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The Therapeutic Process

Learn more about EMDR and the therapeutic process of healing. .

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Bill here for LifeResource Ministries.

We’re talking today about EMDR again. The title is EMDR – The Therapeutic Process.

In the first video of this series, we introduced you to a teenage girl who refused to go to school. If you didn’t see that video and the one that followed, you might want to watch both of them so you can have the complete story. You can see both of them on this channel, LifeResourceVideos, or you can access them from our Website, lifereource.org. On the Website, we also have mp3 files you can download or transcripts you can read.

So this girl, as you may recall, lost a family member in a convenience store killing when she was much younger. We also learned that her father had abandoned her family when she was very young and most of her interactions with him later were disappointing to her. He would promise to do things with her, or for her, and then, most of the time, not follow through.

We postulated that her fear of school stemmed from the traumatic loss of a loved one and that loss was intensified by the loss of relationship with her father. How would we help this girl diminish her fear of school and restore a sense of well-being? Well, I’m going to show you what she and I did together with the idea that, if you or someone you know needs help, you’ll have some idea of what might happen once in the office.

First, we’re going to look at the eight-phase protocol mentioned in the first EMDR video that we did. That eight-phase protocol is what gives EMDR its power.

The first phase is history and treatment planning. In our initial meeting with this girl and her mother, they explained to me that she freaked out – meaning she would have a panic attack, or come close to it, when she went to school. In the rest of that session, after her mother left, I quizzed her about her likes and dislikes, best things, worst things, what it was like for her to go to school, what she’d gained, what she’d lost from not being able to go. And at this point, I’m just waiting for her to feel more comfortable with me, and kind of get a bead on what kind of person I am, and to help her feel comfortable and safe. I remember, in that first session, she asked me if she was going crazy. So we can see how afraid she was about these unexplainable episodes. So I explained to her that when a fear like this just suddenly appears in our life, there’s always a really good reason for it, even if we don’t know what it is. And that it doesn’t mean that we’re going crazy. I told her the reasons are usually related to other frightening events in the past, like the ones we just discussed. I also explained that we would have to become a couple of detectives to find the things that might be causing the problem. So right there, I’m trying to introduce the idea of working together. And I remember, after I made that statement, she said, “My mother and my other therapist think I’m just trying to duck school.” And I said, “But I thought you said you loved school, and liked to work hard, and got really good grades, and liked having friends.” And she said, “Well, that was all true until I started freaking out.” And I said, “Well, there you go then. Anybody who freaked out at school wouldn’t want to go.” From the beginning, I’m working to build an alliance with her, so she can feel safe and supported. It’s really important for a young person, who is afraid of a lot of things, to feel safe and unafraid in my office. It helps her to do that very hard work that she has to do.

Now, at this point, I didn’t know specifically why she was not going to school. So I went down a symptom list and I gave her a PTSD screen. And she did have a PTSD with its attendant depression, anxiety, insomnia, panic attacks, and feeling the need to be on alert all the time. So I asked her to start thinking – after we got done with that – I asked her to start thinking about the ten best things that ever happened to her –and we made a list – and then the ten worst things that made her feel sad, afraid or worthless. Three of those things had to do with her father. Four had to do, more recently, with the loss of the loved one. And three had to do with school. It took two sessions to accumulate all this information, as she was somewhat scattered about it, which I took to mean that her memories of these events were not encoded adaptively. We covered that last time.

So we talked about what order in which to process these events and I explained to her that, even though her experience with her father seemed to have nothing to do with her fear of school, it probably did make it worse. And I thought that, if we could start there, we would get better results, but the choice I was going to leave up to her. So she agreed to go with her father first, which means she’s relying on me and trusting me to make a good choice for her.

Okay, two sessions and we’re done with phase one – treatment planning. And now we move into phase two, which is preparation.

