|
Dorothy’s Dilemma: A Patient with
an Insecure Base for Treatment
December 2005 Editor'sNote: Psychotherapist James R.
Samec in Sweden offers an enlightening case discussion of a client/patient whose
therapeutic journey required a sensitive reworking of several aspects of EMDR
treatment. This case is especially illuminated by the wisdom of psychoanalytic
notions of the unconscious and trauma, and the value of understanding these
when applying EMDR. Samec’s responsiveness to the unique story and needs of
the client/patient, and his courage to adapt the EMDR protocol to generate the
best therapeutic results, offer a fine example of the adaptability of EMDR needed
to do our best work. We are delighted to present Mr. Samec’s review! - SEBorrelli
Abtract:
A traumatized adolescent, sensitive to rejection and exposed to real threat by
the perpetrator who caused past traumatisation, would seem to have an insecure
base for therapeutic treatment. Such a patient may have difficulty developing
resources according to the Eye Movement Desensitization and Reprocessing (EMDR)-resource
installation procedure and accepting EMDR-cognitive interweaves. Treatment of
such a patient demonstrates that therapy is possible, if the patient is given
the possibility to confront the perpetrator in an imaginary anticipatory situation
and process that event with EMDR, even though not all past and current issues
have been completely treated.
Keywords: trauma, adolescent, EMDR, resource installation, cognitive interweave The narrative in The Wonderful Wizard of OZ (Baum, 1960) reveals that the Scarecrow, Tin Man, and Lion already possess the resources they desire, that is, a brain, a heart, and courage. When given artificial representations of those resources, they are satisfied. Dorothy, the heroine of the novel, lives in the middle of a trauma--she cannot return to her loved ones after having been swept away from them by a tornado. She needs something else, but she does not know what it is. Dorothy’s dilemma, living in a current threatening situation, is also a dilemma for the clinician as the patient and clinician have an insecure base from which to work. Hofmann (2004) states that a patient who is not free from the perpetrator’s control does not have the social stability necessary for therapeutic treatment. Treating a traumatized patient still being threatened by the perpetrator responsible for the traumatisation, required the author to examine how treatment could proceed to a satisfactory conclusion. The patient will be called Dorothy. Dorothy, 17 years old, came with her mother to an open psychiatric clinic after slashing her arms and wrists. She was remitted by a hospital and came against her will. Dorothy was reluctant to speak and seemed uncertain and shy, but after a while, she sought contact with the psychologist who interviewed her. During the first session with the psychologist, Dorothy described suicidal thoughts that had plagued her for over two years. These thoughts stemmed from difficulties in her relationships with peers. However, she refused to specify those difficulties. In a later session, Dorothy revealed a number of compulsive thoughts and actions that tormented her. She was depressed, according to the Beck’s Depression Index test administered by the psychologist. She kept a company of men who drank in excess, used narcotics, and were involved in criminal activities. Dorothy met with the psychologist 32 times during twelve months, several times with her mother and twice with both parents. During session 15, the psychologist wondered aloud about traumatisation. Dorothy confirmed this, but refused to describe its nature. During session 28, Dorothy reported that she recently had suffered a miscarriage. Because treatment led only to minor improvements and because of the traumatisation and miscarriage, the psychologist contacted the author. Dorothy was reluctant to meet the author, as she did not want to give up her contact with the psychologist, but finally, she agreed. During that meeting with her mother and the psychologist present in the room, EMDR-treatment was described. Dorothy was offered treatment with the understanding that she could return to the psychologist when treatment was concluded. Thereafter, for nine months, the author met Dorothy 16 times for 45-minute sessions. Method
An Attempt at Treatment with Psychodynamic Psychotherapy
with EMDR Dorothy’s self-destructiveness and compulsive behaviour and thoughts indicated a negatively charged self and the absence of adequate defences—factors that contributed to her depression. Because Dorothy refused to reveal the details of her trauma, the author considered that psychodynamic psychotherapy with EMDR could be suitable as EMDR-treatment can proceed without the patient having to reveal material he or she wants to keep secret (Shapiro, 2001). EMDR is a psychotherapeutic tool with the Adaptive Information Processing model as its theoretical framework (Shapiro, 2001, s. 29-56). The theory is only a working hypothesis as the knowledge of the human brain is too limited to explain EMDR’s effectiveness. According to the theory, EMDR-procedure initiates a physiological condition that activates the brain’s information processing system and allows the processing of dysfunctional material. This physiological condition is attained during a period of approximately 20 seconds (a “set”) during which the patient’s attention is simultaneously occupied by two phenomena: 1) that which is disturbing for the patient and 2) movements or sounds which the psychotherapist makes. During such a set, the patient is usually asked to follow with her or his eyes the psychotherapist’s hand as the psychotherapist moves it in front of the patient’s face. When the psychotherapist stops, the patient is asked to report that which he or she experiences. Often the patient comes