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SUCCESSFUL EMDR IN CONDITIONS OF PATIENT AVOIDANCE:
TO SEEK OR NOT TO SEEK THE NEGATIVE COGNITION
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 JMU
where she had previously worked as staff/ student counsellor. She has been
an accredited EMDR Practitioner since 2003 and a Chartered Counselling Psychologist
since 2005. She became an EMDR Consultant in 2006.August, 2007 After moving into Private Practice in 1993, Pauline 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 JMU, and for five years was a tutor and sessional lecturer on the Post Graduate Counselling Diploma. At the same time she continued work in Independent Practice and Primary Health Care. Since 2001 the main focus of her work has been Trauma Therapy, much of it with Lancashire Constabulary. She worked for 2 years in a Psychiatric Unit in Liverpool with PD patients who serially self harm and ligature, some very cognitively impoverished, low functioning and psychotic patients, and some PTSD patients who had been misdiagnosed. Pauline specialises in the management of anxiety, OCD, PTSD and ASD. She can be reached at: pauline.fullam@ntlworld.com Introduction The willingness of a victim to re-experience trauma through the use of words and felt emotion, to approach rather than avoid the experience under conditions of safety, is generally associated with the resolution of the trauma (Van der Kolk 2002, Harbour & Pennebaker, 1992). This is usually considered an essential prerequisite for successful therapy. In this paper I would like to consider two associated areas, those of control and the role of semantic processing as they relate to the conduct of brief therapy under adverse conditions in cases where there remain high levels of avoidance. Alexithymia The fear of being overwhelmed by intolerable levels of emotion and inability to cope, contributes to the high drop out rate in many trauma therapies (Ford & Kidd, 1998; Pitman, Altman, Greenwald, Longpre, Machlin, & Poire, 1991; Hopper & Van der Kolk , 2000). Indeed, Van der Kolk (2002) suggests that it may be the very elements and sensations the victim seeks to avoid which may constitute the basis for flashbacks and nightmares which are such salient features of PTSD. Under normal conditions we work to resource the client or patient to the extent that they have some framework of confidence. This allows them to feel able to tolerate emotion in speaking about their experience and in so doing to form narrative – for most, the first substantive step in trauma resolution (Foa, Hembree, Jaycox, & Street, 1999; Resick & Schnicke , 1992). For some people, however, there is no access to words, only sensations and perceptions, with perhaps vague images or images devoid of sensation or meaning. This state, alexithymia, represents an inability to create semantic constructs from the fragmented traumatic experience in order to identify sensations. This is possibly due to the reduced function during traumatic experience of Brocas area, which generates words (Rauch, van der Kolk, Fisler, Alpert, Orr, Savage, Fishman,Jenike, & Pitman, 1996). Hence, such people cannot know what they feel because there is no way to construct a form in which to hold it cognitively. Therefore, they are even less likely to communicate it. However, experience and some of the literature support the view that narrative may not always be strictly necessary for trauma resolution in therapy (van der Kolk, 2002). Indeed, Spector ( 2003) has pointed out that the use of aversive images alone can sometimes be powerful enough to initiate processing as they inherently contain associations generating the greatest emotional arousal. Control, Narrative and the Identification of Negative & Positive Cognitions In a system in which emotion is feared as being overwhelming to the sense of self, the emotional part (EP) may be dissociated or split off from the apparently normal part (ANP) (van der Haart, Nijenhuis, & Steele, 2006). The detailed semantic exploration of the traumatic material required for the construction of negative and positive cognitions in EMDR may threaten that protective separation. Such people are, perhaps, more likely to disengage from therapy as this threat, together with the inability to form their experience into words, adds to their sense of powerlessness and inability to “get it right.” I have found that under conditions of safety, it can be effective to give the client explicit permission to avoid detailed narrative content. This can increase the client’s sense of control over process, and hence reduce the level of threat experienced. By so doing, effective desensitisation may be achieved where there would otherwise be dissociation or disengagement. These conclusions have derived from the experience of working in occupational health offering brief therapy, and in a hospital setting where, due to brevity of patient availability, depth of resourcing prior to treatment is sometimes limited. Over the years I have frequently found that rape victims and those with CSA may