A Simple and Metaphor-Guided View of Working with Complex Trauma using EMDR
Phase One of EMDR therapy is an important part of the recovery process. It is often the point where a new client meets his new therapist. First impressions matter, particularly to people who are in a high state of distress and are seeking therapy more from a place of survival than from a place of personal development. In that first contact, a lot of information will be communicated and more will remain unspoken. Some of the critical tasks in Phase One can be started in an initial session, but EMDR therapists seasoned in the work and struggles of complex trauma view Phase One (and each of the phases) as an ongoing and evolving process.
Phase One is Also an Assessment of Adaptive Information
It does not matter where we want to go if we don’t have a reasonable sense of where we are right now. Knowing “where the client is” is an essential part in developing a plan of treatment that might move the client in the direction of his goals. However, this process is much more involved that simply gathering enough information to make an initial diagnosis and lining up some potential targets. Phase One is not primarily an assessment of “what happened” to the client. Particularly for clients with complex trauma, it should be a comprehensive assessment of client struggles, client goals, the ways they managed to survive their wounding and its aftermath, and the advantages or difficulties that came from those particular survival strategies.
Phase One should begin to assess what the client has learned about himself and the world that is adaptive. As we will see throughout this exploration of EMDR with complex trauma, the difficult stuff in reprocessing (such as the traumatic memory) must always connect with present and existing adaptive information. Enough relevant adaptive information must be present for the maladaptive information to metabolize into. In EMDR therapy, that link-up is the only pathway of healing. There is nothing magical in the eight-phase protocol that will spontaneously create the needed adaptive information where it does not already exist. When the client lacks important adaptive information, we need to help the client create it. We need to do this preparation work carefully and respectfully with clients with complex trauma because remarkably little of this work will feel intuitive for the client. The initial assessment of the fund of adaptive information starts in Phase One.
The Vehicle Metaphor
In order to journey anywhere, we need a means. Some clients come to session highly resourced and highly articulate about their goals and their struggles (although very few of my clients do). Others come to session with complaints about particularly troubling symptoms (panic, anxiety, depression, sleep disturbances, flashbacks, etc.) but may completely lack the language or insight to account for the etiology or development of those symptoms. Phase One is our initial assessment of the health of the client’s “vehicle” of recovery. Some clients come to session with the metaphorical equivalent of a 2017 Toyota. We just need to check the tires and fuel and we can start the drive across the country once we have a map and enough resources to sustain through the journey. Other clients will show up with what seems like nothing but a dirty pair of fuzzy dice. For clients who are profoundly under-resourced for the journey, will need help building every essential thing for the journey that is lacking. Much of this work will be done in Phase Two, but our initial assessment of it occurs in Phase One. When a client comes to session with only a pair of fuzzy dice, we know that we are going to need to build a rearview mirror, then a windshield, etc. We do this after we do everything can to support and leverage as much as we can from the fuzzy dice. It takes a while to build a vehicle from scratch. In EMDR therapy (and perhaps every other psychotherapy) the only way to do it is to start building with tools and raw materials that are already accessible to the client.
Phase One is Not a Sprint
For the vast majority of clients with complex trauma, Phases One and Two are not single sessions. It’s helpful to remember that Dr. Shapiro developed EMDR using a population of relatively healthy Californians. She was investigating the effectiveness of EMDR as a treatment for PTSD with a particular focus on event trauma. She was also deeply interested in showing that EMDR could be an incredibly efficient psychotherapy in helping clients metabolize and adaptively process traumatic events… often in only a handful of sessions. EMDR was not developed specifically for clients whose whole life experience was wounding, although it is effective for all types of wounds. When working with clients with extensive and life-long wounding from all stages of the lifespan, our primary focus in therapy isn’t finding the path of maximal efficiency that requires the least number of sessions possible. We recognize that EMDR therapy with clients with complex trauma is likely to be a long journey because we are reprocessing much of the client’s existence (including what didn’t happen that should have), rather than a handful of discrete and isolated horrible events. Phase One isn’t something we sprint through. It also isn’t somewhere we loiter. It’s a start of the process that we visit and continually revisit as new layers of the onion of wounding reveal and peel away.
A Detailed Chronological Trauma History is Often a Terrible Idea with Complex Trauma Clients
Clients who are relatively healthy—who have been well resourced by their broadly positive life experiences—typically have mountain ranges of adaptive information that is at least accessible if not always embodied. Their traumatic experiences were a narrow and exceptional part of their experience. They may have a language for it. They are more likely to have some type of support, visibility, or validation after the experience. Relatively healthy clients can be debilitated by single traumatic experiences, but these are often a small sliver in a mountain of adaptive information built by nurture, attunement, safety, connection, validation, and support. Clients with complex trauma have a full lifetime of horrible memories. They have mountain ranges of them that span thousands of miles. Experiences that are not stressful, horrible, or overwhelming have been the exception.