At the beginning of the third session, I took part of the session to explain how EMDR works to her and her mother and got consent from both of them to use it. One of the goals of this therapy is to make sure clients can take care of themselves out of session while they’re doing the treatment. Preparation can take as little as one session or much more, depending on the state of the client. This girl needed only one session. She had pretty good ego strength. And she processed things well.

I like to accomplish two things at once by teaching a relaxation technique called the safe place. I use eye movement to install it. I also teach several breathing and meditation techniques and most people report them very helpful. While we’re working on these, the client gets to use the lights, buzzers, ear phones or tapping, and we learn which ones of those work best for them. The client gets to see how bilateral brain stimulation affects their thought process. You may remember that she could not come up with a safe place, so I explained that, if she thinks about her breathing – she’s not in the past, thinking about her losses, nor is she in the future, afraid of what might happen, but she’s in the present moment, realizing that she is okay and breathing, which is a safe place to be. So I told her that the more she works at focusing on her breathing, the easier it will get and the better it will calm her down when she’s freaking. I also taught her the butterfly tap, which is like this: you make a butterfly out of your hands and touch your thumbs together, and you tap like this on your chest with your index fingers just under your collar bones. I don’t want to do it because I’ll tap the mike, but you just tap with your index fingers and hands just under your collar bones. They tell me there’s an acupressure point there that relieves anxiety. Then I assigned her three minutes of each kind of breathing each day – at night, while she’s in bed and can see her clock on her night stand. I later found out that she liked an exercise called the light stream. So I installed that and practiced it with her and used it when she got stressed.

So that’s preparation – phase 2. The next phase is called assessment. Now I’m going to skip her relationship with her father and go to the issue, which was losing a loved one. And I’m doing this because the events that occurred with her father are so specific that it might degrade her confidentiality. But I can tell you that processing past negative events with her father was complex and it took quite a few sessions. However, as it turned out, once she started feeling more lovable and worthwhile, her feelings about the loss of a loved one changed dramatically, and it was much easier to process that event – that traumatic event.

When we started on the murder of a loved one, I asked her if she could find a memory of that event that felt like the worst one to her, or the saddest, or scariest. And she came up with one. And I asked her, when she thought of that time and that picture, how did it make her feel about herself? And she said, “I felt like I was in danger.” “And how would you like to feel about yourself today?” And she said, “Well, I know I’m safe, but I always feel unsafe. So I’d like to feel safe as well as know it.” And I said, “So you did very well! Most people have a really tough time with that one – even the adults. How true is it that you feel safe now, on a scale from one, which would be the least true, to seven, the most true?” And we call this VOC – validity of cognition – and we use it to judge progress. She said, “One. I’m afraid most of the time.” So this part is really important. We’re more controlled by how we feel than how we think. “I know I’m safe” isn’t as powerful as “I feel afraid” in this girl’s life. So this might be a no-brainer, but I do need to hear it. “What emotions come up for you when you think about it?” She said, “Fear.” “And how strong is the fear on a scale from zero to ten?” She said, “Maybe a nine.” So we call that measurement a SUD – subjective unit of distress. And we use it to judge progress. “And where do you feel the fear?” “In my stomach, like tense.” I said, “Okay.”

So that’s assessment. We’ve assessed how strong the upsetting event is and we’re now ready to move on to the fourth phase, which is desensitization.

I asked her to think about the memory – the emotion – and notice where she felt it in her body, and I turned on the light for about thirty-six passes. She reported feeling anxious.

She reported seeing police, ambulances, yellow tape, family members crying or angry, hearing sirens, a crowd of neighbors standing outside the yellow tape, and the paramedics bringing a body bag on a gurney out the house to the ambulance. How unfortunate that she had to be there! This feels a bit like the face of your mind is a movie screen – the therapist’s office the theater – and the memories pass by one by one, like the images on a screen, but very actively tracking what’s coming to your mind, but not controlling the flow – just letting the thoughts, images, emotions and body sensations come as they will. Of course, they’re all stimulated by the bilateral stimulation, and, as those thoughts come up, they’re actually being re-encoded.