take the first step in approaching their experience by coming to therapy. In these cases, however, engagement is fragile and they are very easily frightened off by even the most circuitous explanation of the reasons why they feel as they do – in terms of mechanisms of memory in trauma and the rationale underpinning the approaches to treatment. More often than not, I have found that engagement is swiftly secured, and subsequent explanation made possible, if I can assure the client at the outset that “you can speak as much or as little about the experience as you wish. I do not need you to tell me the details unless you feel you want to. This is the most private therapy you will ever know. All I need you to do is to help me to understand the circumstances or the setting of the attack and help me track any changes as we work, whether in imagination, physical or emotional sensation– without telling me the nature of that change.” Working with minimal narrative can be like flying blind, as there is often no verbal feedback from the client beyond a nod or a grunt, alterations in body tension or increased rate of breathing, until after they indicate cessation. Taking this approach, I find that I am able to more safely outline the rationale for treatment. Once the approach is understood, with a little minimal narrative and some guessing on the part of the therapist, identifying the positive and negative cognitions becomes possible through discussion and agreement. The subsequent processing is frequently very rapid and completed in no more than one session, as if the material was waiting to come. CASE 1: Jenine - Victim of Child Sexual Abuse (CSA) To give a recent example, a 31 year old woman had been persuaded with great difficulty by friends to attend therapy, only to disengage after the first session. When she returned a year later, following the death of her older sister, she remembered the details she had been given at the previous meeting a year before, relating to mechanisms of memory and the rationale for the treatment approach using EMDR. However, she felt entirely unable to speak about her experience until I assured her there was no need to give me more than a skeletal outline to work on with her. It was then clear that we had a more solid engagement. Despite wanting to avoid, she returned the following week and, though very apprehensive, was able to identify negative and positive cognitions and to process through rapidly the CSA by a cousin of which she had never spoken before to anyone. The intrusions from that experience had disrupted each sexual relationship she had had thereafter. Following one session of therapy she reported an absence of all intrusions and she felt able to speak about the abuse in some detail without distress, indicating that the rapid processing was real and effective, rather than associated with dissociation. Clearly in this case there was some initial degree of approach to the fear. The balance was, I feel, tipped towards a greater feeling of control and hence ability to trust and engage, by the assurance that in the absence of the requirement to speak in any detail about the experience, she need not fear being overwhelmed by her emotions. Case 2: Ruth - Borderline Personality Disorder – Repeat Offender – Avoidance & the Absence of Explicit Negative and Positive Cognitions Another, perhaps more striking experience of working with avoidance based minimal narrative was the case of “Ruth”, a 19 year old girl with borderline personality disorder who had been involved in theft since the age of 12 , following the death of her much loved grandmother . She had served 3 custodial sentences, the last of which followed an incident in which she held support staff as hostages over several hours. She was to be with us at the hospital for no more than three months prior to placement in a probation hostel. The providers were unmoved by our protests that we needed time to resource the patient prior to treatment. She would be moved, treated or not. When I first saw Ruth on the ward of the low security hospital following her release from prison, I was reminded of the extraterrestrial beings, the Daleks, from the Dr. Who series. She was about 4ft 11ins and almost as round. Her body seemed to move as a whole without any flexibility. Her face was stone-like and impassive, her eyes appraising, but cold and rather dead. New to work with psychiatric patients, I was daunted by the challenge. We established that having had some excellent CBT therapy in her last term of imprisonment she was keen to follow up on the ward staff’s suggestion that she would benefit from trauma therapy. She was well stabilised, with no incidents of violence or of self harm for two months. She spoke mechanically, making direct eye contact, but without any vestige of warmth. There was no resonance – no feeling of contact, and instead a sense of implacability. Ruth was a fortress. Staff described Ruth as withdrawn, but occasionally interacting favourably to a minimal degree with patients. She had unescorted leave of 6 hours a