Walter, 37, is a married Jewish male with a son, age 12, and two twin daughters, age 8. His wife is a status-seeking woman who comes from “old money.” Walter works as a sales rep for Nike, but has been living above his means so that his wife and her parents will accept him as one of their own. His father-in-law had given him the Nike connection. As the only child of two elderly parents who covertly wanted him to make their lives a success, Walter grew up with insecure and ambivalent attachments to his parents. He suffers from esophagitis and had chronic acid reflux before being started on Previcid by his gastroenterologist. Though Walter has a bache- lor’s degree in business administration, he finds even the most mundane business chores overwhelming. The reason was found when Walter was evaluated as having the symptoms of depression, specifically a loss of
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energy, interest, and motivation. Walter was also terrified of a presentation he was due to give the very next day after our first session. He was not prepared for it.
Walter presented himself as an anxious, needy man in crisis, and he expected a miracle to happen during that first session. After all, this is what he had heard EMDR does. This miracle would manifest as an increased ability to analyze and present data to the evaluators at Nike and would save his job. His desired belief was, “I am confident.” His EMDR cli- nician got caught up in Walter’s immediate problem, did not establish a firm collaborative working alliance, and missed the fact that Walter was not prepared with his facts. In essence there was no therapeutic relation- ship. The clinician, though well intended, only relied on the procedures and protocols of active trauma work in EMDR, and did so in an inaccurate way. He began targeting the most frightening scene (being at the presenta- tion, trying to answer questions, and going blank). Walter’s negative cog- nition was “I am a fraud.” Fifteen minutes after bilateral stimulation began, Walter started having chest pains and ended up being hospitalized. Fortunately, he was found to have suffered a panic attack, not a heart attack.
Shapiro has made it clear that EMDR can alleviate suffering in an indi- vidual who has painful state-dependent memories but not in a client who has a reality-based reason for worrying about an immediate upcoming stressor. (In the latter case, however, EMDR could be used over time to reprocess an old trauma that resulted in the person’s being a procrasti- nator.) In Walter’s case, the clinician made two important mistakes. Not only did the clinician attempt to make EMDR do what it is not meant to do, he did not elicit enough client history from Walter to make an informed judgment about how to proceed. He did not inquire deeply enough into why Walter presented in this manner. This left Walter vulner- able to the triggering of partially dissociated, state-dependent memories before he had been evaluated for affect regulation. Walter became over- whelmingly stimulated during the sets and shut down without resolution. The risk of retraumatization must always be in the forefront of the clini- cian’s mind as he or she gets to know a new client.
But Walter’s clinician did not stop to ask an even more important ques- tion: Who is this client to me? Does he stir up any old state-dependent memories in me? (In Chapter 9, I will go into greater detail about the sig- nificance of this issue and suggest strategies for dealing with it.) Instead, the EMDR clinician took responsibility for treatment without thinking the issue through. In this case, the clinician’s misjudgment was driven by an irrational need to believe that he could use EMDR to save Walter’s career.
Here’s an example of how misuse of the method and uninformed counter- transference can hurt a client. This assumption rested not only on an incomplete understanding of information processing but also on the clinician’s own state-dependent memories and beliefs of inferiority. The clinician overcompensated for these implicit memories by proceeding with active trauma work in an attempt to heal Walter right away, which would make the clinician feel better about himself.
Apparently the clinician thought that this was a chance for him to fix someone with an immediate need. But EMDR therapists do not fix any- one. We facilitate. And we start our facilitation on the first day, when we evaluate the client. If the client is needy and wounded, we do not rush into doing bilateral stimulation. We know that education in mindfulness, distress management, emotional regulation, and interpersonal skills is needed before active trauma work can commence (Linehan, 1993).
