THREE CO-RESEARCHERS' EXPERIENCES DURING THEIR FIRST SESSION OF EYE MOVEMENT DESENSITIZATION AND REPROCESSING by BRETT PETERSON B.A., The U n i v e r s i t y o f B r i t i s h Columbia, 1989 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Counselling Psychology We accept t h i s t h e s i s ^ a s cpRforming t o the r e q u i r e d THE UNIVERSITY OF BRITISH COLUMBIA March 1996 © Brett Peterson standard In presenting degree, at freely this the thesis in partial University of British available for copying of department publication this or of this for his thesis scholarly or for her Department The University of British Columbia Vancouver, Canada Date DE-6 (2/88) fW IS l(o the requirements that the I further agree that purposes may representatives. financial permission. of Columbia, I agree reference and study. thesis by fulfilment It gain shall not an permission for granted is understood allowed advanced Library shall make be be for by the that without it extensive head of my copying or my written 11 ABSTRACT Eye Movement D e s e n s i t i z a t i o n and Reprocessing Shapiro, 1989a, 1989b, 1995) i s a r e l a t i v e l y new (EMDR; procedure used p r i m a r i l y f o r t r e a t i n g p o s t t r a u m a t i c s t r e s s d i s o r d e r (PTSD). T h i s study i s the f i r s t t o s y s t e m a t i c a l l y i n v e s t i g a t e the moment-to moment experiences of PTSD v i c t i m s d u r i n g t h e i r first treatment s e s s i o n . U s i n g v a r i a t i o n s of I n t e r p e r s o n a l Process R e c a l l 1994), and C o l a i z z i ' s (1978) phenomenological (Elliot, research methodology, f i n d i n g s confirmed many of Shapiro's (1995) d e s c r i p t i o n s of experience, with nothing of a d i s c o n f i r m i n g nature b e i n g d i s c o v e r e d . Three d i s t i n c t p a t t e r n s of c o - r e s e a r c h e r e x p e r i e n c e were i d e n t i f i e d , w i t h one c o - r e s e a r c h e r r e a c h i n g f u l l in-session r e s o l u t i o n of her b a s e l i n e measures. F u r t h e r , t h r e e broad c a t e g o r i e s of experience were discovered ( P a r t i c i p a n t Experiences and S p e c t a t o r Experiences [Cochran, 1990]; and Treatment S p e c i f i c E f f e c t s ) ; each of which was f u r t h e r found t o c o n s i s t of f o u r dimensions, components, of experience. S p e c t a t o r realm was through, memories. or Movement from the P a r t i c i p a n t t o consonant w i t h c o - r e s e a r c h e r s ' working c o n t e x t u a l i z i n g and making meaning of t r a u m a - r e l a t e d I l l TABLE OF CONTENTS ABSTRACT . ACKNOWLEDGEMENTS CHAPTER ONE: v i i INTRODUCTION TO THE RESEARCH PROBLEM Purpose o f t h e Study CHAPTER TWO: i i . .1 4 LITERATURE REVIEW.. The E f f e c t s o f Trauma 5 5 S h a t t e r e d Assumptions 5 I n t r u s i o n , Hyperarousal and C o n s t r i c t i o n . . . . . . . . . 11 Intrusion. 11 Hyperarousal 14 Constriction 16 C u r r e n t Treatments f o r Post Traumatic S t r e s s Disorder.18 Imaginal F l o o d i n g 19 C r i t i c i s m o f Imaginal F l o o d i n g Hypnosis 20 22 C r i t i c i s m o f Hypnosis 24 Systematic D e s e n s i t i z a t i o n 25 C r i t i c i s m o f Systematic D e s e n s i t i z a t i o n Eye Movement D e s e n s i t i z a t i o n and R e p r o c e s s i n g 25 26 The O r i g i n a l P r o t o c o l 26 The Revised P r o t o c o l 28 H e a l i n g Mechanisms. 30 P r e v i o u s Research 32 i n t o EMDR Controlled Studies 33 Case S t u d i e s 37 C r i t i c i s m o f EMDR Research 40 iv E t h i c a l Considerations. 41 D e s c r i p t i v e Accounts 42 o f EMDR S i n g l e Memory P r o c e s s i n g E f f e c t s 43 Multimemory A s s o c i a t i v e P r o c e s s i n g E f f e c t s . . 4 5 CHAPTER THREE: METHOD. 48 Rational 48 Phenomenological Research I n t e r p e r s o n a l Process R e c a l l Overview o f t h e Research Method S e l e c t i o n o f Co-Researchers 48 49 50 51 Selection Criteria 51 Demographic Information 52 Procedure 52 The EMDR In-Session Interview 53 The C l a r i f i c a t i o n Interview 53 A n a l y s i s o f t h e Data CHAPTER FOUR: .55 RESULTS 57 C a t e g o r i e s o f Experience.... 57 P a r t i c i p a n t Experiences. 57 S p e c t a t o r Experiences 58 Treatment S p e c i f i c E f f e c t s 60 Dimensions o f Cp-Researcher Experience P a r t i c i p a n t Experiences 61 61 P a s s i v e Endurance o f Trauma 61 Narrowness o f P e r s p e c t i v e 62 Immediacy o f F o c a l Image 62 I n t e n s i t y o f Emotion 63 V S p e c t a t o r Experiences. 63 A c t i v e A l t e r a t i o n o f Experience 63 Broadening o f P e r s p e c t i v e 64 D i s t a n c i n g o f t h e F o c a l Image 65 V a r i e t y o f Emotional Experience Treatment ....65 Specific Effects 66 Momentary C o g n i t i v e Impairment 66 Heightened P h y s i c a l Sensations 66 Change i n Energy L e v e l . 67 Meta Awareness o f t h e Process 67 Co-Researchers' Experiences Co-Researcher "A" EMDR Expediences o f Co-Researcher 68 "A" 69 S e q u e n t i a l Experiences by Category 72 Summary o f Experiences by Category 73 Co-Researcher " B" EMDR Experiences o f Co-Researcher 75 "B" 76 S e q u e n t i a l Experiences by Category ....77 Summary o f Experiences by Category 81 Co-Researcher "C" . EMDR Experiences o f Co-Researcher CHAPTER FIVE: 68 83 "C" 84 S e q u e n t i a l Experiences by Category 86 Summary o f Experiences by Category 90 DISCUSSION 92 Review. 92 I m p l i c a t i o n s f o r Theory 94 Implications f o r Counselling 98 vi I m p l i c a t i o n s f o r Research. L i m i t a t i o n s o f t h e Study 99 100 Number o f Subjects 100 L i m i t a t i o n s o f V e r b a l Communication 101 Researcher B i a s and I n f l u e n c e 102 Therapist Style 102 Medication 103 Summary .103 REFERENCES APPENDIX A: 105 Consent Form 116 vii ACKNOWLEDGEMENTS First, the I would l i k e t o express my deep a p p r e c i a t i o n t o t h r e e c o - r e s e a r c h e r s who p a r t i c i p a t e d i n t h i s study. T h e i r courage i s both moving and admirable; and w i t h o u t them, t h i s r e s e a r c h would not have been p o s s i b l e . To Dr. Gary Ladd, f o r l e n d i n g h i s time and e x p e r t i s e ; t o Dr. Du-Fay Der, f o r coming on board a t t h e l a s t minute; t o Dr. M a r s h a l l Wilensky, f o r p a r t i c i p a t i n g and i m p a r t i n g a s m a l l p o r t i o n o f h i s EMDR knowledge over s e v e r a l lunch hours; and f i n a l l y , t o Dr. L a r r y Cochran, f o r h i s c l a r i t y , wisdom and p e r s i s t e n t encouragement t o aim h i g h e r , I o f f e r my s i n c e r e s t , heart-felt appreciation. To my f a t h e r , past and present; f o r h i s g r a c i o u s , unending and l o v e . support 1 CHAPTER ONE: INTRODUCTION TO THE RESEARCH PROBLEM That we should d i e i s i n c o n c e i v a b l e . That we s h o u l d suddenly, without warning, be f o r c e d t o touch the dark f a c e of a n n i h i l a t i o n and remember, i n t o l e r a b l e . For i n such a case, t o s u r v i v e death i s not t o escape i t , but t o awaken an i n e l u c t a b l e shadow. I b e g i n t h i s i n t r o d u c t i o n t o trauma and i t s treatments w i t h a r e f e r e n c e t o death, as any e n c o u n t e r — e v e n vicarious- -with a p r o f o u n d l y t r a u m a t i c event, f o r c e s one t o encounter one's own a n n i h i l a t i o n , f r e q u e n t l y with severe p s y c h o l o g i c a l repercussions. Whether the t r a u m a t i c event i s rape, war, d i s a s t e r , o r simply a w i t n e s s i n g t h e r e o f , as natural Janoff-Bulman w r i t e s a l l "traumatic events i n v o l v e perhaps t h e most b a s i c of t h r e a t s , t h a t t o our v e r y s u r v i v a l " (1992, p. 56). A c c o r d i n g t o the Comprehensive Textbook of P s y c h i a t r y (Andreasen, 1985) the commonalty between a l l p s y c h o l o g i c a l trauma i s an experience of " i n t e n s e f e a r , h e l p l e s s n e s s , of c o n t r o l , and t h r e a t of a n n i h i l a t i o n " The word "trauma" was loss (p. 921). o r i g i n a l l y d e r i v e d from Greek v e r b s meaning " t o p i e r c e , " or "wear out," and was used t o denote a "wound," or " o b j e c t damage" (Wernik, 1969). Freud (1888) extended t h i s meaning t o i n c l u d e p s y c h o l o g i c a l damage. "For him, trauma, p a r t i c u l a r l y i n the developmental phases, was the core of a l l subsequent psychopathology such as h y s t e r i a , melancholy and obsessive-compulsive d i s o r d e r " (Benyakar e t a l . , 1989, p. 432). He b e l i e v e d trauma t o be a 2 consequence of an e x t e n s i v e breach being made i n the psychological "protective s h i e l d " against s t i m u l i (Freud, 1920) . T h i s "breach" i s the r e s u l t of a sudden p s y c h o l o g i c a l a s s a u l t on the s e l f too g r e a t t o i n c o r p o r a t e or (Freud, 1920; Benyakar e t a l . , 1989) symptoms of p o s t t r a u m a t i c and r e s u l t s i n the s t r e s s d i s o r d e r (PTSD; APA, and the concomitant " s h a t t e r e d assumptions" 1992) and withstand 1994) (Janoff-Bulman, l o s s of meaning ( F r a n k l , 1963). J u s t as i n the Greek myth of Persephone, i n which the p r o t a g o n i s t , abducted from a s t a t e of r e l a t i v e n a i v e t e raped i n the Underworld, h e n c e f o r t h must r e t u r n and repeatedly t o the dark s i t e of her trauma, so too, many v i c t i m s of trauma are " f o r c e d " by t h e i r i n t r u s i v e symptoms t o experience private The a frequent, u n p r e d i c t a b l e descent own "underworld." symptoms of PTSD ( r e c u r r e n t nightmares; anxiety; hyper-arousal; o r i g i n a l trauma; APA, treat into their avoidance of reminders of 1994) flashbacks the are n o t o r i o u s l y d i f f i c u l t (Kleinknecht & Morgan, 1992; Spector to & Huthwaite, 1993) ; w i t h t r a d i t i o n a l trauma treatments such as f l o o d i n g , (Stampfl and L e v i s , 1967); systematic d e s e n s i t i z a t i o n , (Wolpe, 1959, 1990); hypnosis, Dondershine, 1988; (Janet, 1919; Stutman & B l i s s , 1985); group (Yalom & Yalom, 1990); and pharmacotherapy, 1986; S p i e g a l Hunt & (Bleich et a l . E p s t e i n , 1989;) being g e n e r a l l y regarded partially effective (Janoff-Bulman, 1992; therapy, as Shapiro, only 1995). 3 Hence, with t h e advent o f Eye Movement D e s e n s i t i z a t i o n and Reprocessing (Shapiro, 1989a; 1989b; 1995), comes new hope f o r v i c t i m s o f PTSD. normally Proponents have claimed that the treatment r e s i s t a n t symptoms from a s i n g l e - e v e n t trauma can be e r a d i c a t e d i n one t o t h r e e s e s s i o n s o f EMDR (Shapiro, 1989a; 1989b; 1995). F u r t h e r , some have d e c l a r e d i t e f f e c t i v e i n t h e treatment o f a v a r i e t y o f o t h e r diagnoses as w e l l (Shapiro, 1995; S i n c e i t s i n c e p t i o n i n 1989, Marquis, 1991). r e s e a r c h i n t o EMDR has e s c a l a t e d t o the p o i n t where "there are a t p r e s e n t more p o s i t i v e c o n t r o l l e d s t u d i e s on EMDR than on any o t h e r method used i n t h e treatment o f p s y c h o l o g i c a l trauma" (Shapiro, 1995, f o c u s i n g on p. x ) . Yet no in-depth d e s c r i p t i v e study the phenomenology o f EMDR has been undertaken; and i s , hence, t a c i t l y suggested by the "gap" i n the l i t e r a t u r e . Such a study might p r o v i d e r e l e v a n t i n f o r m a t i o n t o r e s e a r c h e r s , t h e r a p i s t s and f u t u r e c l i e n t s , and h e l p e l u c i d a t e t h e "EMDR experience," and the meaning i n d i v i d u a l s ascribe to i t . PURPOSE OF THE STUDY I t was n o t t h e i n t e n t o f t h e author o f t h i s study t o a f f i r m o r deny the claims o f EMDR treatment e f f i c a c y ; an undertaking such would r e q u i r e a c o n t r o l l e d experiment beyond the scope o f a Master's t h e s i s . Rather, as some o f t h e e x t a n t EMDR l i t e r a t u r e claims use o f t h e technique l e a d s t o profound experiences often o f i n s i g h t ; memory r e t r i e v a l ; the emergence o f a f f e c t i v e l y o r s e m a n t i c a l l y r e l a t e d 4 a s s o c i a t i o n s ; and dramatic and s w i f t a l l e v i a t i o n o f symptoms ( K l e i n k n e c h t & Morgan, 1992; McCann, 1992; Shapiro, 1995), i t was hoped a close-up f i r s t s e s s i o n experiences 1989a, investigation of subjects' o f EMDR would h e l p shed l i g h t on these phenomena (should they o c c u r ) , and on what, e x a c t l y , occurs f o r s u b j e c t s d u r i n g t h e i r EMDR e x p e r i e n c e ( s ) . 5 CHAPTER TWO: LITERATURE REVIEW The E f f e c t s o f Trauma S h a t t e r e d Assumptions When i t occurs t o a man t h a t Nature does n o t r e g a r d him as important, and t h a t she f e e l s she would not maim t h e u n i v e r s e by d i s p o s i n g o f him, he a t f i r s t wishes t o throw b r i c k s a t t h e temple, and he hates deeply t h e f a c t t h a t t h e r e a r e no b r i c k s and no temples. — S t e p h e n Crane, "The Open Boat" E v i l has come though I expected I looked f o r l i g h t good; but t h e r e came darkness. . . . When I stop t o t h i n k , I am f i l l e d w i t h h o r r o r , and my whole body i s convulsed. —Job In Stephen Crane's s h o r t s t o r y , "The Open Boat" (1960), a s h i p has sunk i n t h e open sea, l e a v i n g o n l y f o u r s u r v i v o r s i n a t i n y dinghy. Exhausted and t e r r i f i e d , they a r e t o s s e d m e r c i l e s s l y by an endless p r o c e s s i o n o f " s n a r l i n g " waves, which t h r e a t e n , with each t h r u s t , t o c a p s i z e and devour them, w h i l e a s h a r k — e q u a l l y hungry f o r t h e i r d e a t h — c i r c l e s repeatedly. T h e i r sudden r e a l i z a t i o n of t h e randomness and meaninglessness o f t h e i r s i t u a t i o n , and Nature's indifference to i t , i s intolerable. profound That t h e r e s h o u l d be no 6 God, no benevolent C r e a t o r t o save them a t such a moment, or a t l e a s t p r o v i d e some meaning t o t h e i r p l i g h t , i s overwhelming, and, i n t h e i r eyes, i n e x c u s a b l e . They, i n f r u s t r a t i o n and anger, want t o complain and appeal t h e i r case t o a h i g h e r a u t h o r i t y ; and, b a r r i n g a f a v o r a b l e r u l i n g , "throw b r i c k s " a t the Temple o f J u s t i c e ; but a r e even more d i s t r a u g h t and demoralized upon r e a l i z i n g t h a t " t h e r e are no b r i c k s and no temples." So, attempting t o r e s t o r e order, and assuage t h e i r a n x i e t y , they p e r s o n i f y and blame F a t e ; as i f , by t h r e a t e n i n g or p l e a d i n g w i t h her, they might r e g a i n some c o n t r o l over t h e i r l i v e s , and a f f e c t the outcome of t h e i r drama. still In v a r i o u s ways they are t r y i n g t o f i n d order and meaning i n , and make sense o f , t h a t which i s i n h e r e n t l y random, b i z a r r e and meaningless. S i m i l a r l y , the B i b l e ' s Job, renown as a "blameless and u p r i g h t " man, d e s p i t e the why "the g r e a t e s t man i n a l l the E a s t , " cannot, r a t i o n a l i z a t i o n s of h i s v i s i t o r s , understand the God he l o v e s and r e s p e c t s , and b e f o r e whom he has behaved most p i o u s l y , has v i s i t e d upon him the s l a u g h t e r of h i s c h i l d r e n , the l o s s of h i s l i v e s t o c k and shepherds, and smote him w i t h "running sores from head t o f o o t . " He c o u l d w e l l be i n the same boat w i t h Crane's c h a r a c t e r s . For a l l are i n the process of e x p e r i e n c i n g one of the most profound e f f e c t s of trauma: one's b a s i c assumptions A s h a t t e r i n g of about the s e l f and world. 