day, and throughout her relatively brief stay with us, spent a lot of time off the ward. She had a good, if difficult relationship with her father who visited her, and to whom she would go on home leave. Her relationship with her mother and her stepfather was significantly more wary, though she would go to them when she was in rebellion from her father’s attempts to curb her social activities which Ruth felt were unnecessary. Ruth stipulated the condition under which she was prepared to work. There was to be “no childhood stuff” discussed. This stance was maintained despite my rationale for taking a history and identifying any early trauma which might underpin the pattern of her later experiences. It was clear right from the start that, for Ruth, being in control of the therapy was paramount, and that she wanted a surgical intervention to target and neutralise the traumas she listed. These were: 1. Sudden death of grandmother whilst abroad on holiday when Ruth was 11. Her Grandmother lived across the road from Ruth’s own immediate family, acted as a surrogate mother to her, since Ruth’s own parents were “always busy”. 2. Parental divorce/ abandonment by mother when she was 13. 3. Gang rape at 13 carried out by youths. 4. Assault by 5 police officers for being “mouthy “whilst in custody. The next two sessions were spent trying to help her begin to develop emotional literacy. She was quite unable to identify emotions unless they were at full amplitude. We began the exercise of identifying minimal emotion, on the understanding that she needed to be able to track small physical and emotional changes within her in order to guide me when we were using EMDR. This took the form of getting her to pick out a coloured pencil of her choice and to notice the difference in feeling generated between this and another colour I would hold up. Over the week she was given the task of increasing her emotional and physical awareness by noticing what she felt at meal times about the food served, or about the individual exchanges she had with other patients and staff. I encouraged her to make a note on paper to allow her to reflect upon what she noticed. Though she did not make any notes (I would have been surprised if she had), Ruth was slightly more available at out next meeting. Using the same rational, we explored the feelings associated with using different coloured crayons and the effect generated by drawing different lines and shapes on paper in response to different ideas or everyday situations. This was a very stiff affair until I took a purple crayon and used it to make a jagged line across the paper which I spoke of in terms of both my anger and my energy. At that point, Ruth was able to identify, but not name, a shift in emotion. She took a red crayon and very slowly and deliberately drew two parallel very straight horizontal lines in red on the paper. This she said was her anger. We both sat contemplating the difference between our lines; one freely expressed and the other an act of full rigid control. We ended by working out a visualisation - a still candle flame burning in the dark, which she could focus on to assist her in keeping calm rather than merely “shutting down.” The next session was full and very engaged. It felt as if the brief resourcing we had done was paying off. Ruth began to tell me sparingly in flat unemotional matter of fact tones, about the “busyness” of her parents when she was young and the role her grandmother played in making a place for her in her life. She spoke of the phone call from abroad at 11, in which she heard her father receive the news of her grandmother’s death. In the same matter of fact way she described her parent’s divorce in her early teens, which her father blamed her for, on the grounds of the “trouble” she brought to the house with her offending. Narrative was minimal, phlegmatic, and devoid of any emotional content except by inference. Keeping our mutual communication very level and almost mechanical, we concluded the session with the candle visualisation. This was Ruth well insulated from her emotional self. The next session began with a discussion of the week and was followed by the candle flame visualisation which Ruth took as her safe place. Encouraged by this and the engagement of the last session, in an effort to construct a negative cognition, I began to work with the memory of her father’s face as he took the call telling of her grandmother’s death. There was no reaction – no response in terms of change of expression in Ruth’s face. This was as it had been throughout the sessions to date. I was often left guessing and wondering, feeling as if I was groping in the dark. There was a long silence. Without any warning, Ruth threw her hands up in the air, arched her back, and said she wanted to go back to the ward. I had clearly stepped over the line. The session was dead. I asked her if she could tell me what she had found so difficult, but she remained adamant. She wanted to end the session and return to the ward. After de-briefing staff to ensure increased