Phase Four

Why Some Clients Don’t Want to Do EMDR Therapy After Doing Some EMDR Therapy

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It’s a common enough question and it does make a little bit of sense.  Have you ever seen a client completely resolve a memory (sometimes even a substantial one) and their experience didn’t seem to be terrible… they come back next session and don’t want to do EMDR.  They come back and are like, “Hey, can we just talk today?”

What is going on?  You spend weeks or months preparing and you help them clear something and they are done.  Let’s explore this through several case scenarios because my suggestions about resuming are going to vary based on the scenario. First, let’s assume that nothing particularly difficult emerged in their EMDR session, they didn’t report a horrible time after session, and let’s assume that the memory they worked on fully resolved.  They may have even expressed astonishment at the end of that session.  Why in the world would they not want to immediately resume work in this approach?

People can learn multiple things at once.  They can learn that they can heal from something quickly and profoundly.  They can have that information in their back pocket and it can be good there.  They might also learn that EMDR therapy is hard.  It kind of sucks, but it’s also great.  It can be exhausting.  And, it’s exhausting in ways that clients can’t predict, manage, or control.  And where it goes and how long they going to have to stay with what really really sucks in it, they also cannot predict.  So, here is what happens sometimes.  Clients can know that they can heal and they also know that this week has been hard, that they haven’t slept well, and they may need to see their mom one of the next few evenings and don’t want to be feeling a certain way.  So, clients come to session and they have a calculation to make.  They like you.  They can get a predictable benefit from your presence, kindness, and your attunement.  And they may take what feels like the safer bet today.  If this is what’s happening, none of that is about you, except that you are awesome and spending time with you is lovely.  If this is what is happening, have that conversation.  It’s okay to ask a client why they are choosing not to do EMDR therapy across multiple sessions.  It’s information.  Use that information in the service of the client’s recovery.  Some people just need you to ask.  Some people will have real concerns that they may need your help navigating.  Lots of people come to consultation and ask me this question.  Ask them.  And if you do it in a way that is open and doesn’t lead with a lot of agenda, you’re likely to get good information.

Here is a different scenario.  Some people have real difficulties in session or after.  None of us likes it when the lid pops off.  It is scary. Client’s don’t like when everything they have tried to stay ahead of starts to catch up all at once.  If clients have a difficult time, we anticipated that might happen.  We prepared for that.  And there are so many options you can suggest for more effective management of it.  EMDR is not binary and we need to work at the intersection of what it productive and tolerable.  We learn what that is by making our best guess and by starting this work.  If clients have a difficult session, that is not failure, that is information.  We have options.  We don’t have to return to that territory right now.  We can work on other, more tolerable memories.  We can strengthen your attachment figure resources if you got stuck in an attachment wound memory.  We can take steps to discourage the target from going everywhere.  You can show the client how to interact with the memory in ways that allow pieces of it to come into awareness a little bit at a time.  The book, EMDR With Complex Trauma, has chapters on these little guardrails we can put up if clients need them.  If the client had a difficult EMDR session, ask about those difficulties.  They do not know what their options, but they are pretty sure what their experience was.  Ask.  Again, difficulties are inevitable.  They are not failure, they are information.  Get and then use that information.

Here is another really common dilemma.  We see clients start with memories with a SUDs of eight and we see them in a single session process it down to a two.  And next session, they do not want to work on that two.  That makes perfect sense from their perspective.  That two SUDs is not causing them distress right now.  Lots of other things are.  They might argue with you about working on that two this session or next session.  Clients are looking for less distress.  We are in pursuit of generalization, because when a memory fully resolves, many other things we never have to touch may also resolve automatically.  So, when I have this type of dilemma, I want to share that dilemma with the client and also make it theirs.  I want to share why that two out of ten SUDs is like a tunnel that we dug from France to England, but we stopped four miles short.  We need to finish projects like this sometime (not necessarily today, but soon), so information can flow through that pathway for the rest of your life.  Finishing up unresolved memories is a great thing to do once clients understand that there are really good reasons for doing it other than therapist OCD. So, when you have a dilemma like this, invite the client into it.  Start with, “I hear that so many other things have your focus now and this seems like it’s not worth revisiting.  But, in EMDR therapy the memories that we fully resolve help build what we need to more easily resolve the others, including the ones you would like to work on today.  Does it make sense why I’m suggesting that we finish some of the stuff we have started before working on new things?”

Again, some ideas.  Talk with your clients about their hesitations.  Talk openly and without too heavy of an agenda for this session.  We want to follow our clients, but when doing this puts us in a dilemma, share that dilemma with them.  They are likely to give you information.  If you don’t know what to make of the information, come to consultation and we are likely to be able to help you translate it.

Thank you for the amazing work that you do in the world.  Be in touch.

