BLOCKED PROCESSING
John Spector, Consultant Clinical Psychologist
London, UK.
February 2003
When EMDR goes at it is suppose to, there is no psychotherapeutic procedure as remarkable, effective, and efficient for the treatment of trauma based disturbance and especially PTSD. However, as with all psychotherapy, things do not always go according to plan and as we might expect. Clients bring a whole range of personality and relationship issues into therapy that can make progress problematic as well, of course, as different degrees of disturbance and psychopathology with the most long standing difficulties and deeper disturbance causing the greatest problems.

Five days training in EMDR that constitutes the current level one and level two (basic and advance training), cannot equip us to deal with all eventualities and further learning and supervision are required. In EMDR problems usually manifest themselves as blocked processing by which I mean that the normal movement of associations or video replay of material either doesn’t happen at all or very quickly gets blocked. After 11 years of working with EMDR I am still finding creative ways to overcome blocked processing. I see these strategies as being on a continuum from checking that preliminary work has been done properly; through good cognitive interweave strategies, through distancing strategies, through finally incorporating more sophisticated imagery and “hotspots” working. With regard to these last two elements I draw on the work of Hackman (1998) on working with images in clinical psychology, and the work of Grey et al (2002) upon working hotspots.
Preliminary Work
Not infrequently problems arise with processing because preliminary work has not been carried out with sufficient care and attention to detail. The following are the most common problems:
  1. Either the negative cognition or the positive cognition is incorrect. If either the NC or the PC is not resonant for the client they are likely to block processing. The first and most important step is to get the NC right and generally there are plenty of clues as to the “ball park” area or cognitive domain in which the NC is likely to be, from the words the client uses about themselves, others, and the world, during careful assessment. To state the obvious the NC needs to be a presently held negative self referencing belief which is an “open” enough statement to generalize to associated feeder memories. The PC should follow on naturally from the NC and as well as being self referencing and positive it should be from the same cognitive domain as the NC. It should not be magical or absolute i.e. I can be in control is better than I am in control.
  2. Has the client being properly educated in trauma and EMDR? As I get more experienced in EMDR over the years, I find myself spending more time educating clients into trauma effects and into the nature of EMDR. This preliminary work really pays off because clients frequently come into treatment sceptical of EMDR and/or feeling helpless that their difficulties can change. Giving them a cogent explanation of what typically happens with trauma and PTSD, and why EMDR may change things, is a huge relief to most clients who feel contained by these explanations and develop a cognitive mindset that change is possible.
  3. Have fears or resistances been tackled? It is not only important to educate clients around EMDR but to explore as a matter of course any anxieties or resistances or fears that they may have about the treatment. The most common of these are “I am not safe”, “I can’t trust my judgement”, “I will loose control”, “I am responsible for what happened “ or “I feel ashamed about what happened”, “I cannot risk …(e.g. expressing emotions)”.

    All of such fears and resistances and any others need to be brought out into the open and made available for re-evaluation and reassurance so that they do not block processing.
  4. Have depression/guilt and shame/ego strength been properly assessed? Sometimes, processing is blocked because the degree of the client’s depression has not being appreciated. PTSD almost always is a co-morbid pathology and depression is one of the most common co-morbid diagnoses. If the depression is moderate to severe, then it will need to be addressed before using EMDR on the PTSD because of the overriding negative and retarding depressive symtomatology blocking processing. Similarly, excessive guilt or shame will need to be addressed before EMDR is likely to be effective. Shame in particular will need to be understood, explored and “normalized” for successful processing to occur. Shame questionnaires can be useful in this regard. Finally, ego strength or, if you like, the clients’ robustness for treatment needs to be assessed. If their self-esteem is particularly low then procedures like resource installation may be needed first.
  5. Has a Good Therapeutic Relationship Been Built? This almost goes without saying but having a good therapeutic alliance with your client is a prerequisite for success whatever psychotherapeutic procedure is being used. If processing is not moving along as it should, it may be worth just re-checking whether there has been any mismatch between you and your clients understanding, or whether any thing that you have said has jarred.
  6. Are There Secondary Gains for Staying Dysfunctional? Clients sometimes do not process properly because there are secondary gains for not improving or changing. The most likely areas here are whether , for example, the client asked to come into therapy or whether they were sent, for example, by a lawyer or a family member. If it is the latter then the client may have particular reasons for not improving, such as the client I saw for a number of initial sessions where processing was not going according to plan and it was only when I brought her husband in that he let slip that she was still angry with him for having had affairs in their marriage – something she had not declared to me but which was providing a powerful secondary gain for her continuing to stay dysfunctional to “punish” her husband. The other main issue here is whether the client is involved in legal compensation because sometimes this too can act as a secondary gain for non-improvement if the client is more interested in monetary recompense than psychological improvement.
Cognitive Interweave
If processing is blocked and one has checked that all the preliminary work that should have been done has been done, then cognitive interweave is of course the most common strategy we all use to shift processing that has become blocked or stuck or is “looping”. I wont spend too much time on this since we have all learnt it but it is perhaps worth just re-emphasising the following.