Clients with complex trauma carry extensive wounds that are stored and containered in the limbic brain. It is very easy to trigger a client with complex trauma at intake. Much of their wounding doesn’t have a name (particularly the wounds that come from what didn’t happen that should have). In short, much of it is unspeakable. Asking a client with complex trauma, who has likely spent all of his life trying to keep trauma containered, to speak about and identify over and over the earliest, worst, and most recent memories is simply a horrible idea. Would you like to tell someone that you just met nine or twelve of the most awful, shameful, and humiliating things that have happened to you if those things were among the worst things a human can experience? If you did open all those targets in a first session, how would you feel when you left that session? How long would it take you to put all that stuff back into all those containers? Would that be something that you would want to–or have the capacity to–come back and do again?
Here is the part that might be surprising and might sound controversial: you don’t need to know. I promise, you don’t. You particularly don’t need to know in the first few sessions. You can get everything you need to know to make a diagnosis, develop an initial treatment plan, and start Phase Two work by exploring symptoms, negative cognitions, and by talking around trauma. Your need to conceptually organize the client’s wounding and recovery should never come before the client’s comfort in communicating that to you. It should also never come before sound clinical judgement of why interacting with the details of a client’s constellation of traumas is necessary at the earliest points in treatment. Dr. Shapiro is clear that some clients will need to engage in some Phase Two work before they are able to do a robust Phase One.
Helpful Assessments and Helpful (and Gentle) Questions
When I meet a client for the first time, I introduce myself and explain what is about to happen and why. When I was a new therapist I got to the end of several intakes and learned that clients thought I was a medication prescriber. Since most of my clients have complex trauma, I assume that we will need to be careful about what we open up during the first 55 minutes after we first meet. I usually say something like:
I never know what clients have been though and their comfort level in talking about those experiences. I just want to let you know that it is okay today to talk around any difficult experiences, because it’s usually not a good idea to talk in any detail about really difficult events the first time we meet. My clients find that these first sessions are easier if we talk about symptoms or effects of things rather than talk in detail about events. If I ask any question that you are not comfortable answering, please feel free to let me know or “swipe left” with your hand and I’ll move on. There is nothing that we have to talk about today and nothing that is more important than your comfort here today.
Complex trauma clients are often able to talk about their symptoms without much difficulty—probably because they are accustomed to being treated by families and institutions (mental and physical health professionals) as though these symptoms have nothing to do with carrying unprocessed trauma. Less than 1% of my severely traumatized clients are triggered strongly by completing the PCL-5 (a freely accessible instrument that is helpful in justifying a suspected PTSD diagnosis). I complete this assessment with the client in session. Going through the assessment together provides a vital opportunity to normalize experiences and provide needed psychoeducation (remember that information is a resource in the context of invisible wounding). When I suspect dissociative processes, I will also complete the Dissociative Experiences Scale-II with the client in session. Again, this is an invaluable opportunity to normalize client experience and provide needed psychoeducation.
One of the most important things that I assess for in Phase One is for attachment wounding, since such wounds are among the most difficult to reprocess and may require specialized resources so that we can consistently end reprocessing sessions in ways that are not horrible (more in Phase Two). Also, when a client has suffered severe attachment wounding through childhood, we can simply assume a broad range of other deficits in many parts of the self (since getting our attachment needs met as children is how we avoid these deficits). For this assessment, I ask a single, simple, and usually non-triggering question: “When you were young, who was really there for you?”
Other versions are: “When you were young, who knew how to love you right?”
Or, “When you were young, who was completely there for you?”
When client’s respond with “Nobody,” they usually do within about a half second (this is a calculation that the nervous system has already performed). When a client says that no one was there for him, please make a point to believe him. That is–by definition–a horrible reality that keeps on cutting: being born into a tiny fiefdom in which you have to either figure out how to get your own needs met or try to figure out how to not need those things (and neither approach is effective in staving off the existential loneliness of attachment wounding). When exploring, the client may say that a grandmother was there sometimes (once or twice a year and therefore not around enough to consistently meet needs). Or, a client may reference an older sibling… which doesn’t really count because we are looking for someone who met the client’s needs whose job it was to meet those needs. If the client had no one really there for him in early or middle childhood, that is a wound that is about everything. That is what gets triggered when things get triggered. Transforming that wound brings an astonishing amount of healing. First, you have to see it. You may not see it if you do not assess for it. In Phases Two and beyond we’ll learn how to effectively treat it.
Whatever the wounds, we have a general framework for how that wound can be reprocessed using the eight-phase protocol. What isn’t always clear at first contact is the adaptive information that the maladaptive information will need to connect to and metabolize into… and if that information is present. Again, Phase One for clients with complex trauma should be at least as focused on the existing adaptive information that the client has as on what has happened to the client. Everything we do in Phase Two (and Phase Two is where the battle is won or lost in complex trauma) is organized around deficits in adaptive information and not the exact nature of the events the client has endured.
[This is the first installment in a series of posts walking through each of the phases. Follow my blog or join EMDR Therapist Resources on Facebook if you are a therapist. If you are and EMDR therapist and would like to schedule a consultation with Thomas Zimmerman (EMDRIA Approved Consultant, you can do so at: EmdrTom.com).]