7 A c c o r d i n g t o Janoff-Bulman (1992), such i n d i v i d u a l s , i n the presence or aftermath of trauma, " s h a t t e r i n g " or l o s s of t h r e e b a s i c may s u f f e r the assumptions: 1. The world i s benevolent and good; and those who it, " b a s i c a l l y k i n d , h e l p f u l and c a r i n g " a f f e c t i n g us w i l l t u r n out w e l l . (p. 6 ) . inhabit Events Though we understand p r i n c i p a l of bad t h i n g s o c c u r r i n g i n the world, we the expect they w i l l not happen t o us. 2. The w o r l d i s meaningful. We can assure our ample r e c e i p t of good t h i n g s by our j u s t behaviour: o n l y t o those who behave badly. Our fundamental One gets what one deserves. assumption not simply b e l i e f s about why about meaning i n v o l v e s events happen i n our world, but, more s p e c i f i c a l l y , why t o p a r t i c u l a r people. We Bad happens these events happen seek t o understand the " d i s t r i b u t i o n " of good and bad outcomes, and i n the s e r v i c e of meaning we r e c o g n i z e or impose seemingly n a t u r a l c o n t i n g e n c i e s between people and t h e i r outcomes (p. 8 ) . We are deeply d i s t u r b e d by the p o s s i b i l i t y n e g a t i v e events c o u l d occur randomly t o us We p r e f e r t o b e l i e v e t h a t she who wonton; he who is i l l was that (Lerner, 1970). raped was d e s e r v i n g or d i d not take c a r e of h i m s e l f ; she who 8 was i n an automobile a c c i d e n t should have been more aware; and t h a t i f we take t h e necessary p r e c a u t i o n s , we w i l l be s a f e from these e v i l s and l i v e h e a l t h i l y u n t i l concept i n which we never r e a l l y 3. Self-Worth. assumptions capable. The t h i r d b e l i e v e ; Becker, o f the b a s i c 1974) . pre-trauma i s t h a t we a r e i n h e r e n t l y good, moral and T h e r e f o r e , we b e l i e v e , we a r e worthy o f t h e rewards which we b e l i e v e w i l l come t o us. circular: are our death (a We g e t rewarded Our r e a s o n i n g i s and l i v e p r o s p e r o u s l y because we good; and we must be good because our p r o s p e r i t y proves it. In sum, t h e assumptions a r e as f o l l o w s : My world i s benevolent. Even i n such a good world n e g a t i v e events happen, even i f r e l a t i v e l y infrequently. Yet when they occur they a r e n o t random, but r a t h e r a r e m e a n i n g f u l l y d i s t r i b u t e d . They happen t o people who deserve them, e i t h e r because o f who they are o r what they d i d or f a i l e d t o do. competent, c a r e f u l person. I am a good, Bad t h i n g s c o u l d n ' t happen t o me (p. 19). When such core assumptions, developed d u r i n g i n f a n c y and c h i l d h o o d (Ainsworth, 1979; Bowlby, 1969; M a r r i s , 1982) are " s h a t t e r e d " by the "shock" o f trauma, t h e v i c t i m i s l e f t 9 f e e l i n g , among other t h i n g s , v u l n e r a b l e , confused h e l p l e s s and (Janoff-Bulman, 1992; Herman, 1992); and through various defensive means, s e t s about t o r e c o n s t r u c t t h e s e l f amid t h e r u b b l e — t o make sense out o f t h e s e n s e l e s s ; meaning out o f t h e meaningless. V i c t o r Frankl (1963), who s u f f e r e d g r e a t l y w h i l e a p r i s o n e r o f war a t Auschwitz, emphasized t h e importance o f f i n d i n g o r c r e a t i n g meaning i n t h e f a c e o f trauma. According t o F r a n k l , one can withstand almost any degree o f s u f f e r i n g i f meaning can be a s c r i b e d t o i t , and he w r i t e s t h a t " s u f f e r i n g ceases t o be s u f f e r i n g i n some way a t t h e moment i t f i n d s a meaning. . . " (p. 179). So important i s i t t o us as human beings t o a s c r i b e meaning t o events (put them i n emotional and i n t e l l e c t u a l p e r s p e c t i v e ) t h a t , as Benyakar, Kutz, Dasberg and Stern "certain (1989) w r i t e , people w i l l choose t o g i v e up t h e i r l i v e s r a t h e r than . . . [surrender] . . . t h e i r ideas and b e l i e f s , which, f o r them, i s incompatible with existence" However, as S p i e g e l (p. 438). (1988) w r i t e s , t h e very essence o f trauma i s t h a t " i t i s i n some sense meaningless," and t h i s i n t o l e r a b l e senselessness v i c t i m s on a search o r absence o f meaning " s e t s f o r some framework i n which t o g i v e t h e otherwise meaningless experience some sense o f importance i n their l i f e " (p. 21), a task which can prove profoundly difficult. I f i t i s t r u e , as i n t e r p e r s o n a l and o b j e c t r e l a t i o n s t h e o r i s t s c l a i m , t h a t "we a r e our o t h e r s " 10 (Cashdan, 1988, p. 4 7 ) — t h a t i s , who we believe ourselves be i s the r e s u l t of our having i n c o r p o r a t e d and "metabolized" r e l a t i o n a l experiences and v a l u e s , f o l l o w s t h a t an encounter with, malicious self. and to then i t incorporation of, the "other" would l e a d t o a profound d i s o r i e n t a t i o n of Hence a s h a t t e r i n g of our assumptive world i s mirrored by a sense of s h a t t e r i n g , or fragmentation of the T h i s n o t i o n of a f r a c t u r e d or d i v i d e d s e l f i s not new self. t o psychology. From a t l e a s t as f a r back as Freud Janet, the predominant metaphors used t o psychopathology and fragmentation. and describe i t ' s symptoms are those of Terms such as " r e p r e s s i o n , " " d e n i a l , " "compartmentalization, 11 "splitting," "dissociation," " d i s i n t e g r a t i o n , "schizophrenic," "schizoid," "multiple p e r s o n a l i t y , " a l l imply a s s o c i a t i o n s between h e a l t h wholeness, i l l n e s s and fragmentation. Further, and the g o a l of many forms of psychotherapy has t r a d i t i o n a l l y been conceptualized as the r e - i n t e g r a t i o n of t h a t which has become d i s i n t e g r a t e d . That we equate h e a l t h with wholeness, and t h e r e o f w i t h fragmentation, i s r e f l e c t e d i n our According a lack language. t o Metzner (1986), the E n g l i s h words "whole" "wholesome, 11 as w e l l as " h o l i s t i c " and " h o l y , " have t h e i r o r i g i n s i n Old E n g l i s h h a l . which meant " h e a l t h y , " as w e l l as "complete." and "sound" He w r i t e s t h a t "wholeness, i n the sense of i n t e g r a t i o n , overlaps considerably w i t h the concept 11 of h e a l t h " (p. 89). Middle F u r t h e r , our modern " c r a z y " comes from E n g l i s h crasen, meaning "to break": " I n s a n i t y and p s y c h o s i s , t h e r e f o r e , are r e l a t e d i n common language thought t o the n o t i o n of p s y c h i c fragmentation" Hence, when one i s "crazy", and (p. 91). ( s u f f e r i n g mental d i s t r e s s ) one i s "broken" or fragmented; and c o n v e r s e l y , when one is h e a l t h y — e m o t i o n a l l y and s p i r i t u a l l y — o n e i s whole, or as the modern v e r n a c u l a r might put i t , I n t r u s i o n . Hyperarousal The "together." and C o n s t r i c t i o n s h a t t e r i n g or fragmentation of s e l f and one's assumptive world have t h r e e concomitant mental and p h y s i c a l m a n i f e s t a t i o n s r e c o g n i z e d by The D i a g n o s t i c and Statistical Manual of Mental D i s o r d e r s , Fourth E d i t i o n IV; (DSM APA, 1994), which have become the d e f i n i n g c r i t e r i a f o r the d i a g n o s i s of PTSD: Intrusion, hyperarousal and constriction. Intrusion. U n f o r t u n a t e l y f o r those s u f f e r i n g from PTSD, the t r a u m a t i c c o g n i t i v e and a f f e c t i v e information which the v i c t i m r e f l e x i v e l y attempts t o e x p e l from awareness, does not remain i n e x i l e . IV d i a g n o s i s of PTSD experience following: DSM one or more of the (a) " r e c u r r e n t and i n t r u s i v e d i s t r e s s i n g r e c o l l e c t i o n s of the event, perceptions"; event"; Those meeting a i n c l u d i n g images, thoughts, or (b) " r e c u r r e n t d i s t r e s s i n g dreams of t h e (c) a r e - e x p e r i e n c i n g of the trauma, as i f i t were o c c u r r i n g i n the moment ( f l a s h b a c k s ) ; or (d) "intense p s y c h o l o g i c a l d i s t r e s s a t exposure t o . . . c u e s " — b e they 12 i n t e r n a l or e x t e r n a l — " t h a t symbolize or resemble an a s p e c t of t h e t r a u m a t i c event" (APA, 1994, p. 209). I n t r u s i v e , t r a u m a t i c memories are u n l i k e our normal " n a r r a t i v e " memories—those which can be put i n t o a s t o r y , and understood w i t h i n a s p e c i f i c c o n t e x t . Rather, they are o f t e n encoded i n the form of v i v i d s e n s a t i o n s and mental images, which possess a " f r o z e n and wordless q u a l i t y " (Herman, 1992, p. 37; Janet, 1919); and o f t e n break spontaneously i n t o consciousness, "both as f l a s h b a c k s d u r i n g waking s t a t e s and as t r a u m a t i c nightmares d u r i n g s l e e p " (p. 37) . A c c o r d i n g t o van der Kolk (1988), i n s t a t e s o f h i g h sympathetic nervous system a r o u s a l experienced d u r i n g trauma, the normal l i n g u i s t i c encoding of memory may become i n a c t i v a t e d and r e p l a c e d by sensory and i c o n i c forms o f memory ( s i m i l a r t o those found i n c h i l d r e n ) which t h e n i n t r u d e i n t o waking and dreaming s t a t e s . Dreams r e l a t e d t o trauma o f t e n i n c l u d e exact r e p l i c a t i o n s of the o r i g i n a l t r a u m a t i c event, and can occur o u t s i d e of r a p i d eye movement (REM) sleep (Herman, 1992; Ross, B a l l & S u l l i v a n , 1989). The i n t r u s i v e r e - e x p e r i e n c i n g of t r a u m a t i c memories Freud (1958) termed a " r e p e t i t i o n compulsion," which he c o n c e p t u a l i z e d as an attempt t o master t h a t which e x p e r i e n c e d as overwhelming and overpowering. Janet was Similarly, (1919) b e l i e v e d t h a t because the trauma v i c t i m e x p e r i e n c e d a p r o t r a c t e d sense of trauma-induced 13 h e l p l e s s n e s s , a sense of what we would now e f f i c a c y i s seen as the a n t i d o t e One call (Seligman, self- 1975). former Vietnam veteran d e s c r i b e d h i s i n t r u s i v e experience this way: At l e a s t twice a week f o r . . . y e a r s I had s u s t a i n e d the same r e c u r r i n g nightmares . . . [of being] back t h e r e f a c i n g the same dangers, witnessing the same i n c a l c u l a b l e s u f f e r i n g , waking suddenly a l e r t , sweating, scared. [At a m e d i t a t i o n r e t r e a t ] the nightmares d i d not occur d u r i n g s l e e p , they f i l l e d mind's eye d u r i n g the day . . . . the H o r r i f i c wartime f l a s h b a c k s were superimposed over a q u i e t redwood grove a t the r e t r e a t c e n t e r . dormitory Sleepy students i n the became body p a r t s strewn about a morgue on the DMZ makeshift ( K o r n f i e l d , 1993). Horowitz (1976), b e l i e v e s t h a t the repetitive, i n t r u s i v e thoughts and memories which haunt the trauma v i c t i m are an attempt by the mind t o r e s o l v e the d i s c r e p a n c i e s between the new incompatible trauma-related e x i s t i n g schemata. The information and intrusive re- e x p e r i e n c i n g c o u l d be viewed as a b i p r o d u c t of " a c t i v e memory's" attempt t o i n t e g r a t e t r o u b l i n g i n f o r m a t i o n which i s o u t s i d e the realm of p r e v i o u s l y h e l d b e l i e f s or schemata; t h a t i s , t o r e c o n s t r u c t " s h a t t e r e d assumptions." Completion ( i . e . , an abatement of i n t r u s i v e symptoms) occurs when the 14 new d i s t u r b i n g i n f o r m a t i o n has been i n t e g r a t e d i n t o , or made compatible with, e x i s t i n g schemata; or c o n v e r s e l y , when o l d schemata have been a d j u s t e d t o allow f o r the i n t e g r a t i o n of the new information. T h i s l a t t e r i d e a i s s i m i l a r t o Kuhn's (1962), n o t i o n of a paradigm s h i f t i n s c i e n c e , or P i a g e t ' s (1952) concept of accommodation. Hyperarousal. Whereas the mental components of trauma are p a r t i a l l y r e f l e c t e d by the s h a t t e r i n g of assumptions and s e l f , and the i n t r u s i o n of d i s t u r b i n g memories, t h e p h y s i o l o g i c a l aspects are manifested two by h y p e r a r o u s a l . or more of the f o l l o w i n g w i l l be experienced victim: And by the PTSD (a) d i f f i c u l t y f a l l i n g or s t a y i n g a s l e e p ; b) i r r i t a b i l i t y or o u t b u r s t s of anger; (c) d i f f i c u l t y c o n c e n t r a t i n g ; (d) h y p e r v i g i l a n c e ; (e) exaggerated response (APA, 1994). As a r e s u l t of h i s work with World War Abram K a r d i n e r startle II soldiers, (1947) coined the term p h v s i o n e u r o s i s to d e s c r i b e the c o n t i n u o u s l y h i g h l e v e l s of autonomic nervous system s t i m u l a t i o n he witnessed. I t appeared t o him that these symptoms were i n d i c a t i v e of the body's almost c h r o n i c preparedness f o r what may be termed " f i g h t or S i m i l a r l y , G r i n k e r and S p i e g a l (1945) observed traumatized that s o l d i e r s s u f f e r e d from what seemed l i k e a " c h r o n i c s t i m u l a t i o n of the sympathetic 219). flight." nervous system" (p. More r e c e n t l y , r e s e a r c h e r s have been a b l e t o c o n f i r m e x t e n s i v e and enduring p s y c h o p h y s i o l o g i c a l changes r e s u l t i n g from trauma. 15 A c c o r d i n g t o van der Kolk (1987) due t o prolonged o r r e p e a t e d exposure t o traumata, t h e body's use o f catecholamines (the n e u r o t r a n s m i t t e r s norepinephrine, e p i n e p h r i n e and dopamine) may exceed p r o d u c t i o n , and a d e p l e t i o n may occur, l e a d i n g t o a neuronal h y p e r s e n s i t i v i t y t o l a t e r s t i m u l a t i o n by these same n e u r o t r a n s m i t t e r s . The r e s u l t i s t h a t subsequent t o trauma, even minor s t r e s s o r s o r s t i m u l a t i o n may t r i g g e r o v e r a r o u s a l o f t h e autonomic nervous system. Janoff-Bulmann w r i t e s t h a t t h e r e i s now some evidence t h a t a s i n g l e case o f overwhelming t e r r o r may be capable o f changing b r a i n chemistry such t h a t some s u r v i v o r s a r e more s e n s i t i v e t o a d r e n a l i n e surges even decades l a t e r Hyperarousal (1992, p. 68). can p e r s i s t d u r i n g t h e waking s t a t e , a f f e c t i n g c o n c e n t r a t i o n , causing h y p e r v i g i l e n c e , i n c r e a s e d s t a r t l e response o r angry r e a c t i o n s , e t c . ; as w e l l as d u r i n g sleep, r e s u l t i n g i n sleep disturbance. Those s u f f e r i n g from PTSD take longer t o f a l l asleep, awaken more f r e q u e n t l y (Herman, 1992) and may experience a dysregulation of rapid eye movement REM s l e e p (Ross, B a l l & S u l l i v a n , 1989) . F u r t h e r , i t now appears t h a t c h r o n i c , h i g h l e v e l s o f s t r e s s can r e s u l t i n s t r u c t u r a l changes t o t h e b r a i n , i . e . , neuronal death and subsequent compensation (Ver E l l e n & van Kammen, 1990). 16 Constriction. Symptoms i n t h i s category i n v o l v e "a p e r s i s t e n t avoidance o f s t i m u l i a s s o c i a t e d w i t h the trauma and numbing of g e n e r a l r e s p o n s i v e n e s s " (APA, p. 210). A PTSD v i c t i m w i l l e x h i b i t one or more of the f o l l o w i n g : an avoidance (a) of thoughts or f e e l i n g s a s s o c i a t e d w i t h the trauma; an avoidance of (b) a c t i v i t i e s , p l a c e s or people t h a t arouse these f e e l i n g s or thoughts; (c) amnesia f o r c e r t a i n a s p e c t s of the trauma; (d) a d i m i n i s h e d i n t e r e s t i n participating in significant activities; (e) f e e l i n g s o f detachment; (f) r e s t r i c t e d a f f e c t ; or (g) a sense of f o r e s h o r t e n e d f u t u r e (p. 209). In the months f o l l o w i n g a t r a u m a t i c event, as the i n t r u s i v e and h y p e r a r o u s a l symptoms tend t o d i m i n i s h somewhat, c o n s t r i c t i v e symptoms may (Herman, 1992, begin t o predominate p. 48). The v i c t i m may begin t o a v o i d people, p l a c e s or t h i n g s which he or she a s s o c i a t e s with the t r a u m a t i c event, i n o r d e r not t o experience p o t e n t i a l l y overwhelming r e l a t e d thoughts and f e e l i n g s (Janoff-Bulman). In an attempt g a i n c o n t r o l over what i s experienced, the v i c t i m may s e v e r e l y l i m i t h i s or her a c t i o n s , thereby a f f e c t i n g e n t i r e f i e l d of p u r p o s e f u l a c t i o n and i n i t i a t i v e " p. to "the (Herman, 46). J u s t as a change i n v i c t i m s ' catecholamine and s e n s i t i v i t y may production occur a f t e r trauma, l e a d i n g t o heightened a n x i e t y s t a t e s ; so too may a dysregulation of endogenous o p i o i d s l e a d t o s i m i l a r f e e l i n g s of a n x i e t y and 17 emotional d i s c o m f o r t (Pitman, van der Kolk, & Orr, 1990). T h i s i n t u r n may encourage those without t h e c a p a c i t y f o r d i s s o c i a t i o n t o s e l f - m e d i c a t e through t h e use o f drugs o r a l c o h o l i n order t o c o n s t r i c t t h e i r range o f n e g a t i v e affect. However, n e i t h e r drugs nor conscious avoidance o f n e g a t i v e s t i m u l i can ward o f f the p e r s i s t e n t emotional and p s y c h o l o g i c a l post-trauma distress. Hence, t h e v i c t i m may u t i l i z e t h e "automatic d e n i a l p r o c e s s " (Janoff-Bulman, 97) p. o f d e n i a l , which h e l p s i n " t u r n i n g o f f awareness o f t h e event o r i t s i m p l i c a t i o n s capacity t o f e e l " . . . [or] . . . s h u t t i n g down t h e (p. 97). D e n i a l may serve a h e a l i n g f u n c t i o n i n h e l p i n g t h e v i c t i m pace h i s o r h e r r e c o v e r y , by n o t a l l o w i n g t h e organism at t o be overloaded w i t h t o o much n e g a t i v e i n f o r m a t i o n one time (Janoff-Bulman, 1992). However, as noted by Janet (1919) l a t e i n t h e l a s t century, a trauma v i c t i m can i s o l a t e t r a u m a t i c i n f o r m a t i o n more o r l e s s completely from conscious awareness, i n what we today d e s c r i b e as fugue s t a t e s , d i s s o c i a t i v e disorder identity (APA, 1994; p r e v i o u s l y known as m u l t i p l e p e r s o n a l i t y d i s o r d e r , APA, 1987), o r amnesia. In such d i s s o c i a t i v e s t a t e s , although the t r a u m a t i c i n f o r m a t i o n i s s p l i t from conscious awareness, i t does not d i s a p p e a r completely from the organism. tendency ways, Hence, t h e v i c t i m r e t a i n s a t o r e a c t t o subsequent