Where Clients with Complex Trauma Tend to Get Stuck and How to Use Interweaves

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More information on EMDR’s Third Weekend: http://EMDRThirdWeekend.com

There is so much to say here. Broad overview. Each point could easily be a chapter. Very little of this is mine, the metaphors are mine, but this is a collection ways of seeing that are helpful for me in understanding where clients get stuck in reprocessing, why, and what might be helpful in getting them unstuck, and what we subsequently do with that information. When clients encounter difficulties in any phase of EMDR Therapy, that isn’t failure and it isn’t evidence that you have done something wrong. It’s important information about the client’s nervous system and means of survival. That information needs to come so that we can use the lessons in it in the service of the client’s recovery.

We train you to stay out of the way, but if a client is stuck, your obligation is to try to help them get unstuck. EMDR Therapy with a client with complex trauma is a complicated task. We’ll explore some of the reasons why and how you might intervene when someone is struggling.
How do you know when someone is stuck when they have really complex trauma? Sometimes it is ambiguous. Because they are often connecting something big with a small amount of adaptive information, the metabolization can be slow. Questions to ask. Clients can be stuck in high anxiety near panic that won’t shift, clients can be stuck in a shutdown response (100 amp breaker), they can be stuck in the big existential loneliness of childhood (particularly if working on an attachment wound), they can be stuck trying to figure something out that is existential, or they can be stuck noticing on channels that just aren’t productive right now (thoughts, memory, etc), where things aren’t moving and shifting and changing.

Defining looping.

When someone is stuck, they are probably stuck in a perspective. Office shortcut metaphor. Interweaves help clients change their perspective.
Ideally, when we intervene, our interventions should match where the client is stuck. We shouldn’t just randomly throw something out. Car metaphor.

They are not sure what their role in this dance is.

Blocking beliefs. Hopefully, you will pick up on these in your Phase Two. Phase Two is the canary in the coal mine for blocking beliefs. What is a blocking belief and why is it a problem?

Too big of a target too soon.

The target memory is an attachment wound. Why attachment wounds are about everything. What might you do. Long resonance after sessions is common when not working with attachment resources.
Detailed Attachment Figure Script:
https://gowiththat.wordpress.com/2022/02/09/attachment/

If the core of EMDR Therapy is activate a piece of difficult stuck information, notice what comes, while the brain gets a left-right stimulation, let’s evaluate potential stuck places.

Activate: Are they activating in ways that are tolerable? Is the activation from the memory or from an agenda? Are they allowing too much memory content to connect too soon. We need memory content to come, but we need it to come at digestible rates.

Notice. Noticing is the bright yellow line in the center of the EMDR road. Is the client noticing? Does the client know how to notice? We may need to be very clear about what noticing means. The difference between being aware and noticing clearly.

Left-Right Stimulation. Always a possibility that switching bilateral may be helpful.

Stuck in guilt, shame, blame, or responsibility. Appropriate and not developmentally appropriate types. Assessing for adaptive information, clues in Phase Three.

How is your relationship with your client? The relationship is a key component in what is effective in EMDR Therapy. How is your client’s parts relationship with you and your parts? Did you ask consent to work on this memory, attempt to address concerns, and listen to a concerned part when that part has an agenda different than yours? If you didn’t, their parts are likely already aware of this quality in you. Working with a system always easier than pretending that you are not working with a system.

A “Dip Your Toe In” Approach to Sensory Grounding with Complex Trauma

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Trauma has the potential to promote disconnection from the present, from experience, from the body, from the self, and from more full engagement with the broader world.  These responses were in the service of survival. They may have been essential.  Sensory grounding is a go-to resource in trauma work because our senses bring us home.  They can help bring us into the “safety” of the present when we want to be or when we need to be more present.

Sensory grounding is a needed resource in trauma work, where we ask clients to “glance” at a traumatic memory, but advise them not to fall into a memory.  Sometimes, simply interacting with the memory in any way can cause it can cause us to fall or dissociate into it.  Sensory grounding in the present brings you home.  It brings you into a place where the bad thing isn’t happening right here, right now.

If you already do 5-4-3-2-1 grounding, you do a version of what I’m about to walk you through.  However, I want to show you a way to do this that includes several things that may be different than many common approaches.  You will notice several things:

  • Ask permission of parts to engage in this (or any other) exercise.  Asking permission gives parts the chance to consent.  Absent that, they know how to communicate discontent and they may communicate it in ways that looks like what we used to call “resistance.”
  • Let the client know how long we will be in this exercise (and it should be really quick).
  • Teach the exercise quickly.
  • I’m not asking for verbal feedback in the middle of the exercise, but I am keeping my eyes on the client and reading nonverbals.  I don’t want to slow the exercise down when I’m first teaching it.  I’ll ask at the end, which is okay, because this exercise is only going to take 60-70 seconds total the first time we do it.
  • I’m adding additional “tasks” to the client’s noticing to promote more active engagement with the senses.  Because, for instance, it’s possible to touch in a fairly disconnected way.  It’s possible to notice objects in a fairly disconnected or dissociated way.
  • We will have already identified something in the room that the client can use for the sense of scent (a candle or essential oil) and possibly taste/temperature (a warm or cold drink) prior to engaging in this exercise.

