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Section 17
EDMR in Multiple Traumas

Question 17 | Test | Table of Contents

In the last section, we discussed how you can aid your client in identifying a focus point from a current issue or problem he or she is facing.

In this section, we will discuss how your client with multiple traumas can develop targets.

The Standard Three-Part EMDR Procedure:

Shapiro has described three parts that make up the overall treatment of clients through EMDR protocol. With each section, the clinician applies the standard protocol steps to selected targets, the protocol we have reviewed in previous sections. The three parts are:

1. Past experiences that have been identified as linked to the client’s present problem
2. Present triggers and situations that currently activate the client’s symptoms
3. Future situations linked to the current situation

I have found it helpful in my clinical experience to group similar traumatic experiences together and then target a representative experience from each group. In this way, your client can experience a generalized positive effect without having to reprocess each traumatic memory individually. Shapiro recommends clients identifying 10 most disturbing memories from childhood and then from there assessing the level of disturbance for each memory and organize order of reprocessing based on order of intensity.

In my clinical experience, I have found that organizing the experiences based on their link to the current problem your client is dealing with is best. The closer the memories are linked to the client’s current symptoms, the stronger the treatment effect.

Tips for Developing a Target:

I will now walk through the seven tips that I have found helpful to develop a target as I begin the EMDR process with my clients.

1. Aid your client in lighting up their memory by engaging different elements including an image, negative cognition (NC), emotion, and body sensations related to the memory and help him or her produce an image.

Even if the image your client has is vague, the image will help stimulate the client’s visual memory track. A symbolic or metaphorical image such as a red blob that stands for the client’s anger can be helpful. For other clients, their body sensations can help form a memory. For example, when asked for an image that goes along with the feelings in his or her body a client might reply "I get the image of someone stepping on me."

I used this tip and the following tips with Colby, a 39 year old who served in the military for several tours.

Colby, first opening up to me about his experience, shared, "I have been diagnosed with fairly severe PTSD. I have been able to still function at work and have an understanding boss who knows about my situation. There are some days I have to go and sit in my car because I feel out of control of my own emotions.

After leaving the military, I spent about ten years fighting and having random emotionally erratic episodes. I just chalked it up to my drinking and partying. My family and friends were too worried to mention my temper issues. During that time I finally left my ex-girlfriend who was an alcoholic, not a good pairing.

I am finally with my wife now. Sometimes there are times when my wife knows that she and my son have to stay away from me because I get pretty emotional and unstable for reason’s I don’t understand."

I helped Colby engage his memories regarding his service by asking questions such as: "When you were in that moment, what did you feel in your body?", "What sort of negative thoughts do you have surrounding that memory?", "What were you feeling in that moment?", and "What images does the memory invoke?"

2. Don’t get caught up in the set up order. Your client will provide you with necessary information as it unfolds for them. Maybe your client will reveal their emotions and body sensations regarding the memory before they realize the NC surrounding the memory. Whenever the details are revealed, simply make a note of them.

Colby began by sharing with me what he was feeling during a particularly upsetting mission. Colby shared, "I remember feeling very scared, the most scared I have ever felt in my life. I felt like this was the moment I was going to die." Colby was able to share the negative thoughts he had regarding this memory after a few sessions. He shared, "Because of this event, I think that I am weak and unable to handle difficult problems." It took a while for Colby to share this NC but he shared it in his own time.

3. If you don’t have time to identify subjective units of distress scale (SUDS), positive cognition (PC), and validity of cognition scale (VoC), then move on. While these are helpful steps, they are additional ones that can be skipped. In addition, if these steps interfere with the flow of your client’s process then they can be skipped.

Colby found adding PC distracting as he tried to work through his traumatic memories. Instead of forcing PC into Colby’s EMDR, I stated, "while PC can play an important role in your healing, we do not have to include it in your EMDR process in order for EMDR to be effective."

4. For clients that find it difficult to elicit memories, help your client stay in that memory while different target components are identified and stimulated. Gather information about image, NC, emotions, and body sensations while the client holds the memory.

When Colby was struggling to identify different target components, I had him close his eyes while he held his memory. I also found it helpful to not attempt to get target information in a specific order. I began BLS by tapping Colby’s knees when I felt I had the memory network well stimulated.

5. Continue with the NC that best stimulates a strong emotional response. I help my clients by stating, "The negative beliefs are often formed unconsciously at the time of the trauma."

For Colby, the strongest NC was the first one that he formed: "I think that I am weak and unable to handle difficult problems."

6. Emotions should be emphasized. If your client is struggling to identify emotions, have him or her focus on body sensations. Don’t push for a label if the client feels something but doesn’t know what to call it. Here is a dialogue I had with Colby.
Clinician: What did you feel in that moment?
Colby: I am not sure.
Clinician: That is ok… What did you feel in your body?
Colby: I felt tense and almost numb.
Clinician: Does that spark any feelings?
Colby: I guess I felt scared in that moment.