s t r e s s o r s i n i n a p p r o p r i a t e as i f t h e trauma were r e c u r r i n g . Van d e r Kolk and 18 K a d i s h (1987) w r i t e t h a t PTSD v i c t i m s may experience emotional i n t e n s i t y of o r i g i n a l trauma without awareness of the h i s t o r i c a l r e f e r e n c e " These o b s e r v a t i o n s "the conscious (p. 7 ) . b r i n g us f u l l c i r c l e t o the of the fragmented or d i v i d e d s e l f ; and l e a d us t o notion the q u e s t i o n of what t h e r a p e u t i c agent the p s y c h o t h e r a p i s t apply t o r e t u r n the trauma v i c t i m t o a s t a t e of might relative wholeness. Current Treatments f o r the E f f e c t s of Trauma Humpty Dumpty s a t on a w a l l Humpty Dumpty had a great fall. A l l the King's horses and a l l the King's Couldn't put him back together men again. — T r a d i t i o n a l Nursery Rhyme As s t a t e d i n E c c l e s i a s t e s , t h e r e i s no new the sun. Centuries b e f o r e t h i n g under the advent of modern psychology, t r a d i t i o n a l h e a l e r s , known as shamans were attempting to h e a l the trauma v i c t i m through r e i n t e g r a t i o n of fragmented p a r t s of s e l f . who They, however, u n l i k e most modern t h e r a p i s t s concern themselves with the "mental" h e a l t h ( i . e . , mind) of the v i c t i m , t r e a t e d the s o u l , which they b e l i e v e d had l e a s t p a r t i a l l y l e f t the v i c t i m ' s body d u r i n g the experience (Ingerman, 1991). the Shaman's v e n t u r i n g H e a l i n g was known as " s o u l r e t r i e v a l . " To t h i s end, traumatic accomplished i n t o the s p i r i t world i n an at by exercise he employed such 19 t o o l s as r a t t l e s , drugs " s o u l c a t c h e r s , " drums and h a l l u c i n o g e n i c (Ingerman, 1991; Achterberg, 1985). Although t h e t o o l s of t h e modern "shaman," o r p s y c h o l o g i s t , may seem t o us l e s s f a n c i f u l , they a r e not n e c e s s a r i l y any more c o n s i s t e n t l y e f f e c t i v e i n r e l i e v i n g a l l of t h e symptoms o f PTSD than those o f t h e Shaman. That i s , the concurrence o f p s y c h o l o g i c a l l i t e r a t u r e can be found i n the above nursery rhyme of Humpty Dumpty: No p r e s c r i p t i v e treatment i s a b l e , i n i t s e l f , o r even i n combination with o t h e r treatments, t o a l l e v i a t e c o n s i s t e n t l y , a l l o f t h e symptoms o f PTSD (Herman, 1992; Shapiro, 1995), and p u t t h e c l i e n t "together a g a i n . " The t h r e e treatments most f r e q u e n t l y r e f e r r e d t o i n t h e e x t a n t l i t e r a t u r e , and g e n e r a l l y regarded as most e f f e c t i v e i n t r e a t i n g trauma are f l o o d i n g , s y s t e m a t i c d e s e n s i t i z a t i o n , and hypnosis (Herman, 1992; Shapiro, 1995). Imaginal F l o o d i n g Imaginal f l o o d i n g (or i m p l o s i v e t h e r a p y — a variation i n c o r p o r a t i n g hypothesized cues) i s a technique whose r a t i o n a l e borrows from the seminal work o f P a v l o v (1927). J u s t as a d o g — c o n d i t i o n e d t o s a l i v a t e a t t h e sound o f a bell (a c o n d i t i o n e d stimulus [CS]) a f t e r t h a t b e l l i s r e p e a t e d l y f o l l o w e d by food (the u n c o n d i t i o n e d s t i m u l u s [ U S ] ) — c a n be taught t o no longer do so i n t h e r e p e a t e d absence o f the US; so t o o can a trauma v i c t i m l e a r n t o respond t o mental or t a n g i b l e cues (the CS) w i t h r e l a t i v e 20 n e u t r a l i t y , i n t h e repeated absence o f r e a l t h r e a t Stampfl and L e v i s (the US). (1967) w r i t e the fundamental h y p o t h e s i s i s t h a t a s u f f i c i e n t c o n d i t i o n f o r the e x t i n c t i o n o f a n x i e t y i s t o r e p r e s e n t , r e i n s t a t e , o r s y m b o l i c a l l y reproduce t h e stimuli (cues) t o which t h e a n x i e t y response has been c o n d i t i o n e d , i n absence of primary reenforcement (p. 499) . Pitman e t a l . w r i t e , "The treatment i s no r o s e garden; i t i s s t r e s s f u l by d e s i g n " (1991, p. 17). That i s , t h e c l i n i c i a n d e l i b e r a t e l y t r i e s t o e l i c i t a c l i e n t ' s a n x i e t y , through a mental r e - e x p e r i e n c i n g o f a t r a u m a - r e l a t e d event. Because t h i s r e - e x p e r i e n c e occurs i n t h e absence o f r e a l t h r e a t , i t i s deemed s a f e — e v e n n e c e s s a r y — a n d i s r e p e a t e d u s i n g i n c r e a s i n g l y a n x i e t y - p r o v o k i n g cues, u n t i l a n x i e t y i s i s i g n i f i c a n t l y diminished. C r i t i c i s m o f imaqinal f l o o d i n g . Pitman e t a l . (1991) w r i t e t h a t although f l o o d i n g has been proven e f f i c a c i o u s i n the treatment o f phobias and o b s e s s i v e compulsive d i s o r d e r , PTSD i s a more complex c o n d i t i o n , o f t e n accompanied comorbid mental by disorders. Whereas the emotional d i s t u r b a n c e i n phobias i s t y p i c a l l y l i m i t e d t o a n x i e t y , PTSD p a t i e n t s o f t e n a l s o s u f f e r from sadness, anger, g u i l t , and/or shame 21 a s s o c i a t e d w i t h the trauma . . . . I t i s not clear whether these emotions obey the same law of e x t i n c t i o n as does a n x i e t y , upon which the r a t i o n a l e f o r f l o o d i n g i s t r a d i t i o n a l l y based (p. 17). They f u r t h e r suggest t h a t i f a c l i e n t ' s emotional d i s t r e s s i n v o l v e s negative p o s t t r a u m a t i c a p p r a i s a l s , r e p e a t e d f l o o d i n g may i n f a c t be e x a c e r b a t i n g "the feelings of anger, shame, g u i l t , s e l f - a c c u s a t i o n , f e e l i n g s of f a i l u r e , and "What i f ? " (p. 19). They p r e s e n t c a s e s i n which f l o o d i n g l e d t o worsened d e p r e s s i o n , r e l a p s e of a l c o h o l abuse, and the advent of p a n i c d i s o r d e r . As one PTSD c l i e n t i s r e p o r t e d t o have s a i d i n r e f e r e n c e t o h i s treatment, "There was much mopping up" a l o t of f l o o d i n g , but t h e r e wasn't (Pitman e t a l . , p. 19). A f u r t h e r weakness i s t h a t the e l i c i t a t i o n of extremely h i g h l e v e l s of a n x i e t y must be repeated over s e v e r a l t o many sessions (Stampfl and L e v i s suggest between 1 and 15, s e s s i o n s , "with t o t a l treatment time r a r e l y exceeding i m p l o s i v e h r . " (1967, p. 1-hr. 30 502). F u r t h e r , f l o o d i n g i s of l i m i t e d t h e r a p e u t i c b e n e f i t . Although the most notable a m e l i o r a t i o n of symptoms o c c u r s w i t h i n the realm of i n t r u s i o n symptoms, numbing and avoidance social tend t o remain u n a f f e c t e d (Lyons and Keane, Herman, 1992). A c c o r d i n g t o Shapiro, 1989; (1989a) l a c k i n g a r e the c o g n i t i v e elements necessary t o complete treatment. 22 Hypnosis Use of hypnosis f o r the treatment l e a s t as f a r back as Freud (1958), who of trauma d a t e s a t b e l i e v e d t h a t the c a t h a r s i s or a b r e a c t i o n induced d u r i n g such a l t e r e d s t a t e s was s u f f i c i e n t f o r r e s o l u t i o n of d i f f i c u l t i e s . proved too simple This concept ( S p i e g e l , 1987), and he found t h a t such a b r e a c t i o n alone c o u l d sometimes l e a d t o the d e m o r a l i z a t i o n of the p a t i e n t (p. 26), due t o p e r c e i v e d l a c k of c o n t r o l over the t r a u m a t i c m a t e r i a l : The c l i e n t s were simply overwhelmed by, and powerless i n the f a c e o f , t h e i r emotion. Janet (1919) emphasized the need t o h e l p the p a t i e n t not o n l y r e - e x p e r i e n c e but i n t e g r a t e t r a u m a t i c i n f o r m a t i o n which had become s p l i t o f f from consciousness. Brown and van der Kolk Van der Hart, (1989) w r i t e Janet c o n s i d e r e d the i n a b i l i t y t o i n t e g r a t e t r a u m a t i c memories as the c o r e i s s u e i n p o s t - t r a u m a t i c syndromes: Treatment of p s y c h o l o g i c a l trauma always e n t a i l e d an attempt t o recover and i n t e g r a t e the memories of the trauma i n t o the t o t a l i t y of people's identities (p. 380).. ' To t h i s end Janet pioneered p a r t i c u l a r h y p n o t i c t e c h n i q u e s , v a r i a t i o n s of which are s t i l l van der Hart, 1989). i n use today (van der Kolk & Under hypnosis, t r a u m a t i c memories which the c l i e n t had r e p r e s s e d were r e t r i e v e d and transformed or r e p l a c e d by n e u t r a l or p o s i t i v e images and 23 feelings (a technique a n t i c i p a t i n g the Erickson, victims 1980). The experience out "frozen," l a t e r work of Milton i n t r u s i v e images which PTSD of context and i n l i e u of memory, were transformed i n t o meaningful "verbal" narratives. P r e s a g i n g l a t e r f l o o d i n g techniques, Janet employed a stepwise p r o c e s s of having the c l i e n t i n c r e m e n t a l l y e x p e r i e n c e and express t h e i r t r a u m a t i c f e e l i n g s . age was regression re- Hypnotic a l s o used where deemed a p p r o p r i a t e . S i n c e the time of Janet many authors have noted s i m i l a r i t i e s between d i s s o c i a t i v e s t a t e s and a f t e r trauma, and occurring the h y p n o t i c s t a t e . Bruer d e s c r i b e d d i s s o c i a t i o n as a "hypnoidal" s t a t e . al. (1987) d e s c r i b e h y p n o t i z a b i l i t y as capacity "the during (1958) Spiegel In f a c t , authors of r e c e n t s t u d i e s e t a l . , 1988) (see scores and the d i a g n o s i s of PTSD. the d i s s o c i a t i v e nature of many PTSD symptoms, and d i s s o c i a t i v e nature of hypnosis i t s e l f , Spiegel Spiegal hypnotizability; i n d i v i d u a l s may be more s u s c e p t i b l e trauma (p. 304). i n d i v i d u a l s who or, c o n v e r s e l y , h i g h l y t o the enhance after effects cannot spontaneously d i s s o c i a t e induce d i s s o c i a t i o n through the 1988). the hypnotizable I t i s further speculated that (Spiegal, Noting et a l . s p e c u l a t e t h a t e i t h e r the experience of trauma may or a l c o h o l setting" have found a h i g h c o r r e l a t i o n between hypnotizability of trauma, may et fundamental t o experience d i s s o c i a t i o n i n a s t r u c t u r e d (p. 302). the of those i n the use face of drugs 24 An advantage of u s i n g hypnosis over o t h e r s t a n d a r d t e c h n i q u e s i s t h a t , due t o the e f f e c t s of memory (see Bower, 1981) memories may state-dependent the i s o l a t e d , d i s s o c i a t e d t r a u m a t i c more e a s i l y be accessed i n a s i m i l a r , a r t i f i c i a l l y induced d i s s o c i a t i v e s t a t e ( h y p n o s i s ) . Although, hypnosis as Freud found, simple a b r e a c t i o n under (without i n t e g r a t i o n ) can prove c o u n t e r p r o d u c t i v e , a modulated r e - e x p e r i e n c i n g can h e l p f o s t e r i n the c l i e n t a sense o f e f f i c a c y and c o n t r o l (Smith, 1989) . This perceived sense of c o n t r o l can a r i s e when the c l i e n t — w i t h the t h e r a p i s t ' s h e l p — r e a l i z e s he or she has the power t o slow down r e c a l l of the e v e n t ( s ) , and r e - e x p e r i e n c e o n l y p o r t i o n s of the trauma, "drawing on the heightened capacity for p h y s i c a l and emotional c o n t r o l t h a t the h y p n o t i c s t a t e provide" One (Watkins, (Smith, p. 130). h y p n o t i c technique, c a l l e d the " a f f e c t b r i d g e " 1971) i s used t o h e l p the c l i e n t r e t r i e v e p r e v i o u s t r a u m a t i c i n f o r m a t i o n which i s s i m i l a r i n a f f e c t i v e to can t h a t o f which the c l i e n t i s c u r r e n t l y aware. " s p l i t s c r e e n " technique (see S p i e g a l , 1987) content In the the client s i m u l t a n e o u s l y imagines the t r a u m a t i c events appearing on one s c r e e n , w h i l e on another, what he or she d i d a t the to time cope, thereby a i d i n g the c l i e n t i n g a i n i n g a b i g g e r , more i n t e g r a t e d p i c t u r e of the trauma and h i s or her r o l e i n i t . C r i t i s i s m of hypnosis. Although hypnosis facilitates access t o , and c o n t r o l over, d i s s o c i a t e d s t a t e s , as S p i e g e l w r i t e s , "There i s nothing t h a t can be done w i t h hypnosis 25 t h a t c o u l d not be done without i t " (1987, p. 30). Further, d e s p i t e the tendency toward i n c r e a s e d h y p n o t i z a b i l i t y among PTSD v i c t i m s , not a l l are h y p n o t i z a b l e . (1919), some traumatized As noted by s u b j e c t s take weeks o r months b e f o r e they can enter i n t o a h y p n o t i c s t a t e (presumably t o a f e a r of r e - e x p e r i e n c i n g the trauma-related i f they enter a t a l l . Janet due emotions), S p i e g e l (1987) notes the danger l a t e n t i n hypnotic transference: P a t i e n t s may have the sense of being r e a s s a u l t e d (by an i n s e n s i t i v e t h e r a p i s t ) d u r i n g the h y p n o t i c procedure. Systematic D e s e n s i t i z a t i o n Developed by Joseph Wolpe (see Wolpe, 1959, 1990), s y s t e m a t i c d e s e n s i t i z a t i o n i s based on the assumption t h a t because an a n x i e t y response i s l e a r n e d or c o n d i t i o n e d , " i t can be i n h i b i t e d by s u b s t i t u t i n g an a c t i v i t y t h a t i s a n t a g o n i s t i c t o the f e a r response" (Kanfer & G o l d s t e i n , 1991, p. 163). Hence, a t h e r a p i s t u s i n g t h i s exposes the c l i e n t , i n s m a l l graduated s t e p s , t o d i s t u r b i n g memory, w h i l e having the c l i e n t emotions incompatible with a n x i e t y calmness). technique the experience ( i . e . , r e l a x a t i o n and An a s s o c i a t i v e l i n k i s then formed between r e l a x a t i o n and the p r e v i o u s l y a n x i e t y provoking memory. In o t h e r words, the c l i e n t l e a r n s t o remain calm i n the f a c e of t h a t which once was d i s t u r b i n g . C r i t i c i s m of systematic d e s e n s i t i z a t i o n . t h e r e i s some support Although f o r using systematic d e s e n s i t i z a t i o n i n the treatment of PTSD (Russel, 1991), s e v e r a l authors 26 (Lyons & Kean, 1989; Shapiro, 1989a; Spector & Huthwaite, 1992;) are c r i t i c a l of t h i s procedure First, f o r s e v e r a l reasons. systematic d e s e n s i t i z a t i o n requires a h i e r a r c h i c a l o r d e r i n g of a n x i e t y r e l a t e d m a t e r i a l (Wolpe, 1959) which i s i n a p p r o p r i a t e and o f t e n impossible t o a t t a i n w i t h PTSD symptoms (Shapiro, 1989a; Spector & Huthwaite, 1992). Second, i t tends t o address o n l y i n t r u s i v e , and not c o n s t r i c t i v e , symptoms or i n a p p r o p r i a t e c o g n i t i o n s (Shapiro, 1989a). I t a l s o has been c r i t i c i z e d due t o l e n g t h of treatment r e q u i r e d (Shapiro, 1989a); and f o r s u b j e c t noncompliance (Lyons & Kean, 1989). Eye Movement D e s e n s i t i z a t i o n and Reprocessing The O r i g i n a l P r o t o c o l As the reader i s p o s s i b l y u n f a m i l i a r w i t h r e l a t i v e l y new procedure, (see Shapiro, 1989a, 1995 this a b r i e f d e s c r i p t i o n w i l l be g i v e n f o r complete d e t a i l s ) . In the o r i g i n a l p r o t o c o l , treatment begins by having a t r a u m a t i z e d c l i e n t focus on the t r o u b l i n g memory or image from which he or she wants r e l i e f . For example, i f the c l i e n t i s s u f f e r i n g from PTSD from having been i n an automobile a c c i d e n t , he or she would p i c t u r e the most a n x i e t y provoking image of the a c c i d e n t and would c o v e r t l y r e h e a r s e the concomitant c o g n i t i v e b e l i e f , i . e . , "I'm t o d i e , " or "I should have done something," e t c . going Then, he or she r a t e s the l e v e l of a n x i e t y experienced i n d o i n g this, u s i n g the S u b j e c t i v e U n i t s of Discomfort S c a l e (SUDs; Wolpe, 1982), an 11-point L i k e r t s c a l e , w i t h 0 being no a n x i e t y , 27 and 10 r e p r e s e n t i n g extreme p a n i c . The c l i e n t then imagines a p r e f e r r e d c o g n i t i o n , such as "I'm s a f e now," e t c . , and rates i t s v a l i d i t y using the V a l i d i t y of Cognition (VOC; Scale Shapiro, 1989a), a seven-point L i k e r t s c a l e . and VOC scores serve as b a s e l i n e measures, a g a i n s t which any changes w i l l be compared. experiencing The SUDs Then, w h i l e once a g a i n t h e d i s t u r b i n g image, f e e l i n g and c o g n i t i o n , the c l i e n t f o l l o w s the t h e r a p i s t ' s index f i n g e r , which he o r she moves h o r i z o n t a l l y , back and f o r t h , a c r o s s the c l i e n t ' s l i n e o f v i s i o n , from extreme r i g h t t o extreme l e f t , distance and o f 12-14 inches from the c l i e n t ' s f a c e . at a Each back f o r t h movement of the f i n g e r (a saccade) i s r e p e a t e d 12- 24 times (one s e t ) . A f t e r each s e t o f saccades, t h e c l i e n t r e l a x e s and blanks out the p i c t u r e . They then generate t h e p i c t u r e and c o g n i t i o n once again and a new SUDs l e v e l i s taken. one The procedure i s repeated u n t i l SUDs r a t i n g s r e a c h o r zero. A c c o r d i n g t o most p u b l i s h e d s t u d i e s , a f t e r one t o s e v e r a l s e t s o f saccades, t h e d i s t u r b i n g image changes o r disappears, and the concomitant a n x i e t y Sometimes, b e f o r e o r a f t e r t h e f i r s t a d i f f e r e n t , but s e m a n t i c a l l y also dissipates. image i s d e s e n s i t i z e d , or a f f e c t i v e l y r e l a t e d image w i l l appear, and the above procedure i s used t o d e s e n s i t i z e it. The procedure ends when a l l t r a u m a t i c images have been desensitized. 