in contact with a number of perceptions that may lead to associations, both psychic and somatic. When the patient concludes his or her report, the psychotherapist initiates a new set of EMDR-stimulation. This is repeated until the patient has completely processed the disturbing material as indicated by specific EMDR-procedure. The patient is fully conscious and has control over the amount of exposure he or she is willing to experience. EMDR is best suited for patients suffering from Posttraumatic Stress Disorder (PTSD: DSM-IV, Diagnostic and Statistical Manual of Mental Disorder, 1994), but has also been successfully employed to treat anxiety, phobias, and other disorders (Lovett, 1999; Wächter, 2002). During the first session, we worked to find an EMDR-“safe place” for Dorothy. A safe place is place or person to which the patient goes to relax. This is an imaginary exercise. At the end of each session, the patient goes to his or her safe place to relax, but the safe place may also be employed during the session or between sessions if the patient experiences excessive distress. According to the author’s clinical experience, patients who have difficulty in finding a safe place often suffer from severe problems. This seemed to be the case with Dorothy whose safe places were invaded by threatening objects, but she was finally able to find a secure safe place toward the conclusion of the first session. The first focus for EMDR-processing was “something that had happened” when Dorothy was eleven years old and which she wanted to keep for herself. Dorothy refused to divulge what she had been exposed to, but by the fourth session, it was clear that her trauma occurred when she was eleven years old, that feelings of shame somehow caused her to believe that she was responsible in spite of her age at the time, and that the perpetrator was a real and present threat in her life. Dorothy never gave any details about the traumatisation nor about the identity of the perpetrator during the entire course of treatment. Attempts to process the trauma failed, as the reprocessing was only partial. After EMDR-sets, Dorothy often reported bodily sensations of emptiness that evoked feelings of loneliness, great fear, and helplessness, but seldom pictures, even though she knew that she could keep them for herself. As Ganzarain (2000) indicates, … feelings of helplessness are experienced as a metaphorical loss of maternal protection. The defenceless inability to respond to the threat of annihilation of the self seems to validate the fears of being annihilated by powerful persecutors—the so-called”paranoid anxieties.” In other words, trauma reactivates and intensifies the basic human anxieties about losing the mother’s caring help and of suffering the annihilation of the self. (pp. 89-90) An EMDR-resource installation (Leeds, 1998; Shapiro, 2001; Korn & Leeds, 2002) was attempted during the third session. In the resource installation procedure the patient is asked what resource the patient needs to deal with the situation (X) disturbing the patient. The resource is gleaned from the patient’s own experience of having to deal with a situation similar to X in the past, from the experience of others, or from symbolic representations. When the resource is secured by the patient, it may be employed in a fantasy encounter with X. Dorothy, who was uncertain of her worth and her perceptions of what she experienced and was still threatened by the perpetrator, could not integrate a resource into her being. That is, after Dorothy seemed to have established an adequate resource developed during the resource installation procedure and met the perpetrator in an imaginary exercise, she felt extreme fear. Dorothy was also unreceptive to “cognitive interweaves”, a useful strategy for moving client’s along the therapeutic journey (Shapiro, 2001, pp. 254-276). Dorothy could answer the author that she did have the right to reject her molester who was older than she. However, Dorothy felt that she was evil and malicious for rejecting him, subsequently feeling overwhelmed by guilt and shame. When this occurred again and again, the author understood that something else was required. Dorothy was not helped by attempts at changing the assault scenario by shrinking the size of the disturbing image, by distancing herself from it, by immobilizing the image. by making it appear in black and white (Shapiro, 2001, p. 186), nor by encouraging Dorothy in her fantasy to face what she dreaded (Parnell, 1998, pp. 59-61), methods which are useful for some patients. Dorothy and the author had worked with “something which had happened,” the miscarriage, nightmares, a number of current disturbing events, and other phenomena that were disturbing Dorothy or that appeared when “float back” (Shapiro, 2001, 433-34), a free association method, was employed. With each focus the goal was to reprocess manifestations of the disturbing event in accord with the EMDR-protocol to treat “feeder memories” that contribute to the current dysfunction and block reprocessing of it (Shapiro, 2001, 189-192). Thereafter, a “positive template” (Shapiro, 2001, p. 210-214) to be used to deal with situations similar to the trauma event was to be established. However, the problem was that reprocessing did not come further than a bit into a past event or present, occurring event, as Dorothy experienced only strong somatic reactions with few pictures and without apparent reprocessing. The only exception was a spider phobia that was completely treated during session 10, including the creation of a positive template to prevent its return. Thus, during the first 13 sessions, anticipated events were not focused upon, except in the treatment of the spider phobia and the futile attempts at resource installation and cognitive interweave. Nevertheless, Dorothy did want to continue treatment as she felt some symptom alleviation. Symptom alleviation was probably due to EMDR-reprocessing of the spider phobia and the partial reprocessing of other dysfunctional material, as well as the interpretations of the transference and pre-conscious material given by the author at the close of the sessions, after EMDR-processing was completed. Theoretical Considerations