7. Have your clients scan their body and note any sensations as they focus on their memory. I did this with Colby by asking, "What are you feeling in your body right now as you bring up the image?"

Triggers and Flashbacks as Targets:

I have found that many clients become triggered by experiences in their daily lives that end up being good EMDR targets. For example, here is the conversation I had with Colby regarding an incident he had when his wife walked up behind him and unintentionally startled Colby.
Clinician: When you think about the image of your wife sneaking up on you, what do you believe in yourself?
Colby: I’m not safe.
Clinician: What emotions do you feel when you bring up the image?
Colby: Fear and anger.
Clinician: On a scale of 0 to 10, how disturbing to you is the image? 0 is no disturbance or neutral and 10 is the most disturbing.
Colby: 10.
Clinician: Where do you feel that in your body"
Colby: in my chest and arms.
Colby and I then moved on to discussing how he thinks the trigger is related to his past or to an earlier memory.

Many clients also experience flashbacks that can become targeted with EMDR. With these clients, they may not be aware of what their flashback refers to and have very intense emotional responses. You can reassure your client that the information that is needed about the flashback will be made clear during the EMDR process.

Connecting Technique- Bridging from Symptom, Issue, or Current Problem:

Often clients come in because they have symptoms, issues, or current problems they are dealing with because something in the past is distressing them. I have found that the connecting technique is effective for clients that do not have clear memories that link to their symptoms such as a client working on low self-esteem but can’t remember a specific incident that caused her to have low self-esteem.

I have found the bridging technique helpful for a variety of symptoms including phobias, insomnia, procrastination, aversion to sex, anxiety, low self-esteem, work problems, relationship issues, and intimacy problems.

You can use the steps of targeting outlined in the previous section and incorporate the tips discussed in this section to help your client connect their current problem to the earliest root memories.

In this section we discussed how your client with multiple traumas can develop targets. The seven tips we discussed are lighting up a client’s memory by engaging different elements including an image, negative cognition (NC), emotion, and body sensations; don’t get caught up in the set up order; if you don’t have time to identify subjective units of distress scale (SUDS), positive cognition (PC), and validity of cognition scale (VoC), then move on; help your client stay in that memory; continue with the NC that best stimulates a strong emotional response; emotions should be emphasized; and have your clients scan their body and note any sensations.

We also discussed that Shapiro outlined three parts that make up the overall treatment of clients through EMDR protocol. The three parts are: past experiences that have been identified as linked to the client’s present problem; present triggers and situations that currently activate the client’s symptoms; and future situations linked to the current situation.

In the next section we will discuss…

Parnell 148-157 case study: http://woundedwarriorukraine.org/personal-stories-of-ptsd/
Reviewed 2023

Update
To Predict, Prevent, and Manage Post-Traumatic Stress Disorder (PTSD):
A Review of Pathophysiology, Treatment, and Biomarkers

Al Jowf, G. I., Ahmed, Z. T., Reijnders, R. A., de Nijs, L., & Eijssen, L. M. T. (2023). To Predict, Prevent, and Manage Post-Traumatic Stress Disorder (PTSD): A Review of Pathophysiology, Treatment, and Biomarkers. International journal of molecular sciences, 24(6), 5238. https://doi.org/10.3390/ijms24065238


Peer-Reviewed Journal Article References:
Balbo, M., Cavallo, F., & Fernandez, I. (2019). Integrating EMDR in psychotherapy. Journal of Psychotherapy Integration, 29(1), 23–31. 

Houben, S. T. L., Otgaar, H., Roelofs, J., Wessel, I., Patihis, L., & Merckelbach, H. (2021). Eye movement desensitization and reprocessing (EMDR) practitioners’ beliefs about memory. Psychology of Consciousness: Theory, Research, and Practice, 8(3), 258–273.

McLay, R. N., Webb-Murphy, J. A., Fesperman, S. F., Delaney, E. M., Gerard, S. K., Roesch, S. C., Nebeker, B. J., Pandzic, I., Vishnyak, E. A., & Johnston, S. L. (2016). Outcomes from eye movement desensitization and reprocessing in active-duty service members with posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 8(6), 702–708. 

“Rumination and mindfulness related to multiple types of trauma exposure”: Correction to Im and Follette (2016) (2017). Translational Issues in Psychological Science, 3(1), 33.

Shapiro, R., & Brown, L. S. (2019). Eye movement desensitization and reprocessing therapy and related treatments for trauma: An innovative, integrative trauma treatment. Practice Innovations, 4(3), 139–155. 

QUESTION 17
What are the seven tips to help your client with multiple traumas to develop targets for EMDR? To select and enter your answer go to Test.

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