Report by Helena Laughton, EMDR Bedfordshire Steering Group Member
Thirty EMDR practitioners from across the region attended this skills-based day on how to use the Standard Protocol in your own clinical context. Attendees ranged in experience from those having completed Part One training to accredited consultants.
Christine Habermehl kicked off the day, welcoming Richard Holborn who had come to support the Bedfordshire regional group from the EMDR association East Anglia.
Jenny Arthern welcomed and introduced our esteemed speaker John Spector. John, a Consultant Clinical Psychologist, was a pioneer in EMDR: the first person from the UK to train with Francine Shapiro, the first to offer training in the UK and the first to publish about EMDR in the UK.
He has been key in the acceptance of EMDR as a therapy of choice for PTSD and was asked to consult with the National Institution of Health and Clinical Excellence resulting in the inclusion of this therapy in the 2005 guidelines for PTSD.
John started the morning by giving us the background of his journey with EMDR, fleshing out the introduction above and recalling the difficulty getting EMDR accepted initially. He then took us through the detailed handouts he had provided and encouraged everyone to participate in an open questions session.
The first two handouts were an outline of the EMDR Standard Protocol. John told us that there are at least two to three studies that show the closer you stick to the procedural steps the better the outcome.
He reminded us that every word you use carries meaning for the client and if you use different words in a different order you will get different results. The protocol is the result of much refining and we should thus try to stick to it as far as possible, especially when we are less experienced.
Following handouts included: How to Return to Target in Incomplete EMDR Sessions, Tips for Working with Hyper-aroused Clients, The Flash-Forward Procedure, the Back of the Head Scale, the Method of Constant Installation of Present Orientation and Safety (CIPOS), the Loving Eyes Intervention and a list of papers that John had found helpful.
John strongly recommended going to presentations by Jim Knipe and Dolores Mosquera. He also highlighted the importance of taking a careful history and advised us to treat every case as a complex case, which may take a few more sessions but would pay off through selection of right target, NC and PC and offering adequate preparation.
Another participant asked what John thought about letting the client choose their own targets versus starting with the most intense experience.
John stated that we wouldn’t always go for the most intense if the client were not robust enough. He said that as clinicians we have a responsibility to do a full history and to draw up a collection of targets giving guidance on what will be most productive. However we must not get into an argument with our client and thus may decide to go with their preference.
There was a question about a client who suffered with chronic pain and found that pain intensity increasing during processing. John pointed out that whilst some pain was just organic, much of it is body memories and will be triggered once you target a memory where pain featured in the trauma.
He advised reading the book ‘The body Keeps the Score’ by Bessel van der Kolk and stated that the art of EMDR was to keep the client in the window of tolerance. Other participants suggested that CIPOS could be used, or Mark Grant’s protocol for pain.
Another participant asked how might EMDR be used by those not having English as their first language and what blocks were associated with that.
John stated that it was not necessary for the therapist to know everything that happened. It’s enough that the client brings it up themselves and just reports how it’s changing. It would be possible to use the ‘blind to therapist protocol’ (Blore & Holmshaw).
He also stated that where there is a language problem and you need an interpreter you don’t know how the nuances are being conveyed and things will take longer. The relationships with the interpreter are vital elements of the success; Sandi Richman has presented on this.
After the coffee break there was a live EMDR demo with two volunteers from the room after which participants were invited to comment on what they had seen. This highlighted the importance of spending time identifying the right NC and PC. John advised that spending time on history gathering use of Socratic questioning help to get the cognitions, which should be generalisable.
John demonstrated the positioning of the chairs, noting that many therapists place the chairs too far apart.
This may mean the therapist is within the client’s line of sight which may be distracting and may also lead to the therapist having to reach forward to generate hand movements leading to shoulder injuries.
He also suggested taking time to check distance and speed of EMs with clients by starting close and slowly moving back until the client is comfortable and by starting slow and gradually speeding up to the fastest the client can manage as the best results come with fast EMs.
There was a discussion about what to say at the end of each set. John suggested ‘”Let it go” (they have been exposed to the trauma, they can now let it go), followed by “Take a deep breath” (counter conditioning), then “What did you notice?” or “What did you get?” or “What do you get now?” (chance to reflect).
He stated that it is unlikely to make a difference whether we say “Notice that” or “Go with that’ but that we should not say “Stay with that” because we always want to encourage movement and processing. He reminded us that we are governed by an information processing model and that we are looking for change.
After lunch John ran a session on blocked processing, reminding us to ask ourselves the following questions: Has the preparation been thoroughly done? Are the PC and NC correct? Has the client been properly educated in trauma and EMDR? Have fears/resistances been processed? Has depression/guilt/shame/ego strength been accounted for? Has a good therapeutic alliance been built? Any secondary gains for staying dysfunctional?
If all the above has been accounted for. then the first thing to try is to do is change the BLS.
Following this the therapist can use Cognitive Interweaves to address issues around responsibility, safety and choices. Use it when the client is looping, where the client doesn’t have sufficient information, where there is lack of generalisation or where there are time pressures.
John advised that it could include introducing new information, stimulating held information, Socratic method, metaphor/analogy or verbalisation.
John advised not to offer CIs that get into a discussion explaining: “It’s a right brain therapy. We don’t want to get into a left brain conversation”. John also discussed distancing strategies for stuck images.
The afternoon sessions focused on discussion of case studies provided by the participants. Advice was given about working with ASD and intellectual disability (you can do it with some adaptations), we were encouraged to get SUDS to a zero (“What’s keeping it at a one?”), using resources to explain to clients about the limbic system so that they can understand their persisting fear responses.
For clients with the blocking belief “I can’t get over this” consider use Knipe’s Level of Urge to Avoid.
After final questions from the floor we thanked John and gathered evaluations sheets which will reflected upon by the members of the steering group.