(Working Title)
EMDR Clinical Skills: Case Conceptualization and Dyadic Resourcing
Philip Manfield, Ph.D.
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Contents
The following is the full table of contents. In the sample chapters you have downloaded , only the int roduction and Chapters 4-8 are included. The entire book can be downloaded for a fee of $10. An automated webpage is being created for this purpose. It will be accessible from www.p hilipmanfield.com by first clicking on "Books by Dr. M" at the top of the page . A printed copy and DVD will also be available. Readers interested in being notified when EMDR Clinical Skills: Targeting and Trauma Processing is ready for publication or when DVDs illustrating EMDR Clinical Skills: Case Conceptualization and Resourcing are available, should email the publisher at . (Emails must contain the words “EMDR clinical skills” in the subject or body.)
Section I: Case Conceptualization (NOT INCLUDED)
Chapter 1: Case Conceptualization
Chapter 2: Case Conceptualization from a Top 10 List
Chapter 3: Case Conceptualization of Complex PTSD from a Top 10 List
Section II: The Resource Dyad
Chapter 4: Resourcing in the Prepara t ion Phase
Chapter 5: Steps to Develop a Resource Dyad
Chapter 6: Uncomplicated Resourcing Sessions
Chapter 7: Vicariously Experienced Resources
Chapter 8: Connecting to Affect
NOT INCLUDED:
Chapter 10: When Trauma Processing is Not an Option
Chapter 12: Use of an Imagined Nurturing Relationship
Chapter 1 3 : Attac h ment Issue
Appendix A: NLP Accessing Cues
Appendix B: Installing Safe Place/Time/Person
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Introduction
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EMDR began twenty years ago as a technique for resolving single incident traumatic memories. Gradually, over the years, its use has expanded, until now it is used for a wide variety of conditions and has become a psychotherapeutic approach. Throughout this expansion, obstacles to EMDR processing for various types of clients or problems have been encountered and solutions have been found to overcome them. “Cognitive interweave,” an intervention to catalyze connections between traumatized states and adult perspectives, was probably the earliest of these solutions. (Shapiro, 1995, 2001) Resource Development and Installation (RDI) was introduced as a resourcing technique (Leeds, 1998) to facilitate clinical progress in situations where clients perceived themselves as lacking the necessary personal qualities to take on and resolve a particular traumatic memory. In this volume, I introduce a form of resourcing that allows EMDR to go further, and effectively resolve traumas that have continued to represent obstacles for EMDR therapists. The clients for whom this particular type of resourcing is especially important are the ones who were traumatized or neglected at a very early age. They lacked early support from caregivers, and so the resource that they require for resolution of these memories involves a caring relationship. I refer to this type of resourcing as “dyadic resourcing” for reasons that will become clear as the process is described in detail.
During case conceptualization, clients may be identified who are likely to have difficulty with EMDR processing because their trauma began very early in life, typically resulting in attachment problems. For these clients, early traumatization was particularly unbearable because of the lack of nurturing support or protection from adult caregivers. These clients will resist recalling those early traumas if recalling them will simply be a repetition of their early experience. To make the current recall experience different from the original event, they require the adult support that they did not receive in the original experience. The dyadic resources that are demonstrated in this volume are relational resources. They represent a relationship between the “child” ego state that is triggered when certain early traumatic events are mentally accessed and an adaptive adult perspective (resource). The client eventually experiences this relationship as a loving one in which the adult who holds the adult perspective loves and accepts the child self who experienced those early traumas. With this resource, recall of the early event is not retraumatizing because the child self is supported, which makes these very early memories bearable and facilitates reprocessing using EMDR.
When I began offering EMDR trainings, I had observed nearly 50 EMDR trainings offered by the EMDR Institute, the private organization created by Francine Shapiro. At these Institute trainings, videos – sometimes with actors playing the role of the client – were used to illustrate various teaching points. As a non-Institute trainer, I was unable to use these videos in my trainings, so I offered live demonstrations of various aspects of EMDR. I was surprised to notice the lack of anxiety I felt conducting EMDR demonstrations in front of a class. I did not know exactly what the outcome of these EMDR sessions would be, but I was confident that I would be able to address the client’s problem and that the outcome of the processing would be helpful to the client, if not always a complete resolution.
Direct EMDR trauma processing does not work in many cases. The cases where it works best are the ones for which it was originally designed – clients with a history of one or more single incident traumas. When I would sit down with a demonstration client and attempt to do direct EMDR trauma processing, I would first assess the client’s readiness. Doing these demonstrations made me realize how integrated resourcing has become for me with case conceptualization and trauma processing. I essentially assess the client’s needs and capacities, and decide what she is ready for. If she is not ready for direct trauma processing, I look at what she will need first to help her become ready, typically resourcing for stabilization. In each case, I am attempting to offer the client only what she is prepared to handle.
One question I ask to evaluate a client’s readiness to process a particular early target is how the adult client feels towards the traumatized child. Of course, when a client thinks of an actual traumatic event, the client’s view of the child experiencing the trauma will be distorted. It is this distortion that is captured in the “negative cognition.” In evaluating the adult client’s attitude toward her child self, I do not ask her to think of the memory, but rather of the child. I ask her to bring up an image of herself as a child of the age she was when the target event occurred, and to describe the visual details. The process of describing what the adult sees in the image helps to ground the client in her adult perspective. If the adult bringing up this image can not feel caring and compassion for the child, I do not expect trauma processing to proceed smoothly, because the adaptive adult perspective that will be a necessary part of the eventual resolution of the memory is not readily available.