28 The Revised Protocol As w i t h most t h e r a p e u t i c techniques, t h e o r i g i n a l EMDR p r o t o c o l has undergone an e v o l u t i o n which has l e d t o a l t e r a t i o n s i n the procedure. Most n o t i c e a b l y , i n the c u r r e n t p r o t o c o l t h e c l i n i c i a n no longer has t h e c l i e n t remain focused o n l y on the original d i s t u r b i n g image throughout treatment, w h i l e i n s t i g a t i n g eye movements, b u t more g e n t l y f o l l o w s t h e c l i e n t ' s e v o l v i n g processing. F o r example, a t t h e end o f a s e t , t h e c l i n i c i a n w i l l ask the c l i e n t , "What do you get know?" (Shapiro, 1995, p. 37) and w i l l have the c l i e n t h o l d the new image, f e e l i n g , thought, e t c . , i n mind through the next s e t o f saccades (p. 37). Shapiro writes No matter how the i n f o r m a t i o n s u b j e c t i v e l y emerges, as long as p r o c e s s i n g has continued, the c l i e n t should simply be d i r e c t e d f o r t h e next s e t w i t h t h e g l o b a l statement "Think o f i t . " In other words, t h e c l i n i c i a n needs t o address the t a r g e t e d memory i n whatever form i t a r i s e s (1994, p. 77). F u r t h e r , t h e r e v i s e d EMDR p r o t o c o l (see Shapiro, 1995, f o r d e t a i l s ) i n c l u d e s a complete treatment p l a n c o n s i s t i n g of e i g h t phases: (b) p r e p a r a t i o n ; (a) C l i e n t h i s t o r y and treatment planning; (c) assessment; (d) d e s e n s i t i z a t i o n ( g e n e r a l l y eye movements); (e) i n s t a l l a t i o n o f p o s i t i v e cognition; (f) body scan; (g) c l o s u r e ; and (h) r e - 29 e v a l u a t i o n ; and an 11-step standard procedure which i n c l u d e s the f o l l o w i n g : 1. C l i e n t accesses traumatic an image which r e p r e s e n t s t h e e n t i r e event. 2. C l i e n t develops the negative conveys an u n d e r l y i n g l i m i t i n g "I am" s e l f - s t a t e m e n t , which belief. 3. C l i e n t c r e a t e s a d e s i r a b l e p o s i t i v e s e l f - s t a t e m e n t which (when p o s s i b l e ) i n c o r p o r a t e s an i n t e r n a l l o c u s o f c o n t r o l . 4. C l i e n t determines t h e v a l i d i t y o f t h e p o s i t i v e s e l f statement (the V a l i d i t y of C o g n i t i o n ; VOC), on a s c a l e o f l t o 7. 5. C l i e n t i d e n t i f i e s the d i s t u r b i n g emotion which linking the image and negative c o g n i t i o n produce. 6. C l i e n t uses SUDs t o determine the s u b j e c t i v e l e v e l o f d i s t u r b a n c e when t h e memory of t h e t r a u m a t i c event i s stimulated. 7. C l i e n t l o c a t e s where t h e concomitant p h y s i c a l s e n s a t i o n s i n t h e body a r e f e l t . 30 8. C l i e n t processes a l l d i s t u r b i n g i n f o r m a t i o n (using c l i n i c i a n - i n s t i g a t e d eye movements, e t c . ) 9. C l i n i c i a n i n s t a l l s the p o s i t i v e c o g n i t i o n . 10. C l i e n t mentally scans body f o r any r e s i d u a l p h y s i c a l s e n s a t i o n , w h i l e h o l d i n g event and p o s i t i v e c o g n i t i o n i n mind. 11. C l i n i c i a n ends s e s s i o n , i n s u r i n g c l i e n t i s r e l a t i v e l y relaxed. V a r i a t i o n s on the above standard protocol also exist f o r t h e treatment of phobias (simple and complex); g r i e f ; and i l l n e s s and somatic d i s o r d e r s (Shapiro, Shapiro (1995) notes t h a t s i n c e 1990 those excessive 1995). teaching EMDR have i n s t r u c t e d students i n the use of not o n l y eye movements, but hand taps and a u d i t o r y cues; and t h a t have made use o f f l a s h i n g l i g h t s as w e l l . others She w r i t e s , that d e s p i t e apparent e f f i c a c y , " f u r t h e r i n v e s t i g a t i o n may find t h a t eye movements have a unique s t a t u s as a s t i m u l u s that i s a l s o an observable inherent p h y s i o l o g i c a l of some types of c o g n i t i v e p r o c e s s i n g " manifestation (p. 24). Healing Mechanisms In her seminal a r t i c l e (1989a) Shapiro c i t e s P a v l o v ' s (1927) s p e c u l a t i o n t h a t "traumatic overload" p a t h o l o g i c a l n e u r a l changes which keep the leads t o traumatic 31 i n f o r m a t i o n i n a " f r o z e n s t a t e " (p. 220). Wolpe w r i t e s t h a t i f e x c i t a t i o n and i n h i b i t i o n come i n t o c o n f l i c t w i t h each o t h e r a t a g i v e n l o c u s o f t h e c o r t e x , "the n e u r a l elements concerned may be unable t o bear t h e s t r a i n and so undergo a p a t h o l o g i c a l change . . . " (Wolpe, 1959). technique The EMDR ( r e p e a t i n g eye movements w h i l e h o l d i n g t h e memory i n awareness) p u r p o r t e d l y f a c i l i t a t e s p r o c e s s i n g o f t h i s "frozen" information neurological (p. 220), thereby r e s t o r i n g balance. S e v e r a l e a r l y authors, noting the s u p e r f i c i a l p h y s i o l o g i c a l s i m i l a r i t i e s between EMDR eye movements and those found i n r a p i d REM s l e e p , s p e c u l a t e d t h a t EMDR may p r o v i d e an i n f o r m a t i o n p r o c e s s i n g f u n c t i o n s i m i l a r t o t h e p u t a t i v e p r o c e s s i n g mechanism o f REM s l e e p (Shapiro, 1989a; Ross e t a l . 1994). To make sense o f EMDR's r a p i d h e a l i n g e f f e c t s working h y p o t h e s i s makes use o f an " A c c e l e r a t e d Shapiro's Information P r o c e s s i n g " model (Shapiro, 1995, p. 28). According t o t h i s model, t h e i n f o r m a t i o n , which has become " f r o z e n " due t o traumatic o v e r l o a d , i sisolated i n the nervous system i n i t s " d i s t r e s s i n g , e x c i t a t o r y s t a t e s p e c i f i c form" (p. 30), and i n t r u d e s i n t o c o n s c i o u s n e s s i n the form o f t h e i n t r u s i v e symptoms d i s c u s s e d above. Shapiro (1995) w r i t e s In e f f e c t , t h e i n f o r m a t i o n i s f r o z e n i n time, isolated i n i t s own neuro network, and s t o r e d i n i t s o r i g i n a l l y 32 d i s t u r b i n g s t a t e - s p e c i f i c form. Because i t s b i o l o g i c a l / c h e m i c a l / e l e c t r i c a l r e c e p t o r s are unable t o a p p r o p r i a t e l y f a c i l i t a t e t r a n s m i s s i o n between n e u r a l s t r u c t u r e s , the neuro network i n which the o l d information i s stored i s e f f e c t i v e l y i s o l a t e d . No new l e a r n i n g can take p l a c e because subsequent t h e r a p e u t i c i n f o r m a t i o n cannot l i n k a s s o c i a t i v e l y w i t h i t (p. 40) . Hence, one may glean new, c o n t r a d i c t o r y i n f o r m a t i o n from y e a r s o f therapy o r new l i f e experiences, but t h i s i n f o r m a t i o n may prove i n e f f e c t u a l , as i t i s s t o r e d i n i t s own neuro network, separate from the t r a u m a t i c information. EMDR's eye-movements (or a l t e r n a t i v e s t i m u l i ) " t r i g g e r a p h y s i o l o g i c a l mechanism t h a t a c t i v a t e s t h e i n f o r m a t i o n p r o c e s s i n g system" (p. 30), thereby linking previously i s o l a t e d d i s t u r b i n g i n f o r m a t i o n with c u r r e n t l y h e l d beliefs adaptive (p. 31). For now, the h e a l i n g mechanisms o f EMDR, remain speculative. Shapiro w r i t e s t h a t "the a c t u a l n e u r o l o g i c a l concomitants may not be d i s c o v e r e d w i t h i n t h i s generation" (1994, p. 3 ) . P r e v i o u s Research i n t o Eye Movement D e s e n s i t i z a t i o n and Reprocessing In e v a l u a t i n g r e s e a r c h i n t o EMDR, the reader must keep i n mind t h a t t h e r e e x i s t s e v e r a l extraneous v a r i a b l e s which render evaluation d i f f i c u l t . F i r s t , t h e r e are, a t p r e s e n t , a number o f v e r s i o n s o f EMD, o r EMDR, c u r r e n t l y b e i n g used 33 and tested. Those i n c l u d e Shapiro's o r i g i n a l EMD p r o t o c o l (1989a, 1989b); t h e EMD o r i g i n a l l y taught by S h a p i r o i n 1990; t h e r e v i s e d p r o t o c o l taught by Shapiro s i n c e 1991 (see Shapiro, 1995); as w e l l as t h e r a p i s t s ' own c r e a t i v e v a r i a t i o n s o f t h e procedure (Greenwald, 1994). Controlled The Studies seminal study i n EMDR was done by S h a p i r o A f t e r s e r e n d i p i t o u s l y observing t h a t she c o u l d (1989a). desensitize h e r s e l f t o d i s t u r b i n g thoughts and f e e l i n g s by r a p i d l y moving h e r eyes from s i d e t o s i d e (Herbert & Mueser, 1992), she engaged i n c l i n i c a l experiments w i t h t h e eye movement procedure on approximately 70 c l i e n t s and v o l u n t e e r s (Shapiro, 1989b). A systematic i n v o l v i n g 22 rape/molestation veterans, study was then undertaken v i c t i m s and Vietnam combat a l l o f whom were diagnosed by t h e i r c o u n s e l l o r s as h a v i n g PTSD. Subjects were d i v i d e d randomly i n t o a treatment group, which r e c e i v e d EMDR, and a c o n t r o l group, which r e c e i v e d a m o d i f i e d f l o o d i n g procedure. reasons, EMDR was administered For e t h i c a l t o t h e c o n t r o l group a f t e r h a v i n g p a r t i c i p a t e d i n t h e placebo c o n d i t i o n . The r e s u l t s were as f o l l o w s : In t h e treatment group, the mean SUDs score dropped from 7.45 ( p r e t e s t ) t o 0.13 ( p o s t - t e s t ) ; and t h e mean VOC score ( r e p r e s e n t i n g an increase i n subjects' b e l i e f i n t h e i r p o s i t i v e cognition) r o s e from 3.95 t o 6.75. a c t u a l l y increased In t h e placebo group, t h e mean SUDs from 6.77 t o 8.31, u n t i l subjects r e c e i v e d EMDR, a f t e r which t h e i r SUDs l e v e l dropped t o a 34 n e g l i g i b l e l e v e l w i t h i n s e v e r a l s e t s o f saccades. scores i n t h i s group dropped from 2.95 t o 2.36, increased from 2.36 t o 6.77 a f t e r EMDR was Mean VOC and l a t e r administered. A l l s u b j e c t s r e p o r t e d e i t h e r a decrease o r t o t a l e l i m i n a t i o n of t h e i r primary p r e s e n t i n g problem, t h e e f f e c t s o f which were maintained a t a t h r e e month follow-up. Marquis (1991) undertook a study t o " . . . e x p l o r e t h e range o f problems amenable t o eye movement d e s e n s i t i z a t i o n " (p. 187). There were 78 s u b j e c t s i n h i s study, 16 o f whom s u f f e r e d from PTSD. Some, but n o t a l l , o f t h e o t h e r c o n d i t i o n s t r e a t e d i n the study i n c l u d e d e a t i n g disorders, agoraphobia w i t h p a n i c d i s o r d e r , simple phobias, r e l a t i o n s h i p problems, substance abuse, l e a r n i n g disabilities, and p e r s o n a l i t y d i s o r d e r s . H i s r e s u l t s proved s i m i l a r t o Shapiro's: apparently unimproved. and Seventy-three s u b j e c t s were cured o r had improved, and o n l y f i v e were Four o f those s u f f e r e d from severe s e l f - e f f i c a c y problems. self-esteem The f i f t h was a woman who had been d e s e n s i t i z e d t o her husband's " f e t i s h i s t i c activity," and whose a v e r s i o n t o him was q u i c k l y r e - e s t a b l i s h e d . Marquis r e p o r t s t h a t , "In g e n e r a l , sources o f d i s t r e s s t h a t are i n the p a s t and i s o l a t e d were e a s i l y d e s e n s i t i z e d . Themes t h a t were d i f f u s e l y connected o r h i g h l y or t h a t represented generalized, mood-dependent s t a t e s o r a d d i c t i o n s i n the broadest sense, were l e s s s u c c e s s f u l l y t r e a t e d " (p. 189). The " o v e r a l l improvement r a t i n g " f o r PTSD was 2.9; 35 f o r agoraphobia, 2.8; and f o r simple phobias, 2.6 on a 0-3 scale. Sanderson and Carpenter (1992) compared EMDR t o image confrontation (IC) i n a group o f 58 phobic s u b j e c t s (as compared t o s u b j e c t s s u f f e r i n g from PTSD). EMDR and IC ( f l o o d i n g ) were used i n a s i n g l e - s e s s i o n c r o s s o v e r trial. Each procedure was g i v e n f o r seven s e t s o f 20 seconds. T h e i r r e s u l t s showed t h a t both EMDR and IC s i g n i f i c a n t l y reduced SUDs s c o r e s , b u t t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e between the groups. The authors conclude t h a t b e n e f i t s o f EMDR do not come from eye movements, b u t from exposure t o the f e a r e d image ( f l o o d i n g / I C ) . Wilson, C o v i , and F o s t e r (1993) t r e a t e d 18 i n d i v i d u a l s s u f f e r i n g from t r a u m a t i c memories i n a s i n g l e s e s s i o n . Three groups (n = 6 each) i n c l u d e d an EMDR treatment group, a group i n which thumb-taps were s u b s t i t u t e d f o r eye movements, and another group i n which eye movements were omitted. B e s i d e s SUDs and VOC s c o r e s , p h y s i o l o g i c a l measures were taken. The treatment group showed l a r g e and s i g n i f i c a n t improvements which were maintained a t 3, 9 and 12 months. R e c e n t l y , Boudewyns e t a l . (1993) u t i l i z e d both p h y s i o l o g i c a l and s t a n d a r d i z e d assessments f o r twenty Vietnam war v e t e r a n s t r e a t e d w i t h e i t h e r EMDR, i m a g i n a l exposure, o r m i l i e u therapy. PTSD S c a l e The C l i n i c i a n A d m i n i s t e r e d (CAPS); the M i s s i s s i p p i S c a l e ; t h e Impact o f Event S c a l e (IES); t h e r a p i s t r a t i n g s o f treatment 36 r e s p o n s i v e n e s s ; and SUDs were implemented, a l o n g w i t h p h y s i o l o g i c a l assessments o f h e a r t - r a t e ; response (EMG); e l e c t r o d e r m a l response electromyographic (EDR); and s k i n temperature. I n t e r e s t i n g l y , t h e r e was a g r e a t e r r e d u c t i o n o f SUDs l e v e l s f o r the EMDR group than f o r the exposure c o n d i t i o n d u r i n g treatment; y e t no d i f f e r e n c e s were found between groups, on SUDs o r p h y s i o l o g i c a l r a t i n g s , d u r i n g p o s t treatment exposure t o s u b j e c t ' s i n i t i a l audiotaped d e s c r i p t i o n o f the traumatic memory, nor on s t a n d a r d i z e d post-treatment measures o f PTSD. Wilson, T i n k e r and Becker (1994) undertook r e s e a r c h on 80 i n d i v i d u a l s who had been traumatized by a v a r i e t y o f experiences, mental abuse. i n c l u d i n g combat, rape, as w e l l as p h y s i c a l and The traumatic event(s) had o c c u r r e d from between t h r e e months and 54 years b e f o r e t h e study began. S u b j e c t s were randomly assigned t o one o f two groups: r e c e i v e d the EMDR procedure; One the other r e c e i v e d no treatment of any k i n d f o r 30 days, a f t e r which time, they too r e c e i v e d EMDR. F o l l o w i n g treatment, t h e EMDR group showed immediate, s i g n i f i c a n t improvement as measured by the Impact o f Events Scale ( Horowitz, Wilner & A l a v a r e z , 1979), SUDs (Wolpe, 1956), and the A n x i e t y dimension o f the Symptom Check L i s t (SCL-90-R; D e r o g a t i s , 1992); whereas the d e l a y e d treatment group showed no improvement u n t i l EMDR was a d m i n i s t e r e d , a t which time they too showed s i g n i f i c a n t improvement. 