A Therapist's Guide to EMDR: Tools and Techniques for Successful Treatment

by Laurel Parnell

6. Develop a target map with the client. What key memories are linked to the current symptoms? Arrange these targets chronologically, like beads on a string. Target and reprocess the earliest or strongest memories first. Work your way up the strand. Remember to process the past before trying to solve the problems in the present.

What target memories are linked to current symptoms?

can’t emphasize enough the importance of doing symptom-focused work. Too often therapists open clients

You will want to target the experience at 6 even though it came later. The idea in EMDR is to go for the largest generalization effect. The memories with the greater charge will give you the greatest effect. Remember, you need to have charge in order to get processing.

TIPS FOR FINDING TARGETS What are the clients’ symptoms? What brought them into therapy? Get specific, including negative cognitions, emotions, and body sensations. Are there any precipitating incidents? What memories are linked to the symptoms? List the memories chronologically. Note the level of distress. Develop a target map.

the therapist inquires about anything of importance that has come up related to the issue that was worked on in the previous session. The client may have had dreams, insights, memories, thoughts, or flashbacks, or noticed some new physical sensations.

the following targets: Past experiences linked to the presenting problem or symptomology; Present situations or triggers that currently activate the symptoms; Future situations.

Shapiro also recommends asking clients for their 10 most disturbing memories from childhood, assessing the level of disturbance of every event and arranging

More activated memories take priority over earlier ones.

TIPS FOR TARGET DEVELOPMENT

1. Light up the memory network as clearly and completely as possible, engaging the different components (image, NC, emotion, and body sensations) so the processing can best move unimpeded to completion. 2. Get some kind of image if possible. Even if the image is vague, it stimulates the visual memory track. The image can be abstract, such as a red blob that represents the client’s anger or a drawing that represents what the client is experiencing. The image can be metaphorical, symbolic, or dreamlike. For example, with a person who has no visual memory but has strong body sensations, you can ask, “What image goes with the feelings in your body?” The client might say, “I get the image of someone stepping on me.” That image can then be used as the target image. If clients have difficulty visualizing, it is not a problem. Clients can go with a vague sense of a scene. However, make the image as clear as possible. Bring in details. Have clients see as fully as possible what is around them. 3. Don’t worry about the order of the setup. Allow clients to provide you with the necessary information as it unfolds for them. If clients tell you about their emotions and body sensations before the NC, don’t worry. Note them and move on.

4. Skip the SUDS, PC, and VoC if you don’t have the time or it interferes with the flow of the clients’ process. 5. Have clients who have difficulty finding and eliciting a memory stay in the memory as strongly as possible while the different target components are identified and stimulated. For many clients, coming in and out of a memory disrupts the flow and causes them to leave the experience to intellectualize. Therefore, get the image, NC, emotion, and body sensations while the client is in the memory experience. Having clients close their eyes as they bring up the memory can help them to stay with it without interruption. The whole setup can move smoothly and rapidly this way. Some clients provide you with all or most of the target components as they are describing the memory they want to work on. The setup process can flow smoothly without needless breaks if you don’t attempt to get the target information in a specific order. You can ask clients for the information that wasn’t provided in the narration they gave of the memory and then begin the BLS when you feel you have the memory network well stimulated. 6. Use the NC that best stimulates a strong emotional response. The NC is an irrational belief that was developed in the

Tips for targeting memory

feel now when they bring up the memory.

We want to employ the three-pronged protocol, targeting and reprocessing the past, then targeting and reprocessing present referents, and then doing a future pace.

Ask clients for an example of when they did the behavior. (“Can you give me an example of when you found yourself bingeing recently?”) Ask clients to focus on the scene, to bring themselves to the moment right before they began to do the problem behavior. (“Can you bring yourself to the moment right before you opened the refrigerator?”) Ask for the picture they see. (“What picture do you see?”) Ask for the emotions. (“What emotions do you feel?”) Ask for body sensations. (“What do you notice in your body?”) Ask for beliefs. (“What do you believe about yourself?”) Bridge back. (“Trace it back in time. Let whatever comes up come up without censoring it.”)

earliest or strongest memory.

BRIDGING FROM PHYSICAL SENSATIONS Sometimes clients present with physical symptoms that appear to be body memories or have a psychological origin. When clients have somatic experiences that are distressing to them in some way, you can use the body’s experience as the entryway into the processing. You can ask the clients to focus directly on the physical sensations, then ask for the emotions, body sensations, and NCs, and then process. But, in my experience, it is preferable to bridge back and find specific memories associated with the symptoms. It is also easier on the clients as it produces fewer surprises that can be upsetting. In addition, it is much easier to contain a specific memory than an entire network of associations that can be activated if you go in on body sensations that have multiple contributors. Ask clients to close their eyes and bring their attention to the body sensation. As they feel the sensation, what emotions come up for them? What do they believe about themselves now? “Trace it back in time. Let whatever comes up for you come up without censoring it.”

Target and reprocess the pictures or scenes that come up.

Ask clients to close their eyes and repeat the negative belief to themselves, e.g. “I’m not safe.” “As you say those words to yourself, what emotions come up for you?” “Where do you feel that in your body?” “Trace it back in time. Let whatever comes up for you come up without censoring it.” Target and reprocess the scene.

