EMDR FORUM ARCHIVE, 2000
Re:bls/das
Sandra Paulsen Inobe, PhD · 10/28/02 at 6:01 PM ET
Several things. 1. Thanks for the studies. a. Sometimes the standard protocol works just fine, especially if the patient isn't highly conflicted about the material that needs to come up and be processed. But the whole point of being dissociative is to keep conflictual material at bay. b. Sometimes the processing just gets stuck or loops. The institute training is that looping is a cue to introduce cognitive material (after trying changes to the mechanics) in the form of a cognitive interweave (and these are supposed to be Meichenbaumiam "Columbo" or Beckian "Socratic" style questions, just enough to get the patient's positive resources to kick in. Sometimes the cognitive interweave may require injecting a piece of information, an educational interweave. With highly dissociative clients, looping is associated clinically with aspects of self (ego states or alters) that block continued processing. One or more of the trauma channels has been blocked or disowned, because its either affectively overwhelming to for the clients ego strength, or, to allow the blocked traumatic material into conscious mind would threaten some other dearly held belief (over-valued idea) or some aspect of self that functions as a defense (angry protective part of self). c. Sometimes, as the prior poster said so eloquently, the box itself collapses during the EMDR, and there is affective overwhelm for someone with insufficient ego strength or coping skills. Stated another way, there are not sufficient positive resources to tap into, and the negative resources are fully present in conscious mind, with no containment available, since the box has been collapsed. This can be associated with suicide attempts or other acting out. Most of the horror stores we have ever heard for EMDR have been of this variety. Sometimes it isn't as severe a consequence, but there can be considerable affective disturbance for the client, associated with flooding/affective overwhelm. d. Again, its an ethical thing, its a safety thing. The client has to have sufficient ego strength, containment strategies, positive resources, stability, coping strategies... and understanding of the process, and trust and rapport with the therapist, to go through the emotional processing of trauma. I'm really concerned that cbt exposure strategies used on undiagnosed dissociatives/multiply traumatized patients could also have the same effect, which I never worried about before because I have felt that EMDR was the power tool, and exposure therapy was the manual tool -- how much harm could be done. If there is little difference in effect, which I don't yet accept because I used to do standard issue exposure treatment, then the idea of cbt therapists who don't believe in dissociation lancing dissociative barriers gives me concern. If the prior poster is correct that EMDR causes the box to collapse -- and this is my clinical observation too --- then I don't have to worry.
2. I don't think the standard protocol is always dire for dissociative clients (I mean, highly dissociative clients).
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