37 Using Shapiro's (1989a, 1989b) o r i g i n a l EMD p r o t o c o l , Vaughn (1993) t r e a t e d 10 i n d i v i d u a l s with a d u a l of PTSD and substance abuse d u r i n g 4 s e s s i o n s . and diagnosis Significant s u s t a i n e d improvement was found a t post-treatment, month follow-up; y e t the a r o u s a l subsale on the Hamilton a n x i e t y s c a l e , r e t u r n e d t o near pre-treatment months. and 4 l e v e l s by f o u r Vaughn (1993) a l s o r e p o r t e d a study i n which he p l a c e d 36 PTSD s u b j e c t s i n t o one o f t h r e e treatment groups (with members o f each o f those group e i t h e r r e c e i v i n g treatment o r being p l a c e d on a w a i t i n g l i s t ) , r e c e i v e d e i t h e r EMD (Shapiro, 1989a, 1989b), i n which they Anxiety Management T r a i n i n g (AMT; a r e l a x a t i o n t e c h n i q u e ) , o r Image H a b i t u a t i o n T r a i n i n g (IHT; an exposure t e c h n i q u e ) . A l l treatment groups showed g r e a t e r improvement than w a i t - l i s t e d groups; w i t h the EMD group showing most improvements. This group was f o l l o w e d by the AMT and IHT groups, r e s p e c t i v e l y . F i n a l l y , r e g a r d i n g the sometimes c o n t r a d i c t o r y f i n d i n g s of EMDR e f f i c a c y r e s e a r c h , Greenwald, (1996) w r i t e s t h a t d i s c r e p a n c i e s are due t o "the s u b s t a n t i a l i n f o r m a t i o n gap between those who have and those who have n o t undergone t h e formal, supervised [EMDR] t r a i n i n g " (p. 67); and t h a t "the c r i t i c a l v a r i a b l e appears t o be f i d e l i t y t o t h e EMDR protocol" (p. 69). Case S t u d i e s Greenwald w r i t e s t h a t "as c o n t r o l l e d s t u d i e s b e g i n t o be r e p o r t e d , case s t u d i e s p l a y a d i m i n i s h e d role i n the 38 e v a l u a t i o n o f EMDR's e f f i c a c y " (1994, p. 21). He goes on t o note t h a t w h i l e many o f t h e case r e p o r t s do i n c l u d e . . . s t a n d a r d i z e d measures, b e h a v i o r a l i n d i c e s , and l o n g term follow-up, most f a i l t o meet t h e d e s i g n expected o f s i n g l e - s u b j e c t i n v e s t i g a t i o n s Puk standards (p. 21) . (1991) r e p o r t s t r e a t i n g a 23-year-old woman having d i s t u r b i n g dreams and s o c i a l a n x i e t y as a r e s u l t o f b e i n g raped, as w e l l as a 33-year-old woman s u f f e r i n g from f r e q u e n t , i n t r u s i v e images o f her dying s i s t e r , f o r whom she had c a r e d d u r i n g t h e f i n a l stages o f cancer. Presenting symptoms f o r both women were e l i m i n a t e d a f t e r one s e s s i o n o f EMDR, and b e n e f i t s maintained a t 12 months a f t e r treatment. Wolpe and Abrams (1991) a l s o s u c c e s s f u l l y t r e a t e d a rape v i c t i m , a f t e r 15 s e s s i o n s o f t r a d i t i o n a l therapy had f a i l e d t o a l l e v i a t e h e r f e a r o f l e a v i n g her home. L i p k e and B o t k i n (1992) used EMDR w i t h f i v e h o s p i t a l i z e d Vietnam combat veterans. Of t h e f i v e , two showed dramatic improvement. A t h i r d d i d n o t improve due t o t h e r a p i s t e r r o r i n u s i n g t h e procedure. A f o u r t h s u b j e c t had w i l l f u l l y n o t complied t h e r a p i s t ' s i n s t r u c t i o n s ; and t h e f i f t h , who s u f f e r e d b i z a r r e t h i n k i n g and temporal the procedure with from lobe e p i l e p s y , asked t o s t o p f o r f e a r t h a t l o s i n g t h e image would r e s u l t i n harm t o h i s f a m i l y . K l e i n k n e c h t and Morgan (1992) s u c c e s s f u l l y t r e a t e d a 40-year-old male who had s u f f e r e d 39 PTSD symptoms f o r e i g h t years a f t e r having been shot and l e f t to die. S i m i l a r l y , McCann (1992) c l a i m e d s u c c e s s w i t h a 4 1 - y e a r - o l d burn v i c t i m who a l s o had d i s p l a y e d PTSD symptoms f o r e i g h t y e a r s . Wernik (1993) r e p o r t s h a v i n g s u c c e s s f u l l y t r e a t e d 21- and 45-year-old males f o r premature e j a c u l a t i o n and impotence, respectively. Pellicer (1993) r e p o r t s having s u c c e s s f u l l y t r e a t e d a t e n - y e a r - o l d g i r l who had s u f f e r e d most o f her l i f e from r e c u r r i n g nightmares o f h a v i n g snakes c r a w l i n g i n her bed. She, as most s u b j e c t s i n t h e above s t u d i e s , was s u c c e s s f u l l y t r e a t e d i n o n l y one session. Cocco and Sharpe (1993) r e p o r t having used an a u d i t o r y v a r i a n t o f EMDR w i t h a f o u r year, n i n e month o l d boy, "Sam," who had been e x p e r i e n c i n g nightmares, bedwetting, home. i n t r u s i v e thoughts and a f t e r having witnessed an armed robbery i n h i s The authors r e p o r t t h a t , a f t e r one s e s s i o n , t h e s u b j e c t "no l o n g e r evidenced any o f t h e symptoms thought t o be a s s o c i a t e d w i t h i n t r u s i v e thoughts", and t h a t " t h e r e was a dramatic r e d u c t i o n i n t h e b e h a v i o u r a l symptoms immediately f o l l o w i n g t h e s e s s i o n " (p. 375). Although asymptomatic a t t h r e e month f o l l o w up, t h e c h i l d had r e t u r n e d t o s l e e p i n g i n his p a r e n t s ' bed, and was a f r a i d t o go t o t h e t o i l e t alone late at night. Kleinknecht (1993) r e p o r t s t r e a t i n g a 2 1 - y e a r - o l d woman s u f f e r i n g from an i n j e c t i o n and blood phobia i n f o u r t h i r t y minute s e s s i o n s . S e l f - r e p o r t and p h y s i o l o g i c a l measures 40 (blood p r e s s u r e and h e a r t r a t e ) showed s i g n i f i c a n t improvement, which was maintained a t 1, 14 and 24 weeks. A c i e r n o Tremont, L a s t & Montgomery (1994) w r i t e o f a 4 2 - y e a r - o l d female s u f f e r i n g from m u l t i p l e simple phobias o f images r e l a t e d t o dead bodies e t c . ) and darkness. ( i . e . , hearses, f u n e r a l homes, EMDR was compared w i t h a t e c h n i q u e which was i d e n t i c a l i n a l l aspects, except t h a t i t d i d n o t implement the normally p r e s c r i b e d eye movements. The two treatment c o n d i t i o n s were administered " c u m u l a t i v e l y and s e q u e n t i a l l y i n multiple-baseline design fashion across fear areas" (Acierno e t a l . , 1994, p. 295). A t r i p a r t i t e e v a l u a t i o n o f (a) m o t o r i c assessment (avoidance b e h a v i o u r ) , (b) p h y s i o l o g i c a l responses and (c) s t a n d a r d i z e d s e l f - r e p o r t measures (see A c i e r n o e t a l . , 1994 f o r d e t a i l s ) showed a s l i g h t EMDR performance advantage r e g a r d i n g avoidance behaviour r e l a t e d t o dead b o d i e s , b u t n e i t h e r group proved s u p e r i o u r i n any o t h e r measures, i n c l u d i n g SUDs. C r i t i c i s m o f EMDR Research Herbert and Mueser c a u t i o n c l i n i c i a n s a g a i n s t t h e u n c r i t i c a l acceptance conducted o f EMDR, n o t i n g t h a t the " r e s e a r c h i n t h i s area has s e r i o u s m e t h o d o l o g i c a l f l a w s , p r e c l u d i n g d e f i n i t e c o n c l u s i o n s r e g a r d i n g the e f f e c t i v e n e s s of the procedure" (1992, p. 169). Some o f these flaws i n c l u d e (a) l a c k o f s t a n d a r d i z e d measurement used i n g a t h e r i n g b a s e l i n e data and e s t a b l i s h i n g a PTSD d i a g n o s i s (Lohr e t a l . , 1992); (b) subjects' 41 c o n c u r r e n t l y r e c e i v i n g treatment other than EMDR, which b r i n g s i n t o q u e s t i o n the c a u s a l r e l a t i o n s h i p between treatment,and outcome (Page & C r i n o , 1993); (c) t h e r a p i s t demand c h a r a c t e r i s t i c s 1993) ; and (Page & C r i n o , 1993; Acierno et a l . , (d) p o s s i b l e u n i n t e n t i o n a l experimental b i a s (Acierno e t a l . , 1993; Herbert & Mueser, 1992). E t h i c a l Considerations Page and C r i n o w r i t e "[EMDR] stands t o c h a l l e n g e many fundamental b e l i e f s h e l d by c l i n i c i a n s about the nature treatment of PTSD, and may r e p r e s e n t y e t another about whose mechanism we must p l e a d ignorance" 293). and technique (1993, p. They go on t o e x p l o r e the e t h i c a l i m p l i c a t i o n s should such a simple and p o t e n t i a l l y r a p i d treatment prove t o be widely effective: F i r s t l y , what are the i m p l i c a t i o n s f o r c l a i m s f o r damages f o l l o w i n g t r a u m a t i c events? For example, i f the p s y c h o l o g i c a l e f f e c t s of rape can be rapidly removed, w i l l the case f o r the p r o s e c u t i o n be weakened? Secondly, Finally should everyone be t r e a t e d immediately? ... . . . i f [EMDR] were t o s u c c e s s f u l l y a m e l i o r a t e g r i e f , should the d i s t r e s s of bereavement be removed? (p. 293). C o n t i n u i n g i n t h i s v e i n , should a t h e r a p i s t attempt r e l i e v e a 10-year-old of her r e c u r r i n g nightmares, are a r e f l e c t i o n of a d i s t u r b e d home l i f e to i f they (Pellicer, 1993)? 42 D e s c r i p t i v e Accounts o f EMDR E x p e r i e n c e s As mentioned i n t h e i n t r o d u c t i o n , although s e v e r a l authors (see Greenwald, 1994; K l e i n k n e c h t & Morgan, 1992; McCann, 1992, f o r example) have noted phenomenological particular experiences d e s c r i b e d by t h e i r clients d u r i n g EMDR therapy, t h e r e has as y e t been no s y s t e m a t i c study i n t h i s area. In h e r book, Eye Movement D e s e n s i t i z a t i o n and Reprocessing: B a s i c P r i n c i p l e s . P r o t o c o l s and Procedures (1995), Shapiro l i s t s some o f t h e p a t t e r n s o f responses which she and other EMDR t h e r a p i s t s have observed thus f a r . She w r i t e s , " C l i n i c a l o b s e r v a t i o n i n d i c a t e s t h a t approximately 40% o f t h e time c l i e n t s e x p e r i e n c e a c o n t i n u a l , p r o g r e s s i v e s h i f t toward a r e s o l u t i o n o f t h e t a r g e t event" (p. 76). P r o c e s s i n g i s always assessed i n r e l a t i o n t o t h e t a r g e t memory o r memories. Because d u r i n g treatment new memories may s u r f a c e , o r t h e c l i e n t may simply s t a y w i t h t h e o r i g i n a l t a r g e t memory, two categories: Shapiro d i v i d e s such p r o c e s s i n g e f f e c t s into Single-memory p r o c e s s i n g e f f e c t s ; and Multimemory p r o c e s s i n g e f f e c t s . Single-Memory P r o c e s s i n g E f f e c t s In cases where t h e a t t e n t i o n does n o t s h i f t from t h e t a r g e t memory, t h e r e may s t i l l be changes i n any o f " f i v e d i s t i n c t a s p e c t s o f t h e memory: image, sounds, c o g n i t i o n , emotion, o r p h y s i c a l s e n s a t i o n s " (p. 81). 43 Changes i n the Image The image may fade or s h i f t t o a d i f f e r e n t a s p e c t of the t a r g e t event; and may even change i t s content o r appearance (see a l s o K l e i n k n e c h t & Morgan, 1992; 1993; Puk, 1991; Spector & Huthwaite, 1993). O'Brian, Shapiro gives the example of a f a c e which the c l i e n t remembers as " l e e r i n g " changing t o a " s m i l i n g one" (p. 81). She notes t h a t items such as weapons can " d i s a p p e a r " also (p. 81) , and t h a t the "scene" can expand t o i n c l u d e more d e t a i l s of t h i n g s the c l i e n t has f o r g o t t e n , as the p r o c e s s i n g of the predominant a f f e c t which occurred a t the time of trauma a l l o w s the c l i e n t t o f i n a l l y see the event i n i t s l a r g e r context (p. 81). Hence, the more s e l f - a f f i r m i n g i n f o r m a t i o n such as "I d i d a l l I c o u l d , " which has remained b l o c k e d i n the nervous system s i n c e the trauma, can now become integrated. Changes i n Sounds Shapiro w r i t e s t h a t sounds may or may become l o u d e r or s o f t e r , completely disappear from the memory. d i a l o g u e may s h i f t ; and c l i e n t s may a s s e r t themselves d i a l o g u e which was changing begin t o Remembered spontaneously with the remembered persons. completely f o r g o t t e n may Also, emerge w i t h images (p. 83). Changes i n C o g n i t i o n s Shapiro notes t h a t c l i e n t ' s l e v e l of i n s i g h t w i l l o f t e n i n c r e a s e from one s e t t o another, w i t h the client's c o g n i t i o n s becoming "more adaptive as the i n f o r m a t i o n i s 44 processed" (p. 83). "Polar responses"—dramatic a negative t o a p o s i t i v e cognition—may treatment (p. 83). shifts from occur e a r l y on i n For example, Shapiro w r i t e s t h a t "a c l i e n t may s t a r t with the c o g n i t i o n "There i s something wrong w i t h me: i n r e l a t i o n t o s o c i a l s i t u a t i o n s and a f t e r a s i n g l e s e t may s t a r t t h i n k i n g , "I'm f i n e " (p. 83). Changes i n Emotions A c c o r d i n g t o Shapiro, many c l i e n t s d e s c r i b e a change i n the emotion they a r e e x p e r i e n c i n g (see a l s o K l i e n k n e c h t & Morgan, 1992). That i s , they may begin f e e l i n g sad, and then become angry. Emotions may a l s o d i m i n i s h , o r may become more profound before s u b s i d i n g . She w r i t e s , The c l i e n t w i l l o f t e n r e p o r t a p r o g r e s s i v e s h i f t toward more e c o l o g i c a l l y v a l i d , o r a p p r o p r i a t e , emotions. T h i s s h i f t w i l l manifest i t s e l f as movement through d i f f e r e n t " l a y e r s " of emotion (e.g., from g u i l t t o rage t o sorrow t o acceptance). Once a g a i n , each c l i e n t r e a c t s u n i q u e l y . . . (p. 84). F u r t h e r , some c l i e n t s may o v e r t l y manifest t h e s e emotions i n a b r e a c t i o n , o t h e r s w i l l show l i t t l e o v e r t d i s p l a y . Changes i n P h y s i c a l Sensations A c c o r d i n g t o Shapiro, "When a memory i s b e i n g processed, most c l i e n t s experience some m a n i f e s t a t i o n o f t h e i n f o r m a t i o n on a somatic l e v e l " (p. 84). There may be a r e l e a s e o f p h y s i c a l s e n s a t i o n s , l e a d i n g t o a decrease i n 45 i n t e n s i t y w i t h each s e t ; o r c o n v e r s e l y , t h e r e may be a temporary i n c r e a s e o f somatic e x p e r i e n c i n g . The p h y s i c a l s e n s a t i o n s experienced d u r i n g t h e trauma may be r e e x p e r i e n c e d i n t h e same p a r t o f t h e body as i f they were o c c u r r i n g i n p r e s e n t time. P a r t i c u l a r s e n s a t i o n s may move through t h e body, from one l o c a t i o n t o another (p. 85) . Multimemory A s s o c i a t i v e P r o c e s s i n g Shapiro w r i t e s t h a t although memories may emerge d u r i n g EMDR treatment, "no memory w i l l emerge t h a t i s n o t i n some way a s s o c i a t e d w i t h t h e t a r g e t " (p. 78). As i n t h e above s e c t i o n , the f o l l o w i n g categories are hers (Shapiro, 1995). The Major P a r t i c i p a n t o r P e r p e t r a t o r The emergent memory may be l i n k e d by t h e common denominator o f who t h e a s s a i l a n t o r p e r p e t r a t o r was. F o r example, i f t h e t a r g e t memory i s o f an a b u s i v e p a r e n t molesting the c l i e n t , a r e l a t e d memory o f t h e same f a t h e r b e a t i n g him o r h e r may occur (p. 79). The Pronounced S t i m u l i For t h i s category, Shapiro g i v e s t h e example o f a Vietnam v e t e r a n p r o c e s s i n g t h e memory o f an earthquake, "may suddenly r e c a l l who a combat experience i f t h e sounds o f f a l l i n g o b j e c t s o r loud rumbling dominated both e v e n t s " (p. 79). The dominant t h r e a d here may be t h e sensory e x p e r i e n c e s themselves, or t h e meaning which t h e v i c t i m a s c r i b e s t o them (e.g., I am going t o d i e ) . 46 The S p e c i f i c Event Here, "emerging memories may be l i n k e d t o t h e t a r g e t e d memory by t h e nature o f t h e event i t s e l f " (p. 7 9 ) . Hence, when t h e t a r g e t memory i s a rape, memories o f o t h e r rapes o r m o l e s t a t i o n s may occur. The Dominant P h y s i c a l Sensations Because p h y s i c a l s e n s a t i o n s a r e s t o r e d i n t h e nervous system a t t h e time o f each t r a u m a t i z a t i o n (p. 79), memories i n which t h e c l i e n t experienced r e l a t e d s e n s a t i o n s may emerge d u r i n g treatment. F o r example, S h a p i r o w r i t e s o f one c l i e n t who r e p o r t e d having h e r hands t i e d t o a bed w h i l e she was beaten w i t h a broomstick by her mother. During p r o c e s s i n g , t h e s e n s a t i o n s i n her hands brought t o mind t h e memory o f h e r hands being f o r c e d on h e r f a t h e r ' s p e n i s , and l a t e r again, o f a r a p i s t h o l d i n g her hands t o g e t h e r d u r i n g the a t t a c k (p. 80). The Dominant Emotions Memories may be l i n k e d n o t n e c e s s a r i l y by c o n t e x t o r s e n s a t i o n s p e r se, but by t h e emotion(s) at t h e time o f t r a u m a t i z a t i o n . f e l t by t h e v i c t i m Shapiro g i v e s t h e example o f a c l i e n t d e s p a i r i n g a t t h e memory o f a f a i l e d business venture who may r e c o l l e c t a time i n which he o r she was abandoned by a parent and f e l t t h e same subsequent emotion (p. 8 0 ) . To r e i t e r a t e , although t h e above d e s c r i p t i o n s o f c l i e n t e x p e r i e n c e s a r e h e l p f u l , having been gleaned from many hours of t h e r a p i s t s ' involvement i n EMDR treatment, still lacking 47 i n the l i t e r a t u r e i s any systematic, phenomenological i n v e s t i g a t i o n moment EMDR experiences. in-depth i n t o i n d i v i d u a l s ' moment-to- 48 CHAPTER THREE: METHOD Rational In order t o document c o - r e s e a r c h e r s ' moment-to-moment i n - s e s s i o n EMDR experiences, t h e r e s e a r c h e r combined v a r i a t i o n s o f two e s t a b l i s h e d r e s e a r c h p r o t o c o l s : t h e phenomenological r e s e a r c h p r o t o c o l o f C o l a i z z i (1978), attempts t o g l e a n meaning from c o - r e s e a r c h e r s ' experiences; and 1994) , a I n t e r p e r s o n a l Process R e c a l l procedure (IPR; E l l i o t , which used t o cue c o - r e s e a r c h e r s ' memories, and document t h e i r i n - s e s s i o n therapy experiences. Phenomenological Research Phenomenological r e s e a r c h attempts t o a s c e r t a i n t h e meaning i n d i v i d u a l s a s c r i b e t o t h e i r e x p e r i e n c e s 1978; van Manen, 1992). (Collaizi, The r e s e a r c h e r i n v e s t i g a t e s d e s c r i p t i v e l y , i n order t o g a i n i n s i g h t i n t o the way i n d i v i d u a l s "experience the world p r e - r e f l e c t i v e l y , taxonomizing, c l a s s i f y i n g , or a b s t r a c t i n g i t " 1992, Subjects a r e seen by t h e r e s e a r c h e r as p. 9 ) . partners, or "co-researchers, 11 without (van Manen, i n the r e s e a r c h endeavor, and g i v e n r e s p e c t , t r u s t and empowerment, t h a t they may b e t t e r t e l l t h e i r s t o r y ; thereby h e l p i n g t h e r e s e a r c h e r t o g l e a n a t r u e r p i c t u r e o f t h e experiences being i n v e s t i g a t e d ( M i s h l e r , 1988). A c c o r d i n g t o C o l a i z z i , what i s needed i n t h e i n v e s t i g a t i o n o f human experience i s a method which 49 n e i t h e r denies experience nor d e n i g r a t e s i t or transforms i t i n t o o p e r a t i o n a l l y defined behavior; i t must be, i n s h o r t , a method t h a t remains w i t h human experience as i t i s experienced, s u s t a i n c o n t a c t with experience one which t r i e s t o as i t i s g i v e n (1978, p. 53). To a s s i s t i n t h e endeavor, I n t e r p e r s o n a l Process R e c a l l was a l s o used. I n t e r p e r s o n a l Process R e c a l l I n t e r p e r s o n a l Process R e c a l l (IPR; E l l i o t , 1994) i s an i n t e r v i e w procedure i n which t h e t h e r a p i s t a u d i o t a p e s t h e conversation between him- o r h e r s e l f and t h e s u b j e c t ( o r "informant") and p l a y s i t back immediately f o r t h e informant d u r i n g a second i n t e r v i e w . i n t e r v i e w , t h e informant During what becomes a second i s asked t o d e s c r i b e h i s o r h e r moment-to-moment experiences, as remembered, o f t h e f i r s t interview. E l l i o t w r i t e s t h a t p l a y back o f t h e o r i g i n a l conversation a c t s as a cue t o a s s i s t t h e p a r t i c i p a n t i n r e t r i e v i n g memory t r a c e s which would otherwise be l o s t i n t h e w e l t e r o f i n t e r f e r i n g i n f o r m a t i o n generated d u r i n g any communication episode (p. 505). 