“Clinician, heal thyself ” sounds rather preachy, doesn’t it? What might be better is simply to say that clinicians are all human and all subject to times when we are not aware of the activation of implicit traumatic memories. This clinician would have served Walter better if he had taken the time to help Walter develop anxiety-management and problem-solving strategies to cope with the next day’s presentation, and then investigated what led to Walter’s desperate need to be fixed. A fuller trauma case con- ceptualization would also have included issues of Walter’s not being pre- pared to give his presentation and issues related to how Walter evaluated himself. The clinician would have been wise to establish which schemas Walter was most vulnerable to, which ones he was avoiding or overcom- pensating for, and how he had developed character traits to defend against these anxieties.
Schemas develop in childhood based on the interaction of a person’s temperament with the hurtful experiences the child has with parents, siblings, and friends. A schema is a relatively enduring, dysfunctional trait that deals with the ways the client views the world. All people have schemas. Many have “unrelenting standards” schemas, which means roughly that humans usually are quite hard on themselves. This trait may develop in response to a stern parent’s loving concern for the child to do well in school, or in overcompensation for an implicit schema of defec- tiveness being simultaneously defended against and acted out. A comprehensive discussion of schemas may be found in Jeffrey Young’s works, Cognitive Therapy for Personality Disorders: A Schema Focused
Approach (1990) and Schema Therapy: A Practitioner's Guide (Young,
Klosko, & Weishaar, 1993), where he provides a comprehensive under- standing of these issues. Young’s Schema-Focused Questionnaire (available
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in his books) is extremely helpful in Phase 1 to help the clinician discern specific client vulnerabilities. For example, a client’s attachment style can be evaluated to assess stability and make guesses about how the client may overtly or covertly relate to the clinician.
Here is an example. A client told me he “understood that his mother was having a tough time herself when he was little.” He always gave and sacrificed, and she did not realize how wounded he felt. This subservient schema, reinforced with rationalization, was a defense against the pain of his wounding. As always when I notice something like this happening, I went into my “Columbo” routine. I scratched my head, uttered a few “humphs,” then told my client I was confused. “Do you mean that you are not wounded because Mom had a drinking problem?” I asked. (I have found that Peter Falk’s “Columbo” character usually is disarming enough that my client receives the information I give in a nondefensive manner).
“Of course I am wounded!” the client responded. So I talked with him about setting aside some of the judgments he had made so we could focus on his issues.
Dismantling a client’s dysfunctional defenses and assisting him or her to develop better ways of coping is not an art form, but it does take a measure of creativity. Clinicians usually cannot allow the client’s dysfunc- tional defenses to continue, especially when the client has developed enough affect tolerance to cope with them instead of being overwhelmed by them. Do you notice another overlap here? If I were asking the exact same question in Phase 4, desensitization, we would call it a cognitive interweave. Asking the question here in Phase 1, it might be considered a cognitive challenge. What does the relational have to do with a cognitive challenge? Isn’t it important to challenge with sensitivity? Wouldn’t you as clinician like to know how the client takes your feedback and your style? I use this information to test initial response flexibility. This little process helps me understand how to relate better to my client. When I get into trauma processing, this information is invaluable in maintaining empa- thetic attunement.
Of course, we cannot dismantle the client’s dysfunctional defenses by bluntly confronting him or her. In the example above, I knew the client’s prominent characteristics and schemas, so I knew the best way to inter- vene. Because he had to be right all the time and feel in control, I shaped my intervention in a way that would make him feel safe to open up. (Just in case you have never seen Columbo, no one ever feels threatened by Falk’s character because of his ability to play the fool.)
It may take a session or two or three to get a good enough sense of all the significant issues a client needs to impart about the presenting
problem before getting older relevant information. This is the interper- sonal nature of the work. However, there is a reason why it is important to get the rest of this information (core negative beliefs, positive attributes) up front. When clinicians do this, they are acting in concert with the stan- dard method, which seeks to gain all the information needed to help the client heal. When it is time to move into active trauma work in Phase 3 and Phase 4, this information will speed the process of healing. The clini- cian will feel the client’s pain, and the client will not only have expressed the pain, he or she will have felt heard.