observation of the patient, I went off to write a therapeutic equivalent of humble pie, which I later left on the ward for Ruth. In that letter I suggested that if she was willing to continue our work we may need to go forward differently, perhaps leaving the loss of her grandmother for the moment, and starting on an easier area. How could I have been so insensitive as to disregard the client’s message? The metacommunication had always been “no emotion – keep it strictly mechanical ". Ruth had told me that she was not prepared to do the “childhood stuff”. Any attempt to reach a negative cognition relating to the feelings around the death of her grandmother would surely have threatened the defences she had put in place about feeling unwanted by her own parents. I needed to respect the defensive segmentation which allowed the splitting of self schemas and associated memories into good and bad allowing her to maintain her self coherence and continuity of self (Horrowitz, 1996). Instead, in trying to work more conventionally, I had placed at risk her coping mechanism, her functional dissociation between her apparently normal part (ANP) and her emotional part (EP) and hence her ability to feel in control.I knew with absolute certainty that within the time constraints we were operating on, there was no chance of preparing Ruth more fully to cope with her emotions. If she was willing, we would just have to dive in and see what happened, having put in place the protective support needed on the ward. Staff told me later that Ruth cried for two days after the session. She sent a message that she would do no further work. However, when I returned a week later she was ready to talk to me once more, having been deeply encouraged by the ward team who were superb throughout. We had a technical discussion about the use of dual attention stimulus and agreed that she was to be on the lookout for the beginning of any feeling, and was to signal early as we worked so we could go to her safe place if needed. I would make no attempt to link or interpret or seek any expression of feeling or sensation in language when thinking about her parent’s divorce, the area she chose to work on first. Normally, I might have reflected on her experience, commenting, “Sounds as if you felt very alone – pushed away”. In short, I kept quiet and abandoned any attempt to make explicit the negative cognition either by suggestion or by encouraging the client to express one, nor did it feel safe enough to try for a positive cognition. In the desperate attempt to work with what was available, I left all means of navigation behind. Getting Ruth to focus upon the sensation she got when she remembered the point at which her parents broke up, I asked her to tap her upper arms. I deliberately handed full control to her as the most likely route to progress. As I watched, there was a sense of subtle and contained process but without any obvious change of expression by Ruth. Over several brief sequences, she made increased eye contact with me, and explained without emotion that she had never understood why her mother had left her brother and herself with their father. Processing proceeded rapidly over about 30 minutes and included memory of her father’s blame towards her which, using cognitive interweave, was identified in terms of displacement of his anger towards himself. I made no attempt to link Ruth’s behaviour, which her father blamed for the divorce, to either Ruth’s distress at her grandmother’s death or to her fragile emotional connection to her parents. In short, I respected the emotional segmentation. At a point when processing stalled, I was able to take DAS over from her and, using eye movements, we were once more able to progress. In the same session at close of the work on the divorce, Ruth began to speak about the attack by 5 policemen when she was in custody following the incident in which she took staff hostage at her hostel. She seemed more available at this point, and there was the beginning of a real sense of connection between us. As before, narrative was restricted to events and their aftermath when she was transferred to prison and her immediate transfer back to hospital. Ruth seemed quite cut off from feeling about the attack, beyond some indignation at the injustice of it all, and some recognition of the kindness and alarm shown by prison staff in their recognition of her physical state and the appropriateness of the action they took in obtaining medical assistance. She was once more phlegmatic when I asked whether the attack was taken up as an issue. It was, she said. However, the records relating to her period in custody were lost. It was clear that Ruth wished to continue the session and so, very unusually, I decided that it would be appropriate to pick off this second trauma within the one session. Under normal conditions I would have been concerned that further processing in the same session might interfere with the work already covered. I asked whether she would like to continue. Her response was immediate and positive. Processing