50 I n t e r p e r s o n a l Process R e c a l l was chosen t o h e l p t h e r e s e a r c h e r gather i n f o r m a t i o n about p a r t i c i p a n t s ' " s u b j e c t i v e impressions which are m i s s i n g from even t h e b e s t t r a n s c r i p t i o n s o r r e c o r d i n g s o f therapy s e s s i o n s " 1994, (Elliot, p. 505). The r e s e a r c h e r d e v i a t e d from the standard IPR p r o t o c o l by p l a y i n g back the i n - s e s s i o n tape t o t h e c o - r e s e a r c h e r , not immediately, but approximately 24 t o 48 hours a f t e r t h e i n i t i a l taping. T h i s was because immediate p l a y back o f t h e therapy s e s s i o n , as p r e s c r i b e d by IPR, would have been i n a p p r o p r i a t e ; f o r , a c c o r d i n g t o EMDR l i t e r a t u r e (Shapiro, 1995), some s u b j e c t s experience extreme d i s t r e s s and f a t i g u e during (and sometimes a f t e r ) treatment. Hence, had t h e r e s e a r c h e r d i r e c t l y f o l l o w e d a 1 1/2 hour EMDR s e s s i o n w i t h a second i n t e r v i e w , he would have r i s k e d t a x i n g t h e emotional and p h y s i c a l resources o f t h e c o - r e s e a r c h e r s , which might have u l t i m a t e l y l e a d t o a poorer interview. quality As r e s e a r c h i n t o memory suggests t h a t cued r e c a l l i s o p t i m a l w i t h i n approximately 48 hours o f an event ( E l l i o t , p. 504), t h i s time i n t e r v a l was deemed a p p r o p r i a t e . Overview o f the Research Method To r e i t e r a t e , r e s e a r c h e r and c o - r e s e a r c h e r s i n t h i s study were seen, by the former, as " p a r t n e r s " i n t h e endeavor; and i n t e r v i e w s were conducted i n a context of r e s p e c t , t r u s t and empowerment o f t h e c o - r e s e a r c h e r , i n o r d e r t o best g l e a n t h e i r experiences, and the meaning they make o f them. 51 Meaning, as i t i s used here, may be o f broad o r narrow import ( M a r r i s , 1982). I t may denote one's simply making sense o f something (a s e n s a t i o n i n the stomach a r e a may mean one i s hungry); o r i t may have t h e broader d e f i n i t i o n of one's a s c r i b i n g importance t o something (as i n , "My w i f e means a l o t t o me"). Both "types" o f meaning were o f r e l e v a n c e t o the present The investigation. f i r s t step o f i n q u i r y i n t o c o - r e s e a r c h e r s ' EMDR e x p e r i e n c e s i n v o l v e d the a t t e n d i n g p s y c h o l o g i s t ' s t a p e r e c o r d i n g , f o l l o w e d by the r e s e a r c h e r ' s t r a n s c r i b i n g o f , t h e EMDR s e s s i o n . Subsequent t o t h i s , t h e second, o r " c l a r i f i c a t i o n i n t e r v i e w " occurred, d u r i n g which t h e r e s e a r c h e r asked c o - r e s e a r c h e r s t o e l a b o r a t e upon t h e i r i n s e s s i o n EMDR experiences. recorded. first, T h i s i n t e r v i e w was a l s o tape A t r a n s c r i p t i o n was made and compared t o t h e i n order t o g a i n the c l e a r e s t p o s s i b l e p i c t u r e o f each c o - r e s e a r c h e r ' s experiences. The r e s e a r c h e r performed a n a l y s i s o f the data a c c o r d i n g t o the procedure d e s c r i b e d on page 55 o f t h i s t h e s i s . S e l e c t i o n o f Co-Researchers Selection Criteria In o r d e r t o q u a l i f y f o r p a r t i c i p a t i o n i n t h i s study, each c o - r e s e a r c h e r had t o meet s e v e r a l c r i t e r i a , t h e f i r s t being a DSM IV (APA, by t h e 1994) d i a g n o s i s o f PTSD, as determined attending psychologist. was The c r i t e r i o n o f a s i n g l e d i a g n o s i s imposed t o l i m i t t h e number o f p o s s i b l e v a r i a b l e s which a d i f f e r e n t i a l l y diagnosed confounding p o p u l a t i o n might 52 introduce. As EMDR was o r i g i n a l l y developed f o r , and t e s t e d on, a PTSD p o p u l a t i o n (Shapiro, 1995), t h i s p o p u l a t i o n was chosen. Second, c o - r e s e a r c h e r s were r e q u i r e d t o be w i l l i n g t o have t h e i r i n i t i a l EMDR s e s s i o n audio-taped by t h e p a r t i c i p a t i n g p s y c h o l o g i s t , and t o be i n t e r v i e w e d by t h e r e s e a r c h e r w i t h i n 48 hours o f i t s occurrence. Third, co- r e s e a r c h e r s were r e q u i r e d t o possess s u f f i c i e n t v e r b a l s k i l l s t o adequately communicate t h e i r e x p e r i e n c e s . r e s e a r c h e r s met these A l l co- criteria. Demographic Information A l l c o - r e s e a r c h e r s were female, Caucasian, o f t h e middle c l a s s , and i n t h e i r e a r l y t h i r t i e s . Two o f t h e t h r e e were married, w i t h the t h i r d having been r e c e n t l y separated from her husband. Procedure Each c o - r e s e a r c h e r , having a l r e a d y e n t e r e d therapy f o r PTSD, was informed o f t h e study by h e r a t t e n d i n g psychologist. The consent form (see Appendix A) r e q u i r e d f o r p a r t i c i p a t i o n , f u l l y informed each o f t h e nature o f t h e study, and t h a t , should they decide n o t t o p a r t i c i p a t e , n e i t h e r t h e t h e r a p e u t i c agenda, nor r e l a t i o n s h i p , would be a f f e c t e d i n any way. Because t h e s t r u c t u r e o f t h e standard EMDR p r o t o c o l (Shapiro, 1995) r e q u i r e s the t h e r a p i s t t o f o l l o w each s e t w i t h a q u e s t i o n ( i . e . , "what d i d you g e t ? " ; 1995, p. 3 7 ) ; and r e q u i r e s t h e c l i e n t t o answer ( d e s c r i b e h e r e x p e r i e n c e ) , 53 i t may be s a i d t o c o n s t i t u t e an i n t e r v i e w . audiotaped Hence, t h e EMDR s e s s i o n i s here termed t h e " i n - s e s s i o n interview." T h i s was f o l l o w e d by t h e " c l a r i f i c a t i o n i n t e r v i e w , " d u r i n g which the r e s e a r c h e r i n t e r v i e w e d t h e c o r e s e a r c h e r about h e r moment-to-moment e x p e r i e n c e s , p l a y i n g h e r a tape r e c o r d i n g o f t h e f i r s t memory. while s e s s i o n t o cue h e r T h i s second i n t e r v i e w was a l s o audio-taped. Each i n t e r v i e w was conducted w i t h i n 48 hours o f t h e i n i t i a l EMDR s e s s i o n , w i t h t h e exception o f t h e i n t e r v i e w w i t h o c c u r r e d a f t e r an i n t e r v a l o f approximately "C," which 72 hours, due t o l o g i s t i c a l problems. The EMDR In-Session Interview Treatment was conducted e x a c t l y as i t would have been under non-research circumstances, s e s s i o n was audio-taped except t h a t t h e e n t i r e by the p s y c h o l o g i s t , w i t h t h e awareness and approval o f t h e c o - r e s e a r c h e r . was p l a c e d between t h e t h e r a p i s t and c l i e n t , A microphone i n order t o r e c o r d both o f t h e i r v o i c e s ; and t h e c l i e n t was a l e r t e d when a c t u a l t a p i n g began and ended. The The Clarification Interview second i n t e r v i e w was conducted t o c l a r i f y i n f o r m a t i o n gathered from t h e f i r s t . F o l l o w i n g the EMDR s e s s i o n , t h e p a r t i c i p a t i n g p s y c h o l o g i s t telephoned the r e s e a r c h e r t o c o n f i r m t h a t a s e s s i o n had taken p l a c e , and t o p r o v i d e i n f o r m a t i o n about how t o c o n t a c t t h e co-researcher. c o n t a c t e d t h e co-researcher, V The r e s e a r c h e r and scheduled then an appointment 54 for the c l a r i f i c a t i o n interview. Each c o - r e s e a r c h e r was encouraged t o choose a meeting p l a c e i n which she would f e e l comfortable, under t h e c o n d i t i o n t h a t i t be p r i v a t e enough t o a l l o w f o r u n d i s r u p t e d play-back and d i s c u s s i o n o f t h e audio-tape r e c o r d i n g . Co-researcher "A" was i n t e r v i e w e d a t h e r home; "B," a t a l o c a l beach o f h e r choosing; and "C," a t t h e home o f t h e researcher. The r e s e a r c h e r began the i n t e r v i e w by r e q u e s t i n g (a) p a r t i c u l a r demographic i n f o r m a t i o n ; (b) i n f o r m a t i o n about the nature o f t h e trauma experienced; (c) post-trauma symptoms; (d) i n f o r m a t i o n about c u r r e n t m e d i c a t i o n s used; (e) p o s t - s e s s i o n c o n d i t i o n o r e x p e r i e n c e s ; and ( f ) any comments, o f any s o r t , t h e c o - r e s e a r c h e r might l i k e t o make about h e r EMDR experiences. The r e s e a r c h e r then presented a t r a n s c r i p t o f t h e EMDR s e s s i o n t o the p a r t i c i p a n t , and began play-back audio-tape. of the Both r e s e a r c h e r and c o - r e s e a r c h e r had t h e o p p o r t u n i t y t o stop play-back a t any time, i n order t o ask q u e s t i o n s , comment o r e l a b o r a t e upon what was b e i n g heard. The r e s e a r c h e r asked mostly open-ended q u e s t i o n s , such as, " c o u l d you t e l l me what was happening here?" o r " c o u l d you t e l l me more about t h a t ? " as w e l l as more s p e c i f i c questions relevant t o p a r t i c u l a r co-researcher Due experiences. t o r e l a t i v e inexperience, during the f i r s t i n t e r v i e w w i t h co-researcher "A," t h e r e s e a r c h e r asked more p o i n t e d q u e s t i o n s than, i n r e t r o s p e c t , seems d e s i r a b l e . 55 However, as i n f o r m a t i o n gleaned was used t o c l a r i f y t h e f i r s t , from the second i n t e r v i e w i t d i d not prove d e t r i m e n t a l t o t h e i n t e g r i t y o f t h e study. A n a l y s i s o f t h e Data F o l l o w i n g the verbatim t r a n s c r i p t i o n o f t h e c l a r i f i c a t i o n i n t e r v i e w , t r a n s c r i p t i o n s were a n a l y z e d phenomenologically, beginning with a v a r i a t i o n o f t h e r e s e a r c h p r o t o c o l o u t l i n e d by C o l a i z z i (1978). Each i n - s e s s i o n t r a n s c r i p t was read s e v e r a l times i n o r d e r f o r t h e r e s e a r c h e r t o g e t a g e n e r a l f e e l i n g f o r each c o - r e s e a r c h e r ' s o v e r a l l EMDR experience ( C o l a i z z i , p. 59) . F o l l o w i n g t h i s , t h e i n - s e s s i o n t r a n s c r i p t s were c l a r i f i e d through examination transcripts. of the " c l a r i f i c a t i o n interview" Because, each co-researcher had, by t h i s p o i n t , o f f e r e d two accounts o f h e r EMDR e x p e r i e n c e s , little i n f e r e n c e was r e q u i r e d by the r e s e a r c h e r . Once e s t a b l i s h e d , "moments o f meaning" were p l a c e d on a time l i n e — a s t r a i g h t l i n e d i v i d e d i n t o even segments i n d i c a t i n g movement through time. T h e r a p i s t involvement was a l s o t r a c k e d and p l a c e d a t the a p p r o p r i a t e p l a c e s on t h e line. The purpose o f t h i s was f o r t h e r e s e a r c h e r t o g a i n a b e t t e r sense o f t h e o v e r a l l p a t t e r n s o f experience, between, and among, t h e t h r e e c o - r e s e a r c h e r s . t h a t were immediately both Categories e v i d e n t , such as p h y s i c a l s e n s a t i o n s , emotions, and c o g n i t i v e experiences were colour-coded, t o make them more r e a d i l y d i s c e r n i b l e t o t h e eye. 56 F o l l o w i n g t h i s , t h e l a b o r i o u s process o f r e f i n i n g and c a t e g o r i z i n g t h e meaning o f a l l experiences began. elements, as mentioned, seemed t o l e n d themselves Some readily to c a t e g o r i z a t i o n ; o t h e r s remained u n c a t e g o r i z e d u n t i l a c o n c e p t u a l framework was d i s c o v e r e d w i t h i n which they c o u l d be understood. D e s c r i p t i o n s which appeared superficially redundant were e l i m i n a t e d i n favour o f a deeper commonality. For example, many o f t h e p h y s i c a l s e n s a t i o n s e x p e r i e n c e d by the c o - r e s e a r c h e r s i n v o l v e d t h e common theme o f t i g h t e n i n g of t h e musculature; merely others, loosening. Hence, r a t h e r than l i s t i n g a l l such experiences t a x o n o m i c a l l y , those such as "knot i n t h e stomach," o r " t e n s i o n i n t h e s h o u l d e r s " were p l a c e d i n one category; and those d e n o t i n g a l o o s e n i n g or disappearance o f such s e n s a t i o n s , under another. E v e n t u a l l y , these became p a r t o f t h e dimension of experience e n t i t l e d "heightened p h y s i c a l awareness." In s h o r t , p r o g r e s s i v e attempts were made, through l a b o r i o u s and methodical contemplation, q u e s t i o n i n g , and t r i a l and e r r o r , t o achieve a f i t t i n g o r g a n i z a t i o n o f c o r e s e a r c h e r s ' experience. Once completed, t r a n s c r i p t s were r e - r e a d s e v e r a l times i n l i g h t o f t h e above c a t e g o r i e s , t o check f o r i n c o n s i s t e n c i e s , e r r o r s or o v e r s i g h t s . 