1. Presenting problem(s) (include duration and length of problem; why treatment now?) PTSD, secondary to near fatal car crash 3/99
Time in treatment 3 sessions
Most disturbing picture? Seeing the car seconds before impact, and
hearing the glass breaking
Core negative beliefs spoken spontaneously? “I am going to die” Somatosensory experience of the trauma? (also note the lack of feel-
ings or sensations associated) Goes into extreme fear state —
Severe anxiety in the pit of the stomach; and muscle spasms in the back
2. What strategies has the client used to deal with this current problem?
Phase 1 • 61
What has worked? Nothing; that’s why she’s willing to attempt psycho-
therapy (would never have done so otherwise)
What strategies have not worked, and why? Avoids riding in cars, and
is beginning to have a phobia of leaving her house except for medical appointments
3. What old painful memories (feeder memories), especially of the origi- nal cause of the problem, if remembered, does this presenting prob- lem stir up in the client? (List all relevant ones. Also list other traumas client has suffered.) Or can the client not recall or make connections to old traumas of the same type? Is this truly a single-incident trauma?
[Since Madeline would deal initially only with the presenting problem, she did not list any older traumas. They came up later in the processing. These are the parts of her experience that initially plagued her:]
Age 59 Gender F Ethnicity Jewish Marital status Married
Highest level of education
M.S. in teaching
Occupation Retired Teacher
Religious affiliation None
Spiritual path None
Cultural identification Modern American Jew
Current family system (including marital status) and social support system
Married for 36 years to a man 10 years her senior; they have one child, a son, age 39; excellent relationship; has a well-developed social support network; has been estranged from brother and father for over 15 years. No contact whatsoever.
Medical conditions (list)
In physical therapy, finishing the end of a protocol; no lasting physical limitations from the auto accident. She has been very careful in taking care of herself all of her life. No medical conditions. Medications None Substance abuse or compulsive/obsession life patterns None DES Score 3.1 Genetic predispositions None noted
• Being behind the wheel or being a passenger. • Heavy traffic and traffic noise.
• Flashing lights and sirens.
• Seeing a BMW or seeing a Honda Prelude (1992 and newer). • Seeing an accident, either actual or reading about such in a newspa-
per or seeing pictures.
• Having trucks next to or behind her. • Going over bridges.
• Driving in the rain or at night.
• Richard’s symptoms: his moods and upsets, temper fragility and health concerns, lack of self-confidence; countenance and posture: sleepy, dour, dropping, shuffling, defeatist. The deliberateness with which he moves and does things. He has been very slow and quiet (e.g., he places each piece of flatware in sink carefully, one at a time, no noise; walks around the house and places his feet similarly). He has been inappropriately taciturn or loquacious. Does not answer questions or is indirect and placating. This all adding up to the fact that her “beloved lion has lost his roar.”
• Being kept waiting.
• The incompetence or errors of others. • Financial matters.
• Not being in charge of her life.
4. What are the core negative beliefs this client holds, and how do they apply to each of these traumatic memories? [Madeline believed that]
“I’m in danger,” when she sees similar cars, or when she attempts to drive, “I’m going to die,” when she remembers the accident, and “I can’t stand it,” when she thinks about Richard’s emotional outbursts.
5. What resources (including ego strengths, coping skills, self capacities) did the client use to attempt to deal with these old memories? Made-
line had a difficult early life that made her quite strong and resolute. Her beliefs were, “I can do anything I set my mind to” (within reason), “I can overcome obstacles,” “I am capable.”
6. What psychoform and somatoform types of dissociative symptoms does client present with? Madeline shows evidence of strongly numbing
out the pain, worry, and despair that breaks through as crisis calls to me periodically.
7. Clinician’s assessment of client’s ability to tolerate intense abreactive experience? Adequate. Rationale? She’s made it through some hard
times and made a productive and accomplished life for herself. When prompted, she could access feelings and tolerate them.