Timing is very important in cognitive interweave in the sense of delivering an interweave neither too early nor too late. Also choosing the most appropriate interweave is important. Usually, of course, interweaves are addressed around chronologically, the themes of “responsibility”, “safety”, and “choices”. Interweaves can involve the introduction of new information: - “did you know”… for example, that victims often feel grateful to perpetrators or, for example, that it is not uncommon to feel sexually aroused if sexually abused? It may involve stimulating held information such as “I’m confused”, or “what if it were your child”, or “ let’s pretend/suppose”. The use of Socratic questions is helpful in cognitive interweave, for example, questions designed to lead the client to a functional conclusion they have been missing or avoiding. The use of metaphor or analogy can be useful, for example, with a perpetrator talking about how they might “balance the scales” in a way appropriate to the act they perpetrated. Finally, it can be useful just getting the clients some times to verbalize inwardly the thoughts or feelings that they have in relation to a perpetrator and ask them just to “go with that”.
Distancing Strategies
Sometimes, blockages can be surmounted by distancing strategies, for example, where the client is, “like a rabbit in the headlights of a car” and cannot get beyond a scary image. It can be helpful to turn the image from colour to black and white. It can be helpful to imagine the traumatic picture seen through a glass wall. And of course, it can be helpful sometime where appropriate for the client as their adult self or another nurturing figure , for example, you the therapist, to be visualized holding the hand of the traumatized younger individual and helping them through the most traumatic part of their experience.
Working with Images (Hackman 1998)
It had been shown that visual images might contain the greatest emotional arousal – more than the verbal encoding system. Buzan and Buzan (1993) suggested that images were more evocative than words and more precise in triggering a range of associations. In that sense, transforming an image may bring greater emotional shift than challenging verbal thoughts.

It is common with traumatic and dramatic events for people to remember a great amount of detail and we call these memories “flash bulb memories”. These are like a photograph in time. For example, many of us remember with great detail what we were doing when we heard of the death of Kennedy or Diana. These flashbulb memories are the ones we often work with in trauma.

Moreover, images usually reflect the theme of particular disorders. For example, for people with panic attacks, images of physical and mental catastrophes are common and for people with depression, images of defeat and defectiveness are common. In social phobia, images of the self, seen in a distorted way are common. In PTSD, images often appear as flashbacks, commonly to scenes that were especially traumatic and are relived and are often fragments of memories. In cognitive behavioural systematic de-sensitisation a significant ingredient is the use of imagery by the client, and in personal experience if you have overcome some personal fear of your own you will probably recognise the role that imagery played and how it changed as you overcame the problem.

Hackman talks about the need to get to the implicational level of meaning. Sometimes in therapy an image resonates more fully with an expressed emotion than the thoughts expressed in words, for example, the anxiety of an agrophobic who thinks she might fall down makes more sense when she describes an image of the fall in which she sees a crowd gather, summon an ambulance, and take her to hospital where she is kept against her will. So, attending to the content of images can provide a quick route to the implicational (Teasdale 1991) level of meaning (rather than the propositional level).

In PTSD images are often fragments of the trauma and whilst they are closely related to the trauma, they are not identical to it. The example is given of a man who witnessed the body of a headless woman who had images recurring of the woman’s husband swinging an axe towards the dead woman that he hadn’t actually seen. It became apparent that this image came from earlier associated memories where he had seen his father attacking his mother with chopping movements when he was a boy. His cognition was “ I should have prevented it” which was inappropriate but was what he had believed as a boy. So, sensory cues can trigger earlier distress without conscious memory of it. That means we must allow enough time for clients to stay with the strong emotions evoked, in order that associated thoughts, images and memories can come into awareness – and this may be resisted.

Images can be treated as ‘negative automatic thoughts (NAT’s). We can ask Socratic questions to do with the meaning of the image. For example, what led to the events in the image? What is the worse thing about it? Typically, these sorts of questions will give rise to other NAT’s that can be worked on verbally.

Alternatively, these imagery techniques can be used: the float back technique (Aka Zangwill in Shapiro 2001). The “float back” is a bridge to earlier experiences, which are often seminal childhood traumas leading to dysfunctional beliefs. For example, a patient who was obsessionally fearful of Aids had an image of being in a cast white iron bed in hospital being blamed for getting the illness. The float back technique led directly to a memory of lying in hospital with a broken arm as a child and his father blaming him for the accident.