While we were doing that, at one point, she said, “I’m almost ready to freak out.” So she trusts me enough to work with me and disclose her state of upset. And I said, “Okay, let’s breathe a bit.” And I synced with her breathing and breathed with her, and I said, “Pretend that the light bar is two blocks away from you, and let’s continue and see how that goes.” So that seemed to help.

So let me say here that, for the most part, her mind was going from one memory after another, related to the memory that she came up with to begin with – the traumatic memory. That’ what we like to see, but sometimes it doesn’t work that way. Sometimes, the mind can go blank, or we can find ourselves thinking about something that seems unrelated, or we can loop back to the same material we processed earlier, or many things can come at once. And when these things happen, some people worry that they aren’t doing it right. But all of those things happen for a reason and EMDR clinicians know what to do with all of that. So, if you ever do EMDR, don’t worry about it. Just report what you get and everything will be fine.

Okay, back to the girl. After about fifteen minutes of processing, her memory began to turn less fearful and more positive. I asked her if the image had changed any, and she said, “Yes, it’s further away.” “And on a scale from zero to ten, how upsetting is it?” She said, “Zero.” So that’s what desensitization looks like. The image – the memory of it – is no longer upsetting.

Now on to phase five – installation. The idea here is to strengthen the positive thought that has emerged. Her’s was “I am safe.” “And how true is it now that you feel safe?” And she said, “It’s a seven.” “So what are you thinking about that now?” She said, “Well, we’ve always had a burglar alarm, and we lock the doors every night, and my mom is always home, but before that never seemed to help. And now, it does.” “Where do you feel that sense of safety in your body?” “In my heart. And my stomach is relaxed.” And I said, “Okay, that’s great. Think about safe in your body and watch the lights.” So I left it on for two passes – I don’t mean passes; I mean sets – and nothing negative emerged.

So that’s installation – phase five. So we installed that positive view of self as safe. And then comes phase six, which is called body scan.

Now I said to her, “Start at the top of your head and scan down your body to see if you can find any stress anywhere.” She said, “Just a little in my stomach.” “Okay. Just focus on the feeling and watch the lights.” And after two sets, the stress was gone. I said, “How do you feel?” She said, “Good! That’s so cool!”

So that’s body scan. Now, on to closure. We try to ensure that everyone leaves every session feeling better than when they arrived. If they didn’t get finished with a target, for example, they may be feel upset, so we take some time helping them calm down, use their calming techniques and remind them to record anything that comes up between sessions.

With this girl, she was good to go – quite calm. I did ask her to think about what it would be like to go to school.

So we come to the eighth phase – the final phase – which is reevaluation. Now a session is kind of like a sandwich – the meat’s in the middle. We use the beginning to acquire new information and reorient and the end to ensure well-being.

When the girl came in for her next session, I asked her about her subjective units of distress and her validity of cognition, and they were both still holding at ten and seven. I’m sorry – zero and seven. And I asked her what happened when she thought about going to school. There was still some anxiety. The numbers were down – related to the past – but anxiety would come from not knowing what was going to happen when she went to school.

So that leads us to the realization that EMDR is not only a therapy for the past, but also the present and the future. You know, anxiety is a cyclical thing. We become anxious – maybe we have a panic attack – and then we become anxious about having a panic attack. So it all escalates. We become more anxious as we worry about being anxious.

So we spent the next few sessions working on her current feelings about going to school. I asked her to imagine driving with her mother to the school, but coming right home. She took that to zero very quickly. I asked her to imagine driving to the school and walking up to the front door. We took that to zero. Then we started over again and we had her in class, and at lunch with a little anxiety. We worked that and got it to zero. And then I asked her to run a movie in her mind of going to school and feeling good about all of it. And she did that and reported feeling triumphant. So I asked her if she was ready to try it and I had her mother drive her by the school. No problem. On the next run, she went up to the front door. No problem. In fact, it went so well, they went in and went to the administration desk in preparation for reenrollment. The next day, they actually reenrolled and then they went into the counselor’s office and she experienced no anxiety there. She was then sent to class with the understanding that she only had to stay for one class if she was stressed, and she should breathe if she got upset. Well, she was a bit jumpy when she went into class, but she reported that she breathed a bit and was soon fine. She stayed all day. Game over. She won! She was not only back in school, but feeling very much better about herself. Her outlook was more positive and getting more so all the time.