Time and the traumatized patient Van der Kolk (1994) indicates that an untreated trauma causes intrusive memories and somatic sensations and prevents the development of a complete narrative perspective of the experience (see also Pennebaker, 1999 and Syke & Simon, 2002 on the importance of creating a narrative). A complete narrative perspective includes a beginning, a middle, and an end, but for the traumatized patient, these three time specifications are confused and have no chronological order: The patient is disturbed by a past event as though it were happening in the present or could happen at any time in the future. If focus on past and present disturbances gave little result with Dorothy, perhaps focus and treatment of the future would initiate a better reprocessing and even have effect on the past and present as time elements are confused. Thus, a “feeder memory” for Dorothy could be an imaginary confrontation with the perpetrator in the future. The difficulty with this approach was that except for the reprocessing of the spider phobia, not a single past or present event had been completely treated, a condition which Shapiro (2001) stipulates as necessary for successful EMDR-treatment. Hofmann (2004) reported that he treats complex PTSD with inverted protocol in which the first focus is the future and then present and past. In the future focus a resource is created to stabilize the patient, not to treat the trauma.The therapeutic relationship and the traumatized patient A closer examination of the EMDR-standard procedure and the resource installation procedure made the author aware of an important distinction between the two in regards to the therapeutic relationship. The standard EMDR-protocol includes the relationship with the therapist in a tangible manner, while the resource installation requires the patient to focus outside of that relationship to find a suitable resource. A traumatized patient, sensitive to rejection and under current duress, may experience such a procedure as rejection. The resource installation procedure does allow for the relationship with the therapist as a resource, but, of course, the procedure becomes circumstantial and artificial, as the therapist goes from the standard protocol with which the insecure patient is accustomed, to introduce a new procedure in the middle of treatment. This may also be the reason why cognitive interweaves did not have effect on Dorothy, even though she seemed to be initially receptive to them. Cognitive interweaves involve a question from the therapist that is meant to help the patient understand the implications of what the patient has communicated. The therapist’s question involves a prompting that may be perceived as a sign that the therapist feels that the patient lacks something. The prompting may be experienced by the sensitive patient as a distancing by the therapist from the patient. The total acceptance of the patient as she is may come into question and this may be perceived as rejection. With these considerations in mind, the author decided to apply EMDR in another way. Results
During the next session (session 14), Dorothy was asked to imagine that she met
the perpetrator in the near future and that he threatened her. Dorothy created
that situation and met him and the author used the standard EMDR-protocol without
any attempt at resource installation or cognitive interweave. After two more sessions,
Dorothy had reprocessed the situation entirely, established a positive template,
and was certain that her difficulties were resolved. She was thoroughly convinced
that she could deal with the perpetrator and other similar situations. This was
confirmed when she later met with the psychologist and reported that all of her
symptoms had vanished. During an interview four months later in regards to the
contents of this manuscript, Dorothy was still without any symptoms. Her parents
reported that she was happy, could set clear and definite limits, and was mature
in regards to taking responsibility.Dorothy had created a narrative about her life during session 14. During the next two sessions, she reprocessed the traumatic memories that may return as somatic perceptions or affects after a narrative has been constructed (van der Kolk, 1996). Discussion
The present study may seem to contradict Shapiro (2001) who states that when employing
EMDR old memories should be treated first in order to remove feeder memories that
cause the patient’s suffering. However, Shapiro clearly indicates that EMDR should
be applied according to the patient’s needs, especially in the treatment of children
and young adults, and that EMDR is meant to supplement, not replace, the psychotherapeutic
modality in which the psychotherapist is trained and experienced. Dorothy needed
something else than that which the standard EMDR protocol provided, and when she
received it, she was able to successfully process both her trauma and her present