In these situations, when I determine that a client is in need of a greater sense of caring and appreciation of her child self, I instead turn to dyadic resourcing as a way to gain access to that caring adult perspective. I begin by exploring whether she has sufficient access to an internal model of a caring adult and, if so, whether that caring adult can maintain that caring stance when focusing on herself as a child. Some clients can identify with the caring adult part of themselves, but become critical or judgmental when they think of themselves as a child. The objective for the EMDR therapist is to help these clients feel towards themselves as they do towards other children. Those who can maintain that caring perspective towards themselves as children are relatively easy to work with.
Others have difficulty locating an internal model of themselves as a caring adult, and in fact, typically labor at identifying any caring adults. These clients are more challenging to work with. The dyadic resourcing process described in this book enables these clients to identify examples of caring adults, and to build them into powerful internalized caring adult selves who are able feel compassion and caring towards their own traumatized child selves. In short, dyadic resourcing enables these clients to provide their own internal support that makes EMDR trauma processing possible for the internal traumatized child. With the help of cognitive interweaves built around this resource, EMDR processing allows the client’s view of her child self, and by extension her entire self, to change from a defective, unloveable, worthless, weak, or bad person to a loveable, innocent, well-intentioned, good person.
As I began writing this book, a friend and colleague mentioned an adage to me: “Practice does not make perfect; perfect practice makes perfect.” Just as clinical consultation makes more perfect practice possible, I hope that this book and its sequel will also help readers make their EMDR practice more precise and more effective. In addition, it may also open up possibilities for using EMDR effectively with a wider variety of cases.
Nearly from the beginning, the development of EMDR has been guided by the principle of knowing what therapeutic processing looks like when it works, and then, when it isn’t working, asking what is different about this process from those processes that worked. The cognitive interweave was developed as a way to jumpstart processing when it had stalled. Dr. Francine Shapiro, the founder of EMDR, noticed (1995, 2001) that during successful EMDR processing, distortions related to responsibility, safety and choice seemed to be addressed in that order. She reasoned that if one of these distortions was not resolving, it would be necessary to facilitate the resolution of that distortion before the others would resolve in turn.
This book is about clinical interventions that work. For the most part, it contains transcripts of complete treatment sessions. It addresses clinical issues on the most basic level, the way the therapist interprets the client’s comments, the effects of the particular words the therapist uses, analysis of what precisely is preventing the client from moving forward, and discussions of the solutions available to the therapist in each situation. On the one hand, the book is designed for therapists who have mastered the basics of EMDR and now know enough to recognize some of the areas in which they need more information or training. On the other hand, it is designed for EMDR clinicians practicing what they have learned imperfectly, and EMDR-trained clinicians whose training from many years back did not include many of the advancements developed only after they were trained.
There is no substitution for experience and good clinical consultation. This book and its sequel, however, should help. In them, I discuss many of the issues that arise repeatedly in my clinical case consultation groups. Therapists use both their successes and failures in actual clinical practice to improve their craft; I hope that viewing or reading clinical sessions in this book will provide much of the same benefit as clinical experience, but have the added advantage that these sessions were selected for inclusion because they are particularly instructive. Also, because they are not happening in real time, it is possible to stop frequently and discuss the details of what is taking place in the transcriptions, as well as discuss the clinical issues involved.
This book is in no way intended as an EMDR manual. It does not replace Shapiro’s EMDR: Basic Principles and Protocols (1995, 2001). As its title indicates, Shapiro’s book explains the principles and protocols of EMDR; it is intended to include everything that is covered in the basic EMDR training. Its completeness, however, limits the degree of depth to which it can delve into any particular topic. It does not address many of the various practical clinical situations that arise when clinicians newly trained in EMDR are actually conducting EMDR sessions, especially when their clinical experience with EMDR does not match the model described in Shapiro’s book. This book and its sequel pick up where Shapiro’s leaves off. They are about what clinicians encounter when they leave the training and attempt to put EMDR to work in their clinical practices; they are about the practical problems that clinicians encounter when they begin conducting EMDR.
Clinicians newly trained in EMDR often struggle to begin using EMDR and integrating it into their practices. Part of the reason for this is that they may not have many clients coming in their door suffering from the effects of single incident traumas. Clinicians want to start with relatively easy clients, but they may not have easy clients in their practices. Many are understandably hesitant because they feel like novices in EMDR, and they are accustomed to being experts, and their clients expect them to be experts. On the other hand, there are therapeutic approaches that they have been using for years, in which they have become quite expert. They have had many years of practice in using these approaches, and so these approaches can seem more appealing than EMDR. But, as the adage points out, this practice is far from perfect in the face of a clinical approach that can reliably produce superior results in less time.
So, how does a clinician make the transition from being trained to being expert? This is a topic of current concern among EMDR trainers who are trying to address the issues that prevent trainees from integrating EMDR into their practices. The recent inclusion of ten hours of required consultation as part of the basic EMDR training was a positive step in the direction of increased utilization of EMDR by training graduates. This book is also intended to help clinicians, even those who have held off from actively using EMDR in their practices, to achieve greater expertise and confidence in conducting EMDR.
In my trainings, I suggest a triage approach when beginning to use EMDR. I suggest that the very minimum a clinician can do is take a thorough trauma-informed history. As does Shapiro (1995, 2001), I recommend beginning this process by finding out what are the client’s Top 10 most disturbing memories. I add to this a recommendation that clinicians ask for of a list of the client’s Top 10 best memories. I tell trainees that whether or not they actually conduct EMDR with a client, the treatment will be facilitated by obtaining this information. Any clinician, no matter how timid about utilizing EMDR, can take this minimal initial step. The processes of obtaining a trauma-informed history and conceptualizing about a case are part of Phase I (History) of the EMDR 8-phase procedure, but clinicians always have the choice of not proceeding to Phase II (Preparation). Taking a history will be beneficial whether or not EMDR is utilized in the treatment. History-taking and case conceptualization are the focus of Section I of this book.