57 CHAPTER FOUR: RESULTS C a t e g o r i e s of Experience Using the above methodology, i t was found t h a t r e s e a r c h e r s ' experiences c o u l d be grouped i n t o one broad c a t e g o r i e s : coof three P a r t i c i p a n t Experiences. S p e c t a t o r E x p e r i e n c e s or Treatment S p e c i f i c E f f e c t s . P a r t i c i p a n t and Participant Spectator E x p e r i e n c e s Experiences A c c o r d i n g t o Cochran (1990), i n d i v i d u a l s can l i f e ' s dramas from the p e r s p e c t i v e or S p e c t a t o r of e i t h e r a experience Participant ( a l s o see B r i t t o n , 1970). In the r o l e of a P a r t i c i p a n t , an i n d i v i d u a l i s a c t i v e l y engaged w i t h the a f f a i r s and events of the world; and focus i s l i m i t e d t o the present moment. Cochran (1990) w r i t e s [The P a r t i c i p a n t ] decides, p l a n s , a c t s , and a l l from the l i m i t e d perspective an a c t i v e p a r t (p. 46; my i n the of one evaluates, who is immediate s i t u a t i o n taking . . . " emphasis). For the PTSD v i c t i m , the P a r t i c i p a n t r o l e emphasizes the i n d i v i d u a l ' s involuntary r e - e x p e r i e n c i n g of the immediate s i t u a t i o n of trauma from what i s h i s or extremely l i m i t e d p e r s p e c t i v e ; although l a c k i n g may same degree of i n t e n s i t y experienced d u r i n g the her be the original 58 t r a u m a t i c event ( p o s s i b l y due t o t h e d u a l focus o f p a s t and p r e s e n t ; Shapiro, 1995, p. 90). As a l r e a d y s t a t e d , some of t h e c a r d i n a l symptoms o f PTSD i n c l u d e the i n t r u s i v e r e l i v i n g o f , o r p r e o c c u p a t i o n w i t h , p a r t i c u l a r aspects o f t h e t r a u m a t i c event The v i c t i m ' s nightmares, (APA, 1994). f l a s h b a c k s , a n x i e t y and r e a c t i o n s t o otherwise n e u t r a l o b j e c t s o r events which have become emotional " t r i g g e r s " f o r the v i c t i m , suggest he o r she s t i l l experiences c o n t i n u a l l y — o r a t l e a s t re-experiences c o n t i n u o u s l y — t h e "immediate s i t u a t i o n " o f h e r t r a u m a t i c event. The c o n s t r i c t i v e PTSD symptoms (APA, 1994) a r e m i r r o r e d by t h e P a r t i c i p a n t ' s l i m i t e d emotional and c o g n i t i v e movement—her i n a b i l i t y t o see from a n y t h i n g but h e r "limited perspective." As an u n w i l l i n g p l a y e r i n an u n f o l d i n g drama, she can g a i n no i n s i g h t i n t o t h e nature o r s i g n i f i c a n c e o f her drama, any more than a n o v i c e a c t o r c o u l d g a i n a broad p e r s p e c t i v e on the h i s t o r i c a l o r a r t i s t i c s i g n i f i c a n c e o f a p l a y i n which she p a r t i c i p a t e s merely from r e a d i n g her l i n e s . To a c q u i r e such a p e r s p e c t i v e , some distance i s required. Spectator The d i s t a n c e o f a S p e c t a t o r . Experiences Whereas t h e P a r t i c i p a n t i s engaged, o r caught-up i n t h e a c t i o n o f an event, and thereby l i m i t e d i n breadth o f her p e r s p e c t i v e , the Spectator enjoys a freedom o f mental movement not a f f o r d e d the P a r t i c i p a n t . The S p e c t a t o r can " p l a y " and be c r e a t i v e w i t h ideas i n t e g r a l o r p e r i p h e r a l t o 59 the a c t i o n s of "the p l a y e r . " That i s , she i s able to see h e r s e l f and her a c t i o n s c o n s i d e r a b l y more o b j e c t i v e l y than she can as a P a r t i c i p a n t . As a Spectator she i s f r e e r than as a P a r t i c i p a n t t o experiment with or manipulate her thoughts and her mind, she may experience; t u r n over the o r i g i n a l shape of In her t o s s i t about; reshape i t ; or juxtapose i t t o , or j o i n i t with, Spectator feelings. can other "shapes" of experience. " i m a g i n a t i v e l y re-enact i n t e r p r e t i n g , adjusting expectation, the The experience, altering vision, s a v o r i n g p o t e n t i a l , and g a i n i n g i n s i g h t s " (Cochran, p. Through such manipulations, the Spectator's r e l a t i o n s h i p t o the problem or event changes, and her concomitant f e e l i n g s and r e a c t i o n s . . . . as a p a r t i c i p a n t , one misery, and hardship, participant. We too, Cochran w r i t e s as . . . f i n d i t to can laugh a t our own be folly, but not o r d i n a r i l y as a S i m i l a r l y , we can be saddened by our g a i e t y , exuberance, or venturesomeness, but o r d i n a r i l y as a p a r t i c i p a n t . We own not need p e r s p e c t i v e t o t h i s , and breadth of p e r s p e c t i v e i s what the r o l e o f f e r s (p. so c o u l d be t e r r i f i e d , y e t a s p e c t a t o r upon one's experience, extremely humorous. 47). do spectator 46). From a n a r r a t i v e p o i n t of view, t h i s "breadth of p e r s p e c t i v e " i n v o l v e s the v i c t i m ' s c o n t e x t u a l i z a t i o n of her 60 t r a u m a t i c memory. "prenarrative, and No longer a f r o z e n , (Herman, 1992, 11 wordless p. 36), i t becomes a s t o r y ; i n the p r o c e s s , imbued w i t h meaning. Conceptually, the c o - r e s e a r c h e r i s a b l e t o separate the author from t h e a c t o r ; t h a t i s , the I, or witness, from the Me, or witnessed. Hermans and Hermans-Jansen (1995) w r i t e t h a t , as a S p e c t a t o r , or I, the c o - r e s e a r c h e r i s a b l e t o d e s c r i b e . . . h e r s e l f as an a c t o r . In t h i s c o n f i g u r a t i o n , the I can i m a g i n a t i v e l y c o n s t r u c t a s t o r y w i t h the Me as the p r o t a g o n i s t . . . . Such n a r r a t i v e c o n s t r u c t i o n i s p o s s i b l e because t h e I can imagine the Me i n the p a s t i n the f u t u r e and can r e c o n s t r u c t the Me (p. 8 ) . Inherent i n the s t r u c t u r e of the new wordless r u b b l e of the v i c t i m ' s " s h a t t e r e d assumptions," are the p i l l a r s and beams of a new, which can now information s t o r y , b u i l t from the more a p p r o p r i a t e paradigm, house the i n t e g r a t e d t r a u m a - r e l a t e d ( B r i t t o n , 1970; Horowitz, 1976; Janoff-Bulman, 1992) . Treatment S p e c i f i c Effects Treatment s p e c i f i c e f f e c t s are experiences which belong t o n e i t h e r the c l a s s i f i c a t i o n of S p e c t a t o r nor Participant (although they can occur simultaneously w i t h e i t h e r of these experiences). the treatment They are, as the name suggests, p a r t i c u l a r t o itself, and would not, i n a l l l i k e l i h o o d , be 61 o c c u r r i n g , were i t not f o r the s u b j e c t ' s undergoing EMDR. T h i s i s n o t t o say t h a t each such e f f e c t i s n e c e s s a r i l y e x c l u s i v e t o EMDR, i n t h a t i t c o u l d not, o r does not, d u r i n g o t h e r p s y c h o t h e r a p e u t i c procedures. Rather, it is the frequency and context i n which these e x p e r i e n c e s which i d e n t i f y them as EMDR Treatment S p e c i f i c occur occur Effects. Such experiences have both p h y s i c a l and c o g n i t i v e manifestations. Dimensions o f Co-researchers' Experiences The c a t e g o r i e s o f P a r t i c i p a n t Experiences, Spectator E x p e r i e n c e s and Treatment S p e c i f i c E f f e c t s were found t o c o n t a i n a t o t a l o f 12 s u b c a t e g o r i e s , o r dimensions, r e s e a r c h e r s ' experiences. Some dimensions of co- c o n t a i n items which arguably would be a p p r o p r i a t e f o r more than one subcategory. I n such cases, the r e s e a r c h e r has chosen what he b e l i e v e s t o be the most a p p r o p r i a t e subcategory particular for the item. Participant Experiences W i t h i n the category o f P a r t i c i p a n t E x p e r i e n c e s , t h e f o l l o w i n g f o u r dimensions o f experience were i d e n t i f i e d : (a) p a s s i v e endurance o f trauma; (b) narrowness o f perspective; of (c) immediacy o f f o c a l image; and (d) i n t e n s i t y ( r e l i v e d ) emotion; P a s s i v e Endurance o f Trauma T h i s category emphasizes the c o - r e s e a r c h e r ' s p a s s i v e r e l a t i o n s h i p t o her i n t r u s i v e re-experiencing. Lacking i s a sense o f agency t o a c t upon her remembered e x p e r i e n c e s — 62 whether p h y s i c a l , emotional, she c o g n i t i v e or v i s u a l . i s as i f t h e i r p a s s i v e instrument, Hence, used a t t h e i r will. Narrowness of P e r s p e c t i v e Awareness i s l i m i t e d t o the co-researcher's r e c o l l e c t i o n s or r e l i v i n g of the o r i g i n a l traumatic e x p e r i e n c e ( s ) , i n c l u d i n g emotions, c o g n i t i o n s , p h y s i c a l s e n s a t i o n s and unintegrated images. i n f o r m a t i o n remains i n t o a broader p e r s p e c t i v e or c o n t e x t . event i s experienced As the Me The traumatic through the c o - r e s e a r c h e r ' s "own has not y e t emerged, she remains unable t o The eyes." see h e r s e l f i n the p i c t u r e . Immediacy of F o c a l Image The " f o c a l image," (the p i c t u r e imagined by the researcher) appears r e l a t i v e l y c l e a r , v i v i d , and proximity. The co-researcher may co- close in remember f o r g o t t e n d e t a i l s of the image, such as a person's c l o t h i n g or h a i r c o l o u r , if l o o k i n g a t a photograph or watching a f i l m . nature of the new co-researcher's However, the d e t a i l e d i n f o r m a t i o n does not broaden the p e r s p e c t i v e , and does not l e a d t o a c o g n i t i v e or conceptual One as s h i f t i n r e l a t i o n t o the trauma. i s not l o o k i n g a t a new photograph, taken from a d i f f e r e n t p e r s p e c t i v e , as i t were, but simply n o t i c i n g the f o r g o t t e n d e t a i l of a f a m i l i a r photograph. Co-researcher "C" d e s c r i b e d her experience I remember . . . e v e r y t h i n g around me, her g o l d e a r r i n g s , what her f a c e looked the this way: detail, l i k e , what the 63 people looked l i k e . I probably d i d n ' t remember i t so i n t e n s e l y or so w e l l u n t i l I was doing [the t r e a t m e n t ] . I n t e n s i t y of Emotion The c o - r e s e a r c h e r r e - e x p e r i e n c e s the emotions p r e s e n t at the time of t r a u m a t i z a t i o n . Although t h i s i n v o l v e s f e a r , other r e l i v e d emotions may primarily a l s o be p r e s e n t . For example, "C" r e - e x p e r i e n c e d the g u i l t she had r e a l i z i n g she might have caused an automobile f e l t upon a c c i d e n t ; and she a g a i n experienced the anger she had f e l t when a woman a t the a c c i d e n t scene became h y s t e r i c a l . Whatever the emotion experienced by c o - r e s e a r c h e r s , the l e v e l of emotional i n t e n s i t y i s h i g h (although not n e c e s s a r i l y as h i g h as d u r i n g the o r i g i n a l e v e n t ) . Concomitant p h y s i c a l m a n i f e s t a t i o n s (Treatment E f f e c t s ) , i n v o l v e t i g h t e n i n g of the musculature, Specific (such as a knot i n the stomach; t i g h t shoulders; d i f f i c u l t y b r e a t h i n g ; nausea; as w e l l as " f i g h t or f l i g h t " tingling). Spectator Experiences T h i s category c o n t a i n s f o u r dimensions (a) a c t i v e a l t e r a t i o n of experience; of e x p e r i e n c e : (b) broadening perspective; (c) d i s t a n c i n g of f o c a l image; and of experience. emotional of (d) v a r i e t y A c t i v e A l t e r a t i o n of Experience Whereas the P a r t i c i p a n t i s the p a s s i v e instrument her t r a u m a t i c r e - e x p e r i e n c i n g , the S p e c t a t o r becomes an agent, a c t i n g upon the trauma-related i n f o r m a t i o n , and of 64 p u t t i n g i t i n t o a l a r g e r context. However, a paradox e x i s t s ; f o r t h e c o - r e s e a r c h e r i s not a w i l l f u l agent o f these p r o c e s s e s , but i r o n i c a l l y , a p a s s i v e one, i n much t h e same way a dreamer i s both t h e agent and instrument of h i s or h e r own dream. For example, when "B" imagines h e r s e l f a t t a c k i n g her assailant i n a role reversal (suggesting agency), drama o f revenge appears t o her spontaneously, willfully. this brief but n o t She regards i t with as much d e l i g h t and s u r p r i s e as i f watching f i r s t time. a c l e v e r t e l e v i s i o n advertisement Although f o r the a t one l e v e l , her " m i n d " — i n t h e broadest s e n s e — i s a c t i v e l y engaged i n t h e p r o c e s s o f understanding and i n t e g r a t i n g d i s t u r b i n g , n o v e l i n f o r m a t i o n , her "ego," o r sense o f " I " i s p a s s i v e l y e x p e r i e n c i n g i t . F a n t a s i e s o r memories may a r i s e ; o r t h e c o n t e n t o f t h e f o c a l image may spontaneously whole o r i n p a r t . change, o r "morph," e i t h e r i n For example, a h i s t o r i c a l l y accurate f a c i a l e x p r e s s i o n , such as one e x p r e s s i n g f e a r , may change t o one t h a t i s calm and s m i l i n g . Broadening of Perspective The c o - r e s e a r c h e r begins t o move o u t s i d e t h e narrow s p o t l i g h t o f her trauma. No longer t h e a c t o r , c o m p u l s i v e l y r e p l a y i n g her traumatic scene, she becomes an audience member—a S p e c t a t o r — a b l e t o muse and p h i l o s o p h i z e about t h e drama i n g e n e r a l , and the s i g n i f i c a n c e o f t h e v a r i o u s players' roles within i t . From v a r i o u s new p e r s p e c t i v e s , she c r i t i q u e s and e v a l u a t e s the drama i n ways she c o u l d n o t 65 as a P a r t i c i p a n t - A c t o r who p r a c t i c a l terms, she may lacked r e l a t i v e o b j e c t i v i t y . see h e r s e l f i n the p i c t u r e f o r the f i r s t time, as i f a t h i r d p a r t y watching distance. She may the i n c i d e n t from a experience i n s i g h t , or a c o g n i t i v e s h i f t , i d e n t i f y i n g w i t h o t h e r s who may In have s u f f e r e d s i m i l a r l y . Or she f e e l compassion f o r her a s s a i l a n t . D i s t a n c i n g of the F o c a l Image The q u a l i t y of the f o c a l image i s d i m i n i s h e d , as i f the c o - r e s e a r c h e r i s h e r s e l f becoming e m o t i o n a l l y d i s t a n t t h e event. from L o s t i s the " l i v i n g " v i v i d n e s s found i n the P a r t i c i p a n t experience of the f o c a l image. appear faded; may The image may a l t e r n a t e between being c l e a r or c l o s e , and being d i s t a n t or faded; may a f l a s h ; or not appear a t a l l , appear momentarily, as i f i n d e s p i t e the c o - r e s e a r c h e r ' s e f f o r t to retrieve i t . V a r i e t y of Emotional Experience Whereas h i g h i n t e n s i t y of r e l i v e d emotions c h a r a c t e r i z e s P a r t i c i p a n t experiences, g r e a t e r v a r i e t y both i n t e n s i t y (of [high and low] and type) d e f i n e s those of the Spectator. The c o - r e s e a r c h e r i s a b l e t o s t e p o u t s i d e the narrow s p o t l i g h t of trauma-related f e e l i n g s , a l l o w i n g f o r emotions t o emerge. She may new g r i e v e t h a t which i s l o s t ; feel rage a t an a s s a i l a n t f o r the i n j u s t i c e of an a s s a u l t ; or f e e l a sense of j o y or euphoria a t the absence of d i s t u r b i n g emotions and c o g n i t i o n s . Lacking are the emotions experienced during traumatization. 66 Whereas P a r t i c i p a n t emotional e x p e r i e n c e s a r e accompanied by a t i g h t e n i n g o f t h e musculature, emotions i n the S p e c t a t o r category tend t o be accompanied by a l o o s e n i n g ; by a l t e r n a t i n g t i g h t e n i n g and l o o s e n i n g ; o r by s h i f t s i n the l o c a t i o n of physical sensations. Treatment S p e c i f i c Four dimensions Effects o f experience were i d e n t i f i e d : momentary c o g n i t i v e impairment; (b) heightened awareness; (c) change i n energy (a) physical l e v e l ; and (d) meta awareness o f t h e process. Momentary C o g n i t i v e Impairment In t h i s dimension of experience, t h e c o - r e s e a r c h e r undergoes a momentary a l t e r a t i o n o f h e r more f a m i l i a r cognitive state. For example, t h e speed a t which she p r o c e s s e s m a t e r i a l may seem g r e a t l y a c c e l e r a t e d ; s e v e r a l o r many thoughts may " r a c e " through h e r mind, t o t h e p o i n t where she can o n l y r e t a i n a f r a c t i o n o f t h e i r c o n t e n t i n memory. She may a l s o experience a momentary, g e n e r a l c o n f u s i o n , o r s l i g h t d i s o r i e n t a t i o n , as i f m i l d l y intoxicated. For example, one c o - r e s e a r c h e r f e l t as i f drugged on morphine o r Valium. Heightened P h y s i c a l Sensations Co-researchers experiences p h y s i c a l s e n s a t i o n s o f v a r y i n g i n t e n s i t y and type. These s e n s a t i o n s do n o t remain c o n s t a n t , but s h i f t a t v a r i o u s times throughout t h e treatment s e s s i o n . 