DREAMS AS TARGETS Dreams make excellent targets for EMDR processing because they are doorways into the unconscious and provide a wealth of material. Oftentimes, clear and vivid dreams arise between EMDR sessions as a continuation of the work that was done in session. There are a number of different ways to work with dreams. The following are two suggested protocols. PROTOCOL FOR USING DREAMS AS TARGETS 1. The client tells the therapist the dream. It can be helpful to have the client close his eyes and bring the dream as vividly to mind as possible. 2. Ask the client to scan the dream and identify the most disturbing parts of the dream. “What image represents the most disturbing part of the dream?” 3. After the images are chosen, ask for the NC. “What do you believe about yourself in this image?” If the client cannot come up with anything, or the question does not

Identify the emotions and body sensations that go with the images—these should be more readily available. 5. Then, as with the standard protocol, bring up the image, NC, emotions, and body sensations and begin the BLS. 6. Process until the dream is no longer charged—a SUDS of 1 or 0. 7. Ask the client what he believes about himself when the dream images are brought up and install the PC. Some clients prefer to start at the beginning of the dream because all of it feels very significant to them and it does not make sense to them to begin in the middle.

“When you think of your birth, what picture do you have?” For a client who had a near-death experience, I asked him, “When

Don’t spend too much time struggling over the cognitions. If it is not working smoothly, move on to the next part of the protocol. According to Shapiro (1995, 2001), identifying the PC helps set a direction for treatment and stimulates alternative neuronetworks.

THE NC (NEGATIVE COGNITION) is a negative self-referencing belief; is an erroneous belief; still feels true in the present; has affective resonance; is stated in the present tense; is not a feeling; is not a description; is not about how others view the client (e.g., “My father doesn’t love me”); is a general statement that is short and concise (e.g., instead of “I’m not a good dancer,” “I’m incompetent”); can be an essential core belief; uses language a child would use if processing a childhood memory; is a statement that can be simplified by the therapist for the client; is such that the order of the protocol can be rearranged so that the NC is found after the emotions and body sensations;

THE PC (POSITIVE COGNITION) is usually a positive self-referencing belief, but can include statements like “It’s over” should correspond with the NC; must be possible; should not have the word not in it; can include process PCs such as “I can make better choices” is such that the therapist can assist the client in finding it; can create a feeling of hope for the future.

What we are asking is when clients elicit the memory in the present, what do they experience? The now is what they experience when they light up that memory network.

Ask them to pay attention to the feelings themselves in the body. It is most important that the emotional/somatic components are stimulated by the clients’ awareness.

She might rate it a 10. We want clients to rate how disturbing the memory feels to them when they think of it in the moment, not when they reflect back and think how disturbing it was at the time it occurred. Sometimes clients will rate the SUDS

“Where do you feel the disturbance in your body?”

“Nothing,” ask them to look more closely. Tell them that even subtle sensation is important information.

“With just this memory, how true does that belief feel to you now?”

“Close your eyes. Bring up the incident and the belief (repeat PC), and mentally scan your entire body. Tell me where you feel anything.”

“The processing we have done today may continue after the session. You may or may not notice new insights, thoughts, memories, or dreams. If so, just notice what you are experiencing, and write it in a journal or log. We can work on this new material next time. If you feel it is necessary, call me. Please walk around before you drive. You might even want to put some water on your face.”

“What was the most important thing you learned today?”

Therapist: It wasn’t safe to be in your body then. Is it safe to be in your body now? Client: Yes. Therapist: Go with that. >>>>>>>

Grounding Breathing and Loving-kindness Meditation Find a quiet, undisturbed place to sit. Disconnect the phone and make sure that you won’t be interrupted during the time of your meditation. You can sit cross-legged on a cushion or in a chair with your feet on the floor. It is important that you be comfortable and are sitting in an upright position. Close your eyes and feel yourself sitting. Be aware of the places of contact…your bottom on the cushion and your feet on the floor. Be aware of your breathing. In and out. Feel the breath in the body. Let yourself relax into the present moment. Now take a deep breath, drawing the air up from the earth, filling your

“It’s in the past”

and “I am with you now” reassure the clients that the therapists are with them as they are immersed in the early traumatic memories.

For the next set of eye movements, she was asked to give a narrative

account of her experience. As she spoke, she became aware of her emotions, which she was able to process. At the end of the session when she returned to the original image, it had lowered to SUDS of 0. CLIENT NUMBNESS

Recognizing that the processing is blocked or incomplete; Identifying the cause; Intervening using noninterweave or interweave strategies.

You can find the blocking belief by simply asking the clients, “What do you believe about yourself?”

In some cases it is required to shift from processing the target memory and reprocess the feeder memory before the target memory can be processed.

to have strong feelings in order to process.

“If I get through these old memories, who will I be?

“What does the child need? What does the child want? What does the child feel? What does the child long for?” It is helpful to use simple language and a gentle tone. “If the child is frightened, what is scaring him or her? What is the child self seeing that is distressing? What is happening in the scene? What does the child self need in order to feel safe?” This open exploration can lead to a blocking belief or image. The therapists can then design an interweave or other intervention to address the problem. If the child says, “I need someone to help me,” the therapist can ask, “Who can help you?” When the client responds, “I want my dragon to help,” the therapist can say, “Imagine that,” and add BLS.

Therapists can also use interweaves to help close sessions when time is running out. Shapiro (1995, 2001) used the term cognitive interweave, but I prefer interweave because many of the strategies include imagery as well as cognitions.

Psychological memory is memory that is self-referential, emotionally charged, and feels like it is happening in the present. Objective memory is memory that has a global perspective; all of the parts of a situation are seen as a whole. This memory is not emotionally charged or self-referential.

Interweaves are suggested to clients, who are invited to reject them if they don’t fit. It is best to ask a question.

GUIDELINES FOR USING INTERWEAVES Use only when the processing is stuck or to help in session closure.

Offer the interweave, then move out of the way. Don’t interpret; inquire. Use simple language, few words. When processing a childhood memory, use language and concepts a child would understand.