once more proceeded rapidly, with Ruth self tapping either her shoulders or her knees, based upon any pattern of physical or emotional sensation she noticed when she brought up the central image of the policemen entering her cell as a group. As before, when change ceased, I took over using eye movements. After a mere ten minutes there was no further alteration in pattern and Ruth looked once more less rigid. Over the week that followed, Ruth remained stabilised without any distress or incidents of self harm or aggression. Indeed, staff remarked that she had begun to speak more frequently to them and had been laughing with other patients in a way not previously seen. In spite of being physically unwell with a chest infection, Ruth came to session the next week looking more relaxed, her body less rigid. She made eye contact with a glimmer of warmth and seemed less fortress like. I attempted to check out the progress made by the work the previous week. It was like hitting a stone wall. There was no response beyond Ruth stating without emotion that “it felt OK”. She did, however, show me a poem she had written some months previously which spoke factually of her “mum” being “within her”; again, words with no resonance of emotion. I made no attempt to explore more deeply what she offered me, remaining silent to allow her to speak about it. It felt as if this was merely another factual communication. Ruth went on to speak of her plans for the future when she wished to build on a diploma she had taken in prison by going on to do a degree and later work with young offenders. She began smiling and became slightly animated. It was like watching an iceberg begin to melt. Taking the opportunity to possibly enhance her confidence regarding these plans, I asked her about any uncertainties she had. She had none. Once more, the fortress was secure in itself. It felt as if the system was rock solid - either on full amplitude or completely turned off. In the following session, there was a definite sense of warmth. Ruth had had a very successful home visit and seemed more confident in the support she was now experiencing from both her parents, with her mother increasingly engaged and eager to support her daughter’s rehabilitation. It was implicit in Ruth’s description, that she felt more valued and that the changes she was making were being recognised. The session was brief because she was leaving for a pre- assessment session at the supported accommodation she was hoping to move on to. The next session found Ruth eager to continue our work. She seemed more alive, and very available. I chose not to check on the work done, as it was clear she wished to work on the gang rape. Once more, I made no attempt to elicit either positive or negative cognitions. It still felt too risky to do so. However, it felt appropriate to ask her to identify what for her made the attack so traumatic - “I thought they were my mates.” Respecting the emotional containment I made the decision not to probe more deeply for a more immediate self referent negative cognition such as, “I feel betrayed”. Instead, I merely asked her to notice any physical sensations or emotions, and proceeded to work using eye movements followed by hand taps once processing stalled. There came a point at which Ruth began to show significant signs of in depth emotion bordering on distress. It was followed very swiftly by cessation of this change. Using fast processing technique (watching a video of the attack under conditions where she could control the speed) we very swiftly came to a null point. Ruth was able to say that she felt that “there was nothing”. This was the first explicit feedback she had given me. It was the first time I had felt solid ground in helping her track, and the first where there was a sense of resonance. I was no longer working in the dark without any informed instinct. We continued by checking the possibility of further processing by using client self administered taps followed by therapist administered eye movements until it was clear that processing was ended. We did a final check, and there were no physical or emotional sensations attached to any of the images or the implicit negative cognition. Ruth smiled broadly and declared that she felt “chilled out”. When I saw Ruth a week later she was relaxed, using her body in a way which was flexible and free. She was animated as she spoke about home leave, her forthcoming move to the hostel and the studies she was enrolling in. She cracked jokes with me and was fully engaged in the process of reviewing the material we had targeted to date using EMDR. Indeed, we were able to go on and work, at last with the death of her grandmother, taking the image of her father receiving the news of her death in a phone call. As before, I merely worked with the image and its associated non verbalized feeling without the attempt to access deeper emotional expression which might have permitted the identification of negative cognition. Processing was completed swiftly. Ruth was more able to be specific and clear in