I want to start this episode with several assumptions that should be non-controversial, assuming that complex trauma looks here in Ohio the same way complex trauma presents wherever you are. Let me know if these assumptions sound true based on everything you know about complex trauma. Or, let me know if I’m wrong. If we can agree on these assumptions, then we should be able to agree about the need for options when approaching clients with pervasive wounding.
Assumption 1: Clients with really complex trauma have a differently wired nervous system than relatively healthy people do. Real harm might occur if you continually expect a complexly traumatized person’s nervous system to respond in ways that a really healthy one does.
Assumption 2: Clients with complex trauma don’t have a short list of things that they need to resolve so that they can be okay. Complex trauma is pervasive. There are 158,000 hours in childhood and a lot of those hours were spent in survival mode. And the wounding didn’t stop when they were 18. The ratio of good days to bad days are dramatically tilted bad. Their trauma is encyclopedic.
Assumption 3: Regardless of how you have ever worked with clients with complex trauma, when you are working effectively it has always been at the intersection of what is productive and what is tolerable. If it’s not tolerable, that work is not safe.
Assumption 4: Complex wounding in childhood directly affects the type of learning that occurs and does not occur in childhood. Complex trauma is, at least in part, wounding that prevented the formation of the adaptive information needed for healthy and effective functioning.
Assumption 5: People with complex trauma often are forced to develop powerful coping strategies that many healthy people simply do not need. These survival strategies include: staying ahead of it, disconnecting from it (including your own body), numbing, perfectionism or control, and avoidance. Many of these survival strategies move opposite the core mindfulness tasks of slowing down, being present, and noticing. In short, mindfulness is not an intuitive task for most people with complex trauma and is directly triggering for many.
If these assumptions are just some of the things that separate a complexly wounded client from a relatively healthy one, aren’t all of these things directly relevant in a therapy that requires that clients slow down, be present, and notice? That requires that clients already have the adaptive information inside them that is needed for them to heal? Were you trained how to work with a client that has a phobic response to slowing down or being present? What about a client who has a window of tolerance the thickness of a piece of paper? Were you trained how to help a client with no adaptive information develop some of the needed adaptive information? My hunch is that you weren’t. Why? I don’t want to say it, but you already know it is true. I don’t want to get into trouble. But, we train you to work with healthy people. We do. We train you to work with people who already know how to slow down, be present, and notice. We assume that there is enough adaptive information already in your nervous system somewhere. But, those healthy people aren’t your clients. Maybe five in 100 are, but if you work in community mental health… no. We train you to work effectively and with fidelity with the clients that you, by and large, don’t have on your caseload.
And, I want to be clear. If what you are currently doing works really well for your clients, meaning that you can effectively start them doing EMDR therapy and they consistently return to do more, then please keep doing exactly what you are doing. This world needs you to keep doing what you are doing. But, if you are losing clients, or your clients are losing interest in EMDR therapy, and especially if you are wondering if EMDR therapy is the modality you need to be practicing, hang in there. I have really good news. EMDR is effective for treating the shit show that is complex trauma. But it’s not fast. And you have to match your interventions to the nervous system that you are working with. Clients with complex trauma will not be crammed into a machine built for someone else without incident. And I will say it because Shapiro does… sometimes those incidents are retraumatizing or might send a client straight out of this world.
Phase One
Do you know what you can do with a relatively healthy client in Phase One? You can do EMDR therapy exactly the way we trained you. You can even do ten worst memories with them. Whatever. Their trauma history is largely a list of a handful of things. And when those things happened, they probably had support, visibility, and language for that wound. They probably weren’t gaslit, shamed, humiliated, and blamed for the trauma. Their list of traumatic experiences stands out because it is exceptional. It is an exception from what was normal for them and in their childhoods. For healthy people, trauma is rare and exceptional. You can get a really good sense of the clinical picture first session with many generally healthy people. Resource them. Line up their targets and get to work. Your healthy clients are going to be okay. They always were going to be okay. Work with high fidelity to standard protocol with these clients. We trained you well to work with this client.
Maybe You are Way Overthinking Phase One With Clients With Complex Trauma
Tom, do you do a detailed trauma history with all of your clients in the first session? No. Well, I was trained that we have to. Okay… how is that going? Seriously. If clients with complex trauma are generally the same where you are as they are here, how are you doing that? A detailed trauma history here with many of my clients with complex trauma would require that they touch dozens of really difficult developmental eras that contain many of the worst things that one person can possibly do to another person and potentially open up a lot of stuff up. Based on everything we know about complex trauma, we’re then going to send them home with embers scattered literally everywhere. And I’m only going to ask one question… why? Why do you need to know on the very first contact all of that information? What are you going to do with it? Even if you think you got it all, you didn’t. That’s what complex trauma is. It’s complex. It’s hundreds of thousands of hours of wounding. And we are probably months from our first processing session, why do you need to know? Because Francine Shapiro told you that you had to? She didn’t. She itemizes all kinds of options that you probably weren’t trained in. Sorry, but let’s figure it out.
