Re:Exposure in the real world

From my own experience, EMDR as a technique is relatively robust with two major exceptions.

If the client is unable to be mindful of their body, that is they are unable to retain somatic awareness throughout EMDR processing, EMDR will usually go nowhere, or alterantively will not stick; that is, the client will report a high SUD level next session, even though there had been a previous report of a decreased SUDS level.

The other major issue I see in the use of EMDR is targeting, that is, what issues get addressed in treatment. In my experience, addressing the index trauma only, as is commonly done in many forms of Exposure, in the case of EMDR is frequently not effective in the long run unless this is truly simple PTSD without any other traumatic life events, including small t-trauma attachment issues. However, there are those clients who will spontaneously work through those issues even when only the index trauma is targetted. However, with increasingly complex cases this appears to become less likely.

In many cases, sequential targeting appears to work better, as is for instance delineated in the so-called Phobia Protocol, e.g., First-Worst-Most Recent with the addition of a so-called Future Template and commonly an agreement for In Vivo Exposure. In trauma treatment, as compared to phobias, the targetting rather than the addition of the In Vivo Exposure seems to make the difference, but this is based on clinical impression only.

EMDR is certainly easier for therapists to tolerate due to having less detailed material shared by the client, and I believe that this in part what explains its success. As a a psychotherapeutic approach however it struggles with similar issues as Exposure therapy. That is, therapists, together with clients avoid targeting specific traumata, and only doing tapping and/or eye movements without ever actually targeting the traumatic material. Partly this can be attributed to anxiety about possible dissociative disorders. And in my experience certainly EMDR is more likely to break through dissociation. If there is sufficient client preparation can be profoundly therapeutic. If not, the proecess may just stall. However, there is also the potential of signifcant disruption of clients' lives, more so than appears to be the case with Exposure.

Finally, I just want to comment on a psychotherapy tape that Edna Foa has shown to audiences she educates about Exposure. In one case, where the client has difficulties staying with the material and IMO likely is partly dissociating, she touches the person's knee. While large parts of the audience at that time appeared to be upset about the use of touch, IMO this was a brilliant attentional manipulation by a seasoned therapist that created a sense of somatic awareness, allowing the client to stay with the traumatic material.

EMDR contains sensory stimulation in its standard protocol. At times, the sensory or dual attention stimulation may be unecessary in order to obtain a treatment effect - yes, the EMDR protocol can work without dual attention stimulation. However, in other cases, the dual attention stimulation seems critical to obtain a treatment effect. By being part of a standard protocol, it certainly it is less ambiguous for observers, and in some cases I suspect for the client.

Finally, Cloitre who has shown success with complex PTSD and a modified Exposure paradigm, certainly frontloads mindfulness, affect tolerance and sensory awareness by utilizing DBT prior to doing Exposure.

Replies:

There are no replies to this message.

| Behavior OnLine Home Page | Disclaimer |

Copyright © 1996-2004 Behavior OnLine, Inc. All rights reserved.