speaking of her body scan and the lack of any residual emotion as we closed. The desensitisation remained solid at review the following week, with no further issues identified for the present. Following a further review a month later, where Ruth felt she had “covered it all “, the case was closed and Ruth was discharged to supported accommodation. Treatment had taken just over 10 hours. Outcome: I have no doubt that defensive segmentation persisted to a significant degree for Ruth, and that there was much material still needing work. But the evidence that trauma had significantly reduced rests for me in the staggering contrast between the inanimate frozen fortress I had first encountered, and the animated and utterly delightful girl who emerged, able to laugh and crack jokes, and to be actively supportive of her fellow patients. Neither the staff nor I had witnessed anything like it before. I believe it was made possible by the interaction between desensitisation and the safety created by the support shown to Ruth by staff and her parents since her release from prison. Almost a year after discharge, in writing this account, I contacted Ruth once more, and found that she remained symptom free despite a recent move to a new hostel. Conclusions In considering these and other experiences I have come to the following tentative conclusions. Where clients are resourced enough to be able to approach feared emotion, the conscious and active perception of that emotion allows the identification of both negative and positive cognitions, so providing the optimal conditions for processing. In constructing the negative and positive cognitions, the client usually processes semantically and categorically up and down the layers of experience and its aftermath. This gives reference points to focus on and allows ratings for units of disturbance – which, in themselves require more layers of processing. Associative processing is assisted for the majority of clients who are emotionally literate, and helps the therapist to navigate. When circumstances of avoidance generated within a defended or segmented system appear, it is beneficial to provide conditions in which it is explicit that there is no requirement to give semantically constructed and detailed narrative. This increases client perception of control and reduces the fear of emotional overload. The negative cognition here remains implicit both in kind and expressed rated emotion. Aiming for an explicit negative cognition (perhaps more comfortable for the therapist) can result in hyperactivation and withdrawal. Nor is there evidence that material has to come to full consciousness in order to be effectively processed (van Kolk, 2002). Indeed, my own experience earlier this year, of working with an instance of non-identifiable occluded memory after desensitisation of extensive combat trauma, has shown me otherwise. Handing control of dual attention stimulus directly to the extremely defended client, whilst being supported by the therapist as guide, creates a sense of safety which in itself seems to reduce the threat posed by the fear of being emotionally overwhelmed in processing. In deeply defended systems, particularly where emotional segmentation or dissociation between EP and ANP persists despite the client willingness to come to therapy and address the material, absence of the requirement for verbal narrative makes the formation of negative and positive cognitions very difficult. They remain implicit both in kind and in expressed rated emotion. Material, in a largely non categorised /non verbal form, is visceral and elemental rather than constructed and semantic. It remains to an extent below the cognitive scan and hence largely below conscious awareness. This might account for the speed of processing I have found in highly focused and motivated clients such as Ruth who operate such defensive emotional segmentation within a system of chronic trauma. Moreover, these conditions can facilitate unitary processing of each segmented event without reference to other events. Consequently, the emotion generated by any one event is contained at manageable levels without triggering the emotional activation of the whole pattern of negative associations which would otherwise threaten the integrity and continuity of self (the ANP). In this way, it is sometimes possible to increase the likelihood of successful EMDR therapy under conditions that would otherwise contra indicate it. Indeed, I would go further to suggest that EMDR is one of the few therapies where, under necessity, a significant degree of avoidance can sometimes be accommodated without obstructing trauma resolution. References
Foa, E.B., Hembree, E.A., Jaycox,L.H., Street, G.P., (1999). A comparison
of exposure therapy, stress inoculation training and therapeutic combinations
for reduction of post traumatic stress disorder in female assault victims.
Journal of Consulting and Clinical Psychology, 67.194 – 200. ©2007 The EMDR Practitioner - All
Rights Reserved Worldwide
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