Not to belabor the point, but with your clients with complex trauma do you ever get a full and comprehensive case conceptualization the first session with your most wounded clients? If complex trauma is where you are anything like it is here, you do not. You get some. Next session, you will get more information. Before long, often organically, you will learn about the assorted buckets of client’s wounding. You’ll learn some stuff about childhood, about attachment. You’ll learn about the difficult first marriage. You may even learn who some of the other bad guys are. Your Phase One with clients with complex trauma is usually stretched out, because the information needed to conceptualize the case almost always is. This is how you build rapport with clients with complex trauma. The information comes slowly. You already knew that. I’m just reminding you.
The goal in working with healthy people is to work quickly and efficiently. You don’t need to see them long. The goal, even starting in the first session, is to quickly conceptualize their case, start resourcing, and develop a concrete plan to quickly and effectively help them process their wounding. Where to start with healthy people? Start with what things float back to.
My focus in working with clients with complex trauma isn’t to work quickly and to process all of their trauma as fast as humanly possible. My goal is to find ways to resource the client so that we can start somewhere. Consultees get so caught up in the complexity of their client’s wounding, they risk not starting at all. That’s one of the biggest risks. Therapists get so overwhelmed with the extent and severity of the client’s wounding that they don’t start anywhere. Hundreds of thousands of clients with extreme trauma have showed up at sessions with EMDR therapists and they have never actually started processing anywhere. Once you have started, you have started. Because of how we train you, EMDR therapists are dying on the wrong hills when it comes to their complex clients. When the client is prepared, start. Start where? Somewhere at the intersection of productive and tolerable. I don’t care. Start with the guy who pulled out in front of you in traffic five days ago. Start with the break-up of an ex a few exes ago. Starting somewhere will allow you to get information about how well the client does the core tasks of EMDR therapy (tolerably activating and deep present-based noticing). Use that information. Starting somewhere will give you some glimpse into the client’s fund of adaptive information. Use that information to figure out where to go next. Tom, that sounds chaotic. Okay. Your clients with complex trauma have always confounded your attempts to overly organize their recovery.
There are so many helpful metaphors here that you can find in the book, EMDR With Complex Trauma. The Boat and the Whale metaphor, which is based on the AIP model and suggests that you have to be careful about which memories you hook because you have to have a boat of adaptive information big enough to land that memory content. The Marathon metaphor is also helpful. Unless your clients are Olympians, you don’t have them start with a marathon. With most of your clients with complex trauma, you have to start with a Couch to 2K. Walk/jog. Jog more. Jog a 2K race. Jog/run a 2K. Run a 5K. Run a half-marathon. Hang out there. Jog/run a marathon. With complex trauma there is no other sensible way to do it. We trained you to work with Olympians and forcing your clients to run marathons right out of the gate isn’t fair to them. It’s the wrong place to start with them. You may be cramming a client into an expectation that isn’t safe for them and might cause real harm.
There are a growing number of people who report being harmed by EMDR therapy. A good chunk of this harm is done by therapists who are not well-trained and do not adequately prepare clients for the journey. Most clients with trauma caused by EMDR therapy say that they were not prepared to manage the territories that they were directed into. Don’t start with the whales. On day one of running, don’t start with the marathon. It would be surprising if harm didn’t occur. Start somewhere tolerable. Let that information guide you. When clients struggle in EMDR therapy, that is information. When they are doing awesome, that is information. Use that information in the service of the client’s recovery.
I promise you that EMDR can be a magical way to work with clients with complex trauma. We just need to see clearly the nervous system that we are working with and take sensible cautions with it. If you have been working with clients with complex trauma for years, you already know how to do this. And I know that you want to do EMDR correctly. But doing it correctly requires that you do it in ways that make sense for your client’s unique nervous system.
In summary, rapport builds slowly with complex trauma. Work intentionally. Start somewhere. Don’t do anything that isn’t trauma-informed with your client because Shapiro, Tom Zimmerman, or anyone else says to. Remember that EMDR is not a magic wand. We are connecting information to other information; when clients lack the needed adaptive information, we have to help them develop it and that is not an easy or fast clinical task. Your clients with complex trauma, assuming you can keep them, will be on your caseload for a few years before they can largely reset a sizable chunk of their wounding. There isn’t an ideal way to work with clients with complex trauma. There are a lot of bad ways and most of those originate from not seeing the client that is in front of you.
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