threat. Is it possible that the sessions with the psychologist were responsible for Dorothy’s cure? Dorothy had received a degree of symptom alleviation during the sessions with the psychologist and during the previous 13 sessions with the author, but intruding memories from the trauma situation and Dorothy’s fear of the perpetrator persisted at the same level of intensity. Dorothy could not trust her perceptions nor accept that she possessed any resources. When given the opportunity to confront the perpetrator in a future situation and process it with EMDR, Dorothy became convinced that she could deal with her trauma and with the present threat she faced. Thus, Dorothy created and developed a full narrative perspective of that experience and of her life, allowing her to reprocess her traumatic memories. The spider phobia was treated successfully. One may wonder if it was the resolution of that phobia that empowered Dorothy to confront the perpetrator in an imaginary future situation. The resolution of the phobia certainly contributed. In that work, Dorothy and the author had met in her annihilation anxiety and her helplessness. Together with the author, Dorothy successfully met the threat when it crept out in the form of a spider, something that terrified and disgusted her, just as the perpetrator. That may have given Dorothy a feeling of empowerment. After the treatment of the spider phobia, it could be so that Dorothy was forced to return to her helplessness to be certain that the author was with her before she could repossess her right to her own strength. This is difficult to know for certain. What cannot be ignored is the fact that there were three sessions after the treatment of the spider phobia in which other issues came into focus that could not be reprocessed. Reprocessing stopped because Dorothy once again experienced profound emptiness, terror, and helplessness, just as before the successful treatment of the spider phobia. What is the difference between Parnell’s (1998, pp. 59-61) intervention and the intervention presented in this article? Parnell describes how a patient is asked to do something she dreads. This is different from asking a patient to create an imaginary situation in the future and do what she dreads. The difference may seem slight. However, for the traumatized patient, exposed to current threat, the difference between meeting the perpetrator in the present and meeting the perpetrator in a future, imaginary situation is crucial: Asking Dorothy to meet the perpetrator in the present had no effect for that is where she met him and that terrified her. Conclusions
A traumatized patient sensitive to rejection and exposed to current threat by
the perpetrator who caused a past traumatisation would seem to have an insecure
base for therapeutic treatment. Such a patient may have difficulty in developing
resources according to the EMDR-resource installation procedure and accepting
EMDR-cognitive interweaves or other methods to deal with dysfunctional material,
in spite of a stable therapeutic alliance. The work with Dorothy indicates that
trauma can be successfully reprocessed in spite of current threat and even though
not all past and current issues have been thoroughly dealt with, if the patient
is given the possibility to confront the perpetrator in an imaginary future situation,
Acknowledgements
The author expresses his gratitude to the patient who is called Dorothy for her
courage and perseverance and to her parents who supported her. The author also
thanks licensed psychotherapist Lotta Landerholm for her invaluable and insightful
observations, as well as editor Christina Flordh for permission to publish the
English version of this article which originally appeared in Swedish in Insikten
(2005), nr.3, 44-47.Background
James R. Samec is a licensed psychotherapist, psychotherapy supervisor and EMDR
supervisor. He has a private practice in Stockholm and has worked at the Child
and Adolescent Psychiatric Unit in Norrtälje, Sweden. Correspondence
Karlbergsvägen 49, 2 tr., 113 35 Stockholm, Swedenfax: + 46 176 77398 or e-mail: james.samec@telia.com References
American Psychiatric Association (1994). Diagnostic
and statistical manual of mental disorders- DSM-IV (4th ed.).
Washington, D.C.
Baum, L.F. (1960). The wonderful wizard of OZ. New York: Dover Publications, Inc. (First published: 1900). Ganzarain, R. (2000). Group-as-a-whole dynamics in work with traumatized patients: Technical strategies, their rationales, and limitations. In R.H. Klein and V.L. Schermer (Eds.), Group psychotherapy for psychological trauma (89-115). New York: Guilford Press. Hofmann, A. (2004, June). Treatment of complex PTSD with EMDR. Plenary session speech during the Fifth European EMDR conference, Stockholm, Sweden. Korn, D. & Leeds, A.M. (2002). Preliminary installation in the stabilization phase of treatment of complex post-traumatic evidence for the efficacy for EMDR resource development and stress disorder. Journal of Clinical Psychology, 58 (12), 1465-87. Leeds, A.M. (1998). Lifting the burden of shame: Using EMDR resource installation to resolve therapeutic impasse. In P. Manfield (Ed.), Extending EMDR: A casebook of innovative applications (256-281). New York: Norton. Lovett, J. (1999). Small wonders: Healing childhood trauma with EMDR. New York: Free Press. Parnell, L. (1998). Postpartum depression: Helping a mother to bond. In P. Manfield (Ed.), Extending EMDR: A casebook of innovative applications (37-64). New York: Norton. Pennebaker, J.W. (1999). The effects of traumatic disclosure on physical and mental health: The values of writing and talking about upsetting events. International Journal of Emergency Mental Health, 1, 9-18. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. (2d ed. revised). New York: Guilford Press. Syke, M. & Simon, R. (2002). Discoveries from the black box. Psychotherapy Networker (September/October), 26-37 and 68. van der Kolk, B.A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Review of Psychiatry, 1(5), 253-265. van der Kolk, B.A. (1996). Trauma and memory. In B.A. van der Kolk, A.C. McFarlane, and L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (279-302). New York: Guilford Press. Wächter, M. (2002). EMDR—inte bara traumabehandling (EMDR—not just trauma treatment). Psykisk hälsa (Psychic Health), 3, 256-266. ©2005 The EMDR Practitioner - All Rights
Reserved Worldwide
|