Script: When we have difficult experiences, those experiences may be stored in the part of the brain that doesn’t or can’t know that the experience is over.  Sometimes, accessing a memory takes us out of the present and puts us into an experience when we did not feel safe.  I’d like to show one strategy that you can use to find your way back into the present.  Often the present may not feel “safe,” but it is likely to be safer than the experience from the bad memory.  The exercise will ask you to very briefly engage your senses, one at a time.  We will spend only a few seconds at a time getting information from each of the senses. If we keep it very brief, many people are able to tolerate this exercise well.  If anything difficult comes up, we can stop.  Is this an exercise that any part of you might object to, assuming that we do it quickly and that you can stop anytime you like?

If there is an objection. Stop and explore that objection.  See if there is a way to do this that is not objectionable to that part that allows us to continue.  Otherwise, full stop (parts will need to know that they can stop).

Vision: I invite you to look around the room and notice several things you see.  Notice several objects and notice the color of those objects.  Also notice that if you were to go up and touch these objects, would they be hard, soft, or some other texture?  [Wait 5-10 seconds]

Touch: Place an open hand on the table or furniture next to you for just a moment and notice if it is colder, warmer, or the same temperature as your hand.  [Wait 2-5 seconds]  Good.  Move your fingertips across the surface and notice if it is completely smooth or has a texture.  [Wait 2-4 seconds]  Good.  Move your fingertips across the texture of that surface and just notice if the temperature changes as you move.  [Wait 2-5 seconds]  Good.

Hearing: I’m going to be very quiet, notice whatever you hear in order of loudest first.  [Wait 5-8 seconds]  Good.

Smell: I’ll give you a few moments to smell the essential oil [or other object] that you selected.  [Wait 5-10 seconds]  Good.

Taste: I’ll give you a few moments to taste, smell, or feel the temperature of the drink that your brought to session.  [Wait 5-10 seconds]  Good.

How was that?  [explore] What was your experience with that exercise?  [explore]  Which of those senses seemed to be the most helpful in bringing your awareness more into the present? [explore]

As with all resources with client with complex trauma, send the client home to practice first at their baseline and not when something has happened that has severely triggered them.  Once the nervous system becomes comfortable with this resource, then use it as a fire extinguisher.

Understanding the AIP Model: The Whale Metaphor and the Mount Everest Metaphor

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The AIP Model

  • The Difficult Stuff Connects to Right Now/Existing Adaptive Information
  • Enough Adaptive Information Must Be Present
  • You Can’t Easily Connect Maladaptive Information to Maladaptive Information
  • What’s Complex About Complex Trauma Related to the AIP Model?
    • A Different Way of Thinking About Complex Trauma
    • Mountain Ranges of Adaptive Information vs Mountain Ranges of Maladaptive Information

The Mount Everest Metaphor

  • You Cannot Metabolize a Trauma the Size of Mount Everest into Adaptive Information the Size of a Walnut—You Can’t
  • Where to Start with Complex Trauma?
    • Where Not to Start
    • Types of Targets that Make Good Early Targets with Complex Trauma

The Whale Metaphor

  • What are the Whales?
  • What is the Size of the Client’s Boat?
  • You Cannot Land a Whale into a Canoe
  • Helping the Client Build a Bigger Boat
  • What Clients Learn when Working with “Smaller” Wounds First
    • Test the Gear
    • Learn How to Notice Effectively
    • They Learn that the Can Heal
    • Healing Builds Adaptive Information/Makes the Boat Bigger
  • If the Client in a Canoe Connects to a Whale we Need a Strong Pair of Scissors to Safely Disconnect

Overheating on the Memory Channel in Complex Trauma

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Topics Covered

  • Goal is to Move a Memory
  • Leveraging Generalization
  • The Difference Between Feeder and Adjacent Memories
  • Rethinking Abreactions as Events that Take Offline the Client’s Capacity to Notice
  • A Bit about Dissociation
  • When a Whole “Heard” of Memories Come
  • We Have an Important Navigational Role to Play
  • Existential Loneliness as Abreaction
  • The Dive Metaphor

Complex Trauma Modifications Overview: Phases One – Four

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This episode is a quick overview of some of the core skills that we will cover in more detail. When I suggest a modification to standard protocol, I try to explain the reasons for the modifications as clearly as possible.

Skills Covered:
  • Additional Questions to Consider in Phase One, Including Assessing for Complex Trauma
  • Conducting a Trauma Sensitive Phase One that Avoids a Detailed or Chronological Trauma Timeline
  • Starting the Process of Developing Attachment Resources for Attachment Wounding
  • Metaphor: Difference Between Walking Across Ohio and Riding in Bus Across Ohio
  • Metaphor: Don’t Tackle Mount Everest First with Clients With Complex Trauma
  • Events Have a Beginning, Middle, and End… Attachment Wounds are About Everything
  • Using the Videotape Approach with Complex Trauma