Okay. Let’s talk a little bit about the relationship between this girl and me. EMDR can get pretty mechanical. And that’s how we get the results. But with most of my severely traumatized clients, and with teenagers especially, it’s important to take extra time to build a good therapeutic alliance with them. It helps them to know that I care about them, that what they feel is important, that they can ask any questions, say anything, and they will not be judged negatively. With teens, I sometimes text them, during the week, to see if they’re okay, if they’re doing their homework, etc. This lets them know that I’m thinking about them out of session. I do that for adults too, if they’ve had a particularly rough session, sometimes. If they seemed disturbed when they come in, I explore that with them and help them get in touch with their emotions. And all this greases the rails, so to speak, of the therapy.

This girl, after a bit, warmed up quite quickly and she knew that she wasn’t afraid when she was with me. She couldn’t find a safe place when she began, but she told me later that I became her safe place. When she was in my office, she felt safe. She would ask my opinion about things, and want to know what I thought, and was curious about me personally, and would text me to tell me about things that were happening – successes and failures, or little tidbits. And all that showed me that she felt connected and that we were a team. That’s very important, because I need good feedback from her in order to take good care of her and help her move forward. So I believe the talking helped her. She was a girl without a caring father, so I could make a little bit of a contribution that way, too – not to take his place, but a different and positive experience with an older male.

With this therapy, we’re talking about changing perceptions, strategies, emotions, etc. The changes occur so rapidly that sometimes people even don’t realize they’re behaving, feeling and thinking differently. A new neuro-network, unless it’s used, will degrade. So I believe it helps to use them immediately. I kind of think of it as pouring concrete around some fence posts I installed in my backyard.

Some of my clients are referred from other therapists. And I encourage them to keep seeing their talk-therapists, if they can afford it, and to talk about what they’re learning from their EMDR. And that seems to produce exceptionally good results for them. And I think it goes back to using those neuro-networks. If they can’t do that, then I make an effort to engage them about what’s going on internally.

Okay. Shifting topics. Where can a person get help? Well, the EMDR Institute has a Website. It’s emdr.com. On it, there is a page to help find local therapists. The people at the top are usually training facilitators. And they’re usually very busy. If you can’t get in to see one of them, they can usually help you find someone who can see you.

Okay, that concludes our series on EMDR. I used to think that, as I got older, I would get better, have more control, be less depressed, less anxious, but that isn’t true unless we make it come true. If we don’t tend to the losses and the hard things of life, they can pile up and overwhelm our resources for handling them.

It reminds me a lot of a big city. You know, they take everybody’s small pile of garbage and pile it up in one place until it becomes an unmanageable problem. If we all had a compost pile in our backyard, we could turn our garbage into something helpful. It’s the same way with our emotional problems. When we are anxious and depressed, and we don’t do anything about it, our resources can soon be overwhelmed. I meet lots of people in their fifties who are so depressed they can hardly get out of bed, because they’ve never really talked about what’s going on with them. When we’re anxious and depressed, walking the Christian walk becomes way more difficult. It’s harder to have faith. It’s harder to have hope. It’s harder to set a good example. It’s harder to meet our responsibilities. God wants us to take care of ourselves – body, mind and spirit. Better to use good mental health practice and take care of things as they come up. Depression, anxiety, PTSD, panic disorder – these things can be taken care of. The longer we put it off, the worse it gets. The older we get, the harder it is to change. That said, it’s never too late to feel better, to exemplify Jesus Christ in our life, to fulfill our mission by walking the walk.