUD rating, and locate a
body sensation. I consider the image and body sensation to be the two key
and minimal elements necessary for effective processing.
I have had some remarkable and rapid results but this one stopped me in
my tracks.
Presenting issue: Fear of swimming in the sea
out of own depth.
Early one evening, I had just finished a telephone call with a patient canceling
a session due to unforeseen circumstances when Justine, a 32 year old office worker
called me for assistance with “my phobia of not being able to swim in the
sea out of my depth.” She was emigrating in three week’s time
and water activities would feature largely in her new life. I agreed to
see her to assess her needs and, if necessary, refer her to a colleague as I was
fully booked for the remaining weeks.
Justine's medical history was unremarkable. She had recently undergone an
operation for the removal of some excessive skin on her legs and wore spectacles
for reading, a fit and otherwise active and somewhat fearless woman.
History and Identification of Targets
When 11 years old she had participated in an underwater dive to a wreck.
The conditions were rather rough and as she descended, she saw the wreck ahead
of her a hole in the side of the hull, and she began to imagine the images she
had seen in a recently viewed Jaws film. She was convinced that something
horrible would emerge from the hole in the hulk and she headed for the surface.
She continued to see a face emerging from the hole as she headed toward the
surface. Her head was full of thoughts, her heart “sank to my boots,
I had to get up and away.” “I remember thinking the fish are
going to get my feet.” The incident made her think about herself
as “I’m pathetic,” her heart was racing and SUD was 10; this
became target 2 (T2). We agreed a stop signal if the incident became too
fearful.
I established that another incident also featured in her fear, the worst aspect
of which was “fish swimming around my feet”, “I’m pathetic”,
and the heart beating remained relevant. SUD level was also 10 and this became
Target 1 (T1) at her request. Following explanations of EMDR and the treatment,
she had agreed to find out what EMDR was like. I used a Neurotek Eyescan
2000 set at speed 29 and a constant flow of lights without sound. After
two sets of saccadic movements numbering 26 and 20 respectively on T1, there
was no response. I asked her to return her focus to the diving incident
(T2) and asked, “what was the worst aspect for you?”. She responded,
“Coming back up”, and that she “was out of control”.
Again she felt her heart racing.
Eye Sets
After 20 saccades she reported, “I’m still not in control.”
After the next set (21) she found herself in the Lake District (a part of the
UK).
Justine: “Ulswater, with fish around my feet” (Justine had now jumped
to T1).
(20) “Eight years old swimming in Ulswater – can’t get out of the
water fast enough”.
(20) “fear panic all over I want to get out of the water, the fish are going
to bite my feet and legs.”
(21) “walking out of the water – relief. I’m never going
to go back in there again.”
(23) “I lost the image and reclaimed it.”
(20) “My brother is taking the ‘Micky’ (making fun of me).
At this point Justine stared blankly ahead. She was playing her own mental
video and I activated the Eyescan, supportively saying, “just follow the
light.” (22) She reported no change, just her brother teasing her.
FloatBack and Interweave
Clearly, the initial processing had uncovered something that might be the
trigger or the causal incident. I decided to use the floatback technique
to establish if there were any other emerging targets. Justine simply reported
being eight years old and not in control. She was responding well and I decided
on an interweave.
C-B: “Given the reported image of this eight year old, how can you help her
overcome the problem?” (26)
Justine: “I don’t know?” Nothing else was reported.
C-B: “Given you as you are now an adult, how could you teach the 8 year old
you, for everything to be O.K.?”
Justine: “feed the fish by hand.”
C-B: “Just do it.” (27)
Justine (in a young girl’s voice): “The fish are feeding and tickling
my hand (34). This was repeated (29), SUD level now between 1 and 2. - Saccades
repeated with the feeding image (21)
C-B: “Can you help any more?”
Justine: “Put my feet in the water” (26).
(laughing) – "it’s tickling, it’s O.K. (22) We’re (her
adult and child me) holding hands and walking into the water" (26).
(changed to more adult voice) “I’m swimming with me (smiling)”
(31) Swimming and laughing with me” (24) “I’m not coming out,...
I’m happy" (30)
I returned to the initial target and Justine reported “Nothing” disturbing.
There was a tear in her eye (27), “I’m me as I am now, back in the water
playing and swimming.” (26) “I’m walking out of the water
quite happy" (24).
SUD level 0. Body scan revealed nothing at all.
I asked Justine to return to T2. SUD level was reported at 3.
C-B: “What makes it 3?”
Justine: “The murkiness, unable to see properly”
C-B: “Go with that” (23)
Justine was staring ahead blankly again playing her own mental video about “Other
dives, ...I’m O.K.” (29); “I’m enjoying seeing the wreck”
(27); “I’m on the boat going back in again” (31); SUD
check 0 and “I can’t wait to go down there”.
C-B: “Just do it” (27)
Justine: “It’s O.K. I’m happy”
C-B: “through to the end?” (37). I noted her toes and feet had
come from being perched as if standing on her toes in a state of tension to flat
and relaxed.
Justine: “I’m back on the boat, I’m O.K. and quite happy.”
SUD 0, with nothing revealed on the body check.
C-B: “What would you like to believe about yourself ?”
Justine: “I’m confident – I can handle this.” VOC 6.
C-B: “What prevents it being a seven?”
Justine: “Actually doing it.” (21)
C-B: “Fine, it’s O.K.” Positive cognition installed (25).
Further Postive Installation
I then invited Justine to play a mental video of any scenario she could imagine
with her positive cognition (50): “It’s O.K. I’m not frightened.”
There was an incident when she was competing in gymnastics when she won a gold
medal with a “great vault” and her feelings were fabulously confident
and exhilarating – this we used as an anchor resource should she need it
when entering the sea for the first time. Her plan was to go swimming the
following day.
Follow up
Three days later, Justine reported that she had been swimming on three separate
occasions, had thoroughly enjoyed herself, and there was no repetition of her
dysfunctional feelings or behaviour. We shall almost certainly never meet
again – and there is no current need to do so. (810 sacades 31 sets
av 26. Total therapy session 1.5 hours.).
References
Parnell, Laura (1997). Transforming Trauma: EMDR.
New York: Norton.
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