Many images are frozen at their worse point or outcome. Here the strategy is to move the image on in time by, for example, asking the client “what happened next?”

Images can be manipulated. This can be done in different ways such as putting it on a television screen, turning it on and off, making it bigger or smaller, brighter or dimmer. For example, Hackman discusses a woman very distressed by a recurring image of her own gravestone and the faces of her husband and child when they visited it. Verbal exploration helped her to see this was only an image and not necessarily what would happen but this didn’t lessen her distress. What did help was to imagine herself alive and well and looking at this image on TV so that she could switch it on and off and drive away from the house. Putting the image on the screen gave her the message that it was only an image and one she could control. Here we are changing the meaning of having the image rather than the meaning of the image itself – a sort of meta change. With PTSD in particular, putting an image on a screen and altering it keeps the affect manageable and reinforces the idea that it is only a memory or an image and is not in the present.

“Imagine”. Here the strategy is to explore with the patient how the future will be when whatever the problem is, is over, or when they can carry out the desired behaviour competently. This is more like guided imagery and at one level is a complex form of cognitive interweave focussing on imagery.
Working with “HotSpots” in PTSD
Grey et al 2002 discusses PTSD from the theoretical prospective of Brewin et al (1996) and the “Dual Processing” theory of PTSD. According to this theory, situationally accessed memories (SAMs) are encoded at the time of the trauma and are often fragmentary, sensory and context-less. They are triggered subsequently by cues or reminders of the original trauma. Verbally accessible memories (VAMs) are autobiographical memories of trauma that can be edited. When the fragmentary trauma memories stored in the SAMs are triggered, they are experienced as nightmares, flashbacks, intrusions, and do not come with a “time lag”. This leads to the sense of current threat but extreme fear associated with the threat inhibits the full emotional processing of the trauma and disrupts the autobiographical memory (VAMs), which leads memory stored in the fragmentary SAMs.

Richard and Lovell (1999) suggest that hotspots are moments of peak fear that need further exposure to fully reprocess. Ehlers and Clark (2000) suggest that the patient’s predominant emotions give clues to significant cognitive themes and should be explored for meanings. Contrary to diagnostic criteria for PTSD in DSM IV, PTSD may include not just fear meanings but anger, shame, guilt, and humiliation. Exposure may work less well for of these complex meanings, which are probably stored in a fragmentary state in SAMs. Hotspots will be SAMs and more difficult to retrieve. To identify hotspots, clients are frequently asked through their trauma narrative for SUDs levels and meanings to questions like “what’s going through your mind now?” and “what does that mean to you?”. Hotspots are also revealed by visible changes in the client’s affect during the procedure. Another clue is where it becomes clear that the client is speeding through or avoiding some part of the narrative.

When Hotspots have been identified, frame-by-frame working becomes necessary – always working with the meanings for the client. I have sometimes found that this is better done firstly outside of eye movements as eye movement work during initial frame by frame working with hotspots can sometimes facilitate high emotional arousal rather than achieving the objective of habituating the client to the hotspot and reappraising the meanings. The “re-wind and hold” technique can be useful – “what’s going through your mind now?” in connection with an image and probing for cognitive content. It involves a constant checking of the client’s experience often with more reassurance at first than one ordinarily might use. Socratic questioning and cognitive restructuring are employed together with education with PTSD and especially about the absence of a time lag. Where clients get particularly stuck on an image and their belief, reappraisals can be rehearsed together with the moments that they can be introduced in the sequence. The kinds of cognitive interweave one would use here would be “what would you say now?”, “what do you know now?”, “is there another way of looking at that?”. But in order to work, the client must relive these points in the trauma and a number of secondary appraisals and emotional responses may prevent this, such as low mood, high level of anger, lack of trust in the therapist and fears in expressing emotions. Once the client has become habituated to the hotspot and made some reappraisal, I am then usually confident enough to bring them back to going over the material with eye movements in the context of the whole EMDR procedure.

Grey et al suggest three phases in addressing peritraumatic hotspots:
I would add a fourth phase, which is Phase 3 with the addition of eye movements, which completes the job.
Conclusion
EMDR work does not always go as predicted or as we expect, just as in any psychotherapeutic procedure. Although I have found EMDR to be without doubt the most rapid and effective procedure for reprocessing trauma and critical incidents, sometimes these extra techniques are necessary when processing gets blocked. I see these techniques as on continuum and if one thing doesn’t work I will try another. Creativity and a bit of “ducking and diving” gets over difficulties in a vast majority of difficult cases.

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