Phase 1 • 63
8. Clinician’s assessment of client’s body awareness? Adequate. Rationale?
Can feel tears in her eyes when sad, tension in her belly when anxious, and laughter in her chest.
9. List general resources including ego strengths, coping skills, self capac- ities. Intelligence, perseverance, and a belief that she can make her life
better.
10. Past treatment episodes and the diagnoses. None
11. Past responses to treatment both positive and negative. N/A 12. Past responses to previous clinicians and reasons why. N/A
13. How does the client initially appear to relate to you? Guarded and con-
trolling, though she cooperates when I explain the outline of EMDR. She says she will only deal with the problems the accident activated. (That’s okay with me — she understands active trauma work and agrees to cooperate and free associate.)
14. What old memories, negative cognitions, and feeling states does the client induce IN YOU? She reminds me of a strict teacher I had in ele-
mentary school. I feel slightly activated and experience myself as being a little bit more vigilant than usual.
15. Significant symptoms and defenses of client (also note how you are affected by these symptoms and defenses). Actually, I’m amazed by
both her and her husband. I have read their medical records, she is not exaggerating. “Failure to thrive” is not a term that is used lightly. It is used to connote the initial belief that the patient will not survive. She showed me pictures of herself in a body cast. Let her have her defenses, she’s smart and independent — I’m fine letting her have her way as I think she has the right stuff to come around.
16. What is the desired outcome of treatment? Significant detraumatiza-
tion, for instance, being able to travel around by car without distress. Being able to come to terms with her husband’s brain damage.
17. What are the desired positive cognitions at the start of treatment, and what are their current VOC ratings? Positive cognition: I can cope with
my life. VOC = 4
18. Are there any current constraints to beginning active trauma work?
No
19. Trauma case conceptualization summary (including possible transfer- ential and countertransferential reactions)
This is a 59-year-old highly intelligent married woman and retired schoolteacher who presents with intrusive, avoidant, and hyperarousal symptoms of PTSD, secondary to the car accident that almost claimed her life and the life of her beloved husband. Though traumatized, she has an enormous range of abilities as attested both by her history and per-
sonal acknowledgment, “I have never let anything stop me, and I won’t ever give up.”
Her greatest trauma lies in the terror and grief she feels when noticing how her husband has changed since the accident. She has fantasies of running away when he cries, as he is subject to do, when he gets what he interprets as a signal from Madeline that he did something wrong. He also cries when he is alone and he does something that he believes Made- line will disapprove of (this perception is grossly distorted). They had a life that was rich in intellectual engagement. That meant that having dif- fering points of view was part of their normal course of events, but now no matter how gently Madeline presents an idea, he will get activated. I observed this phenomenon happening numerous times in my office with the two of them.
Though she usually activates old state-dependent memories of mine relating to teachers in grade school, I will be aware of them and deal with them, when activated. I am impressed by her intelligence and motiva- tion, and I feel happy to be of assistance.
Madeline has stated that she has been skeptical of psychotherapy and psychotherapists all her life, but is truly willing to engage because she was referred by a treasured friend who knew of my work, and she is at the point of despair.
As you may have noted, some of the information on Madeline’s ques- tionnaire comes from Phase 2, when I focused on her affect tolerance and body awareness skills. In the next chapter, I will describe the specific objec- tives of Phase 2 and then return to how Madeline fared as treatment progressed.
4.7 Conclusion
During Phase 1 and Phase 2, the clinician’s role in the therapeutic relation- ship is that of expert, teacher, and evaluator. The client is being examined. This view of the relationship at this point may not sit well with experien- tial clinicians who want to let the information flow spontaneously. Many times clients, especially when they are new to psychotherapy, are heart- ened that the clinician takes an active interest. I want to reassure my expe- riential colleagues that during the active phases of trauma work, the dynamics and roles of the client–clinician dyad shift to co-participation, and the relational aspects become central to facilitating the release of the pain of state-dependent memory. This is the “Zen of EMDR.” The implica- tions of this shift and its logistics are covered in the next chapter.
65
CHAPTER