67 When o c c u r r i n g w i t h P a r t i c i p a n t E x p e r i e n c e s , these p h y s i c a l experiences tend t o i n v o l v e a t i g h t e n i n g of the musculature ( t e n s i o n i n the stomach; nausea), p a i n f u l emotions. musculature shoulder area; a "knot" i n the as i f the c o - r e s e a r c h e r were r e s i s t i n g Conversely, as a S p e c t a t o r , the tends t o loosen and r e l a x , as one might g i v e n t h a t the c o - r e s e a r c h e r has, by d e f i n i t i o n , expect, gained emotional d i s t a n c e from the p e r c e i v e d t r a u m a t i c t h r e a t . degree of t e n s i o n may i t s location. change throughout The c o - r e s e a r c h e r may the s e s s i o n ; as The may f e e l warmer, or e x p e r i e n c e t i n g l i n g , as i f i n " f i g h t or f l i g h t " response mode. Change i n Energy L e v e l The c o - r e s e a r c h e r may f e e l f a t i g u e d or e n e r g i z e d a t v a r i o u s times d u r i n g the treatment a l t e r n a t e l y f a t i g u e d and e n e r g i z e d . l e v e l may felt s e s s i o n , or may feel T h i s change i n energy be g e n e r a l , and i n c l u d e the e n t i r e body, or may be i n o n l y one s p e c i f i c l o c a t i o n , such as one s i d e of the skull. Meta Awareness of the Process In t h i s dimension watches her own about i t . of experience, the c o - r e s e a r c h e r experience and has f e e l i n g s or For example, i f she experiences her mind as r a c i n g , she may be s u r p r i s e d a t t h i s p r o c e s s , wonder i f i t s h o u l d be o c c u r r i n g , and worry about i t . unexpected thoughts absence of f e a r may i s b l o c k i n g her f e e l i n g s . Or the sudden, l e a d her t o s u s p e c t t h a t she She may wonder how her dramatic 68 c o g n i t i v e and emotional changes c o u l d be o c c u r r i n g ; t h a t i s , she may ask h e r s e l f , as one c o - r e s e a r c h e r d i d , what n e u r o b i o l o g i c a l changes are t a k i n g p l a c e i n the moment, t o f a c i l i t a t e such unexpected thoughts her changes. She may a l s o experience and f e e l i n g s about the t h e r a p i s t , i n r e l a t i o n t o treatment. Co-Researchers' Experiences In o r d e r , t o h e l p the reader b e t t e r understand c o r e s e a r c h e r s ' i n - s e s s i o n EMDR experiences, a b r i e f of pre-treatment synopsis c o n d i t i o n , as w e l l as t h e nature and o r i g i n of t h e t r a u m a t i c experiences, i s p r o v i d e d i n the f o l l o w i n g section. Co-Researcher "A" While working as a c a s h i e r a t a l i q u o r s t o r e 27 months p r i o r t o treatment, "A" was robbed by two men wearing s k i masks, one o f whom c a r r i e d a shot gun. "A" The armed man, whom d e s c r i b e d as " c r a z y , " removed h i s mask, s t a r t e d kicking the counter, and put h i s gun t o the back o f h e r head. Terrified, "A" r e f u s e d t o look a t e i t h e r o f the men, c h o o s i n g i n s t e a d t o stand "scrunched up" w i t h h e r eyes c l o s e d and f i s t s clenched; b e l i e v i n g t h a t , a t any moment, the " c r a z y " gunman would p u l l the t r i g g e r and k i l l her. Nineteen months l a t e r , w h i l e "A" was working i n t h e same s t o r e , a man entered, c a r r y i n g a l a r g e k n i f e i n t h e back o f h i s pants. Again understandably terrified, "A" had t o serve him a f t e r he began t o "scream" f o r s e r v i c e . Although no robbery o r a s s a u l t ensued, h e r p r e v i o u s a s s a u l t 69 had l e f t her s e n s i t i z e d t o the p o s s i b i l i t y of danger, and she a f t e r w a r d found h e r s e l f "sobbing l i k e a baby." Her symptoms a f t e r the f i r s t trauma i n c l u d e d nightmares of b e i n g chased by loud people w i t h guns; and a f t e r second, the of being stabbed and s l i c e d by a s s a i l a n t s w i e l d i n g knives. The frequency of the nightmares n i g h t s per week. was from 1 t o 3 F u r t h e r , she experienced f e a r a t work whenever a customer entered. Similar public situations, such as s t a n d i n g i n a bank l i n e - u p , a l s o evoked s t r o n g f e e l i n g s of a n x i e t y . "A" a l s o experienced recurring d e p r e s s i o n and anger t h a t "someone had taken away [her] life"; and her a n x i e t y profoundly a f f e c t e d her young daughter, who subsequently became a f r a i d t o s l e e p a l o n e . At the time of the c l a r i f i c a t i o n i n t e r v i e w , the coresearcher f e l t flu." t i r e d , and s l i g h t l y i l l , as i f she had "the She d e s c r i b e d having had a dream i n which, f o r the f i r s t time, she turned and a t t a c k e d her a t t a c k e r . EMDR Experiences of Co-Researcher Co-researcher "A" "A" manifested a c l e a r , unwavering movement toward i n - s e s s i o n r e s o l u t i o n of her b a s e l i n e measures. Quite l i t e r a l l y , her o n l y P a r t i c i p a n t experiences were those she brought with her i n t o the t h e r a p e u t i c s e s s i o n ( f e a r , narrow p e r s p e c t i v e of the event, p h y s i c a l t i g h t n e s s , etc.) which ended d u r i n g the f i r s t s e t of eye movements. In o t h e r words, the f e a r , "knot" i n her stomach, and c l a r i t y of the d i s t u r b i n g f o c a l image, with which she began s t a r t e d t o d e t e r i o r a t e w i t h i n the f i r s t s e t of treatment, eye 70 movements. H a l f way through the s e t , she began t o f e e l " r e l a x e d " and "warm," as i f "wrapped i n a b l a n k e t , " which seemed t o p r o t e c t her from the a s s a i l a n t s who had, u n t i l t h i s p o i n t , been haunting her memory. T h i s r e l i e f came w i t h a momentary s e n s a t i o n of d i z z i n e s s , and s t a y e d w i t h her "throughout the e n t i r e s e s s i o n . " By the second s e t , her f e a r had s i g n i f i c a n t l y d i m i n i s h e d ; and by the t h i r d , the f o c a l image was more d i s t a n t , and f a d i n g i n and out. As "A" d e s c r i b e d her experience, ... I j u s t c o u l d n ' t b e l i e v e what was happening. . . . I j u s t f e l t l i k e laughing. anymore. I didn't f e e l frightened I d i d n ' t f e e l anxious. . . . I t just seemed funny t o me. The q u a l i t y of the f o c a l image continued t o d i m i n i s h , sometimes appearing and out. Although i n " f l a s h e s " ; a t other times, fading i n she o c c a s i o n a l l y saw seldom-remembered a s p e c t s of the t r a u m a t i c event, t h i s new i n f o r m a t i o n was f l e e t i n g , and of a s u r r e a l q u a l i t y , evoking emotional response i n her no but a sense of r e l i e f , and t h e impulse t o laugh. At times, d u r i n g the remaining s e t s , no image appeared t o her, o n l y the t h e r a p i s t ' s f i n g e r s : 71 I would j u s t see t h e f i n g e r s . on t h e f i n g e r s . hand. . . . And I would c o n c e n t r a t e And, you know, I saw h i s r i n g on h i s The image j u s t disappeared. I t was j u s t gone. When a f l e e t i n g , faded image would appear, she had d i f f i c u l t y remembering or f o c u s i n g on i t , "almost l i k e [the event] d i d n ' t happen." S e v e r a l times t h e content o f t h e f o c a l image changed. For example, a t one p o i n t t h e a s s a i l a n t d i s a p p e a r e d from behind h e r ; a t another, t h e worried f a c e o f h e r co-worker took on a calm, s m i l i n g demeanor. A t times, "A" t r i e d t o f o r c e t h e o r i g i n a l f o c a l image t o mind, d e s p i t e t h e t h e r a p i s t ' s i n s t r u c t i o n s t o "go w i t h " whatever h e r experience happened t o be. She a l s o became p r e o c c u p i e d w i t h t h e p o s i t i v e changes which were o c c u r r i n g , and wondered about them. By t h e end o f t h e s e s s i o n , her SUDs l e v e l was a t 0, and her c o g n i t i v e a t t r i b u t i o n , "I f e e l s a f e ; he c a n ' t h u r t me"; r a t e d a 7 on t h e V a l i d i t y o f C o g n i t i o n s c a l e , i n d i c a t i n g t h e h i g h e s t measurable b e l i e f i n t h i s attribution. S e q u e n t i a l Experiences by Category In t h i s , and s i m i l a r s e c t i o n s t o f o l l o w , P a r t i c i p a n t Experiences (PE), Spectator Experiences Specific Effects (SE), and Treatment (TSE) a r e presented i n t h e sequence i n which they o c c u r r e d . C l a s s i f i c a t i o n and D e s c r i p t i o n o f Experience SE: F e e l s s a f e , as i f wrapped i n a b l a n k e t . TSE: f e e l s d i z z y and warm SE: Decrease i n f e a r . SE: Image diminished; comes and goes. Sees t h e r a p i s t ' s f i n g e r s i n s t e a d o f f o c a l image. SE: Image faded; sees t h e r a p i s t ' s f i n g e r s . TSE: difficulty SE: Sees image without concentrating. f e a r ; new r e v e a l e d ; wants t o laugh; SE: Sees image without information feels relief. f e a r ; content o f image changes. TSE: Has d i f f i c u l t y b e l i e v i n g her e x p e r i e n c e . SE: Image diminished, image changes. f i r s t time. comes and goes. Content o f Sees h e r s e l f i n image f o r New i n f o r m a t i o n revealed. SE: Wants t o laugh. TSE: Thinks urge t o laugh i s " s t r a n g e " ; has difficulty SE: concentrating. Image i s reduced t o f l a s h e s . New information revealed. SE: F e e l s calm; sees a b r i e f p i c t u r e . TSE: Has d i f f i c u l t y b e l i e v i n g h e r e x p e r i e n c e ; wonders i f she i s " b l o c k i n g . " 73 Set C l a s s i f i c a t i o n and D e s c r i p t i o n of 11: SE: Experience Increased d i f f i c u l t y s e e i n g image; i n c r e a s e d relaxation. TSE: Knot moved from stomach t o upper c h e s t ; f e e l s "drained." 12: TSE: Knot disappeared; d i f f i c u l t y c o n c e n t r a t i n g . 13: SE: Cannot r e t r i e v e image; sees o n l y t h e r a p i s t ' s f i n g e r s ; f e e l s calm. 14: SE: F e e l s present and s a f e , without fear. TSE: Has d i f f i c u l t y b e l i e v i n g her EMDR e x p e r i e n c e . 15: SE: Sees h e r s e l f i n p i c t u r e , without f e a r ; wants to laugh. TSE: Wonders about the process (how i t works). 16: SE: No image; i n c i d e n t seems i n s i g n i f i c a n t . 17: SE: Sees b r i e f image; t r i e s , but cannot b r i n g t o mind o r i g i n a l f o c a l image. 18: SE: Content of image changes, then image i s gone. TSE: Wonders about the process Summary of Experiences by i t works). Category P a r t i c i p a n t experiences. Co-researcher P a r t i c i p a n t experiences which extended through the f i r s t s e t of (how "A" beyond 1/2 had no way saccades. S p e c t a t o r experiences. 1. A c t i v e a l t e r a t i o n of experience: change i n content. Aspects of f o c a l image 74 2. Broadening of p e r s p e c t i v e : (b) f e e l s p r e s e n t ; safe); 3. (a) New information revealed; (c) r e a l i z e s danger i s over (she i s (d) sees h e r s e l f i n the p i c t u r e f o r the f i r s t D i s t a n c i n g of f o c a l image: (b) d i m i n i s h e s ; retrieve i t ) ; The time. image (a) comes and (c) does not appear ( d e s p i t e e f f o r t goes; to (d) appears i n f l a s h e s ; (e) i s r e p l a c e d by therapist's fingers. 4. V a r i e t y of emotional experience. decrease i n f e a r ; (c) d e s i r e t o Treatment s p e c i f i c 1. 2. (b) laugh. effects. Momentary c o g n i t i v e impairment: difficulty (a) R e l i e f ; (a) D i z z i n e s s ; (b) concentrating. Heightened p h y s i c a l awareness: (a) warmth; (b) t e n s i o n m i g r a t e s upwards; (c) musculature loosens; (d) t e n s i o n disappears. 3. Change i n energy l e v e l : 4. Meta awareness of the process: b e l i e v i n g her experience; wonders i f she experiences Feels fatigued. (a) Has difficulty (b) judges her urge t o laugh; i s " b l o c k i n g " ; (d) wonders about how are o c c u r r i n g . her (c) 75 Co-Researcher B The trauma h i s t o r y of "B" was, e x t e n s i v e and complicated perhaps, the most of the t h r e e Eighteen months p r i o r t o treatment, co-researchers. P a r t i c i p a n t "B" been s e x u a l l y a s s a u l t e d w h i l e a p a t i e n t a t a l o c a l by a r a d i o g r a p h e r employed by the h o s p i t a l . o c c u r r e d when she was at thirteen. the same h o s p i t a l , by a man hospital, T h i s was second such a s s a u l t she had endured, the f i r s t had the having I r o n i c a l l y , both occurred of the same m i n o r i t y r a c e . F u r t h e r adding t o her traumatized s t a t e was her having endured the l e g a l a r b i t r a t i o n of the second a s s a i l a n t , d u r i n g which i n f o r m a t i o n about the f i r s t a s s a u l t was made public. Approximately s i x months p r i o r t o the second a s s a u l t , "B" had attempted t o become pregnant through fertilization. depression. She " l o s t the baby" and s u f f e r e d acute Approximately p a r t i c i p a n t and her husband To complicate matters, traumatic invitro one year a f t e r the a s s a u l t , the separated. there e x i s t e d other repressed i n f o r m a t i o n (revealed i n subsequent s e s s i o n s ) not known t o c l i e n t or t h e r a p i s t d u r i n g the f i r s t EMDR s e s s i o n , which might have a f f e c t e d treatment. Her assault symptoms i n c l u d e d i n t r u s i v e r e c o l l e c t i o n s o f the (a m e t a p h o r i c a l image of the a s s a i l a n t c r a w l i n g her back); severe d e p r e s s i o n and a n x i e t y ; d i m i n i s h e d on sexual d e s i r e ; and d i f f i c u l t y m a i n t a i n i n g normal f r i e n d s h i p s . Her sense of t r u s t i n others had been s e v e r e l y i n j u r e d ; and she 76 had been unable t o work f o r s e v e r a l months. As "B" s u c c i n c t l y s a i d o f t h e e f f e c t o f h e r second s e x u a l a s s a u l t : " I t j u s t b a s i c a l l y changed my e n t i r e life." At the time o f the c l a r i f i c a t i o n i n t e r v i e w "B" was p h y s i c a l l y exhausted, and appeared e m o t i o n a l l y f r a g i l e . EMDR E x p e r i e n c e s o f Co-Researcher "B" I f c o - r e s e a r c h e r "A" c o u l d be s a i d t o have moved more or l e s s s t e a d i l y down a g e n t l e s l o p e toward r e s o l u t i o n o f her t r a u m a t i c c o n d i t i o n , "B"'s t r a j e c t o r y was c l o s e r t o t h a t of a s h i p on stormy waters, as she was t o s s e d d r a m a t i c a l l y up and down through p r o f o u n d l y d i f f e r e n t emotional s t a t e s : Anger, f e a r , sadness, j o y (euphoria), and g u i l t were a l l experienced, as were the concomitant p h y s i c a l m a n i f e s t a t i o n s of nausea, t i g h t e n i n g and l o o s e n i n g o f the musculature, extreme f a t i g u e , r e j u v e n a t i o n , t i n g l i n g , and the e x p e r i e n c e of f e e l i n g as i f she were drugged on Valium, a m e d i c a t i o n w i t h which she was f a m i l i a r . She has two P a r t i c i p a n t e x p e r i e n c e s , d u r i n g which she r e l i v e d the t r a u m a t i c i n c i d e n t . I n the realm o f f a n t a s y , "B" imagines g a i n i n g revenge from the a s s a i l a n t through r o l e r e v e r s a l , v i o l e n c e and c o n v i c t i o n f o r h i s crime. i d e n t i f i e s with three f i c t i o n a l characters: literature one from (Hamlet, whom she sees as t r a g i c ) ; another from a children's' story film She (a v e r y sad g i r l ) ; and f i n a l l y , (the p r o t a g o n i s t i n I t ' s a Wonderful L i f e ) . one from During the l a t t e r , she watches h e r s e l f watching the f i l m i n " r e a l time," a t a p o i n t when the p r o t a g o n i s t f i n d ' s h i s daughter 77 Zu Zu's flower p e t a l s i n h i s pocket, and r e a l i z e he has k i l l e d himself. During the c l a r i f i c a t i o n i n t e r v i e w , r e a l i z e d the s i g n i f i c a n c e of t h i s f o r her: She had s e v e r a l i n s i g h t s she d i s p l a y s , and her new not "B" s u r v i v e d , and not k i l l e d h e r s e l f . The compassion f o r the a s s a i l a n t , suggest some working through of her trauma occurs; however, complete r e s o l u t i o n of her symptoms i s not reached. By the end of her s e s s i o n , "B" somewhat m e n t a l l y disoriented. i s exhausted, Both t h e r a p i s t and t h e r e i s more work t o be done i n f u t u r e s e s s i o n s . l e v e l , which began a t "between nine and t e n , " i s and she agree Her SUDs now "sevenish—eight." S e q u e n t i a l Experiences by Category Set C l a s s i f i c a t i o n and D e s c r i p t i o n o f E x p e r i e n c e 01: SE: Anger. 02: SE: Anger. TSE: T i g h t chest; d i f f i c u l t y PE: R e l i v e s event; f e e l s SE: F e e l s enough d i s t a n c e f o r sadness. TSE: R e a l i z e s treatment i s working. 04: SE: R e l i e f she i s s a f e . 05: SE: Anger. 06: SE: Anger; sadness. 07: SE: Anger. 03: breathing. vulnerable. 78 C l a s s i f i c a t i o n and D e s c r i p t i o n o f SE: Experience Blank (no image); f a n t a s i z e s going t o s a f e place (beach). TSE: F e e l s exhausted. SE: P o s i t i v e i n s i g h t ; b e l i e v e s she i s s t r o n g . TSE: F e e l s energized; body r e l a x e d ; f e e l s more i n c o n t r o l of body. SE: Revenge f a n t a s y (assaulting assailant). SE: Revenge f a n t a s y ( r o l e r e v e r s a l ) ; anger. SE: Blank (no image). TSE: F r u s t r a t i o n a t her p r o c e s s ; body r e l a x e d . SE: Profound sadness and g r i e f ; i d e n t i f i e s with sad g i r l i n c h i l d r e n ' s s t o r y . SE: Too d i s t r a u g h t t o continue. comforts s e l f with TSE: Asks f o r break; self-talk. F e e l s n e g a t i v e l y e f f e c t e d by t h e r a p i s t ' s change i n d i r e c t i o n of f i n g e r movements. SE: Revenge f a n t a s y ( a s s a i l a n t being punished). SE: Revenge f a n t a s y ( c o n t i n u a t i o n of above). TSE: Head f e e l s heavy ("as i f on morphine."); wonders about (neurophysiology of) process; wonders i f she i s u p s e t t i n g t h e r a p i s t . TSE: Right s i d e of " b r a i n " f e e l s energized. SE: F e e l s euphoric; wants t o TSE: Feels fatigued. SE: Cannot r e t r i e v e image; imagines s a f e p l a c e . laugh. 79 Set C l a s s i f i c a t i o n and D e s c r i p t i o n o f 23: SE: Complete mental and emotional Experience peace; feels "wrapped i n a cocoon." 24: TSE: Right s i d e of b r a i n f e e l s heavy; i n c r e a s e d p h y s i c a l awareness. 25: TSE: Tension migrated from c h e s t t o s k u l l ; feels drugged, sleepy. 26: TSE: Fingers f e e l 27: TSE: Body r e l a x e d . 28: TSE: Muscles t w i t c h i n g . 29: TSE: Sleepy; tingly. angry a t s e l f f o r being t i g h t n e s s i n c r e a s e s and 30: TSE: sleepy; decreases. D i s l i k e s p e r c e i v e d change i n f i n g e r movements. P e r c e i v e s t h e r a p i s t as r e l a x e d . SE: F a n t a s i z e d watching h e r s e l f watch a movie. TSE: F e l l s drugged and 32: SE: Wants t o be 33: TSE: F a t i g u e d ; i n c r e a s e d p h y s i c a l awareness. 34: TSE: P e r c e i v e s f i n g e r s as "Grim Reaper", p o i n t i n g . 35: SE: Blank. TSE: Right s i d e of b r a i n s t i l l 36: SE: Childhood 37: SE: Sadness; wants t o f e e l s a f e TSE: Nausea; f a t i g u e ; embarrassed a t own 38: TSE: T i g h t chest; d i f f i c u l t y 39: TSE: Tension; 40: PE: A n t i c i p a t e s traumatic 31: relaxed. alone. f e e l s drugged. memory of h i d i n g i n s a f e p l a c e . again. breathing. exhaustion. event. process. 80 C l a s s i f i c a t i o n and D e s c r i p t i o n of Experience SE: Anger. SE: Insight (into metaphorical f o c a l SE: S e l f blame (she c o u l d n ' t stop image). incident). TSE: T i g h t c h e s t . SE: Anger. TSE: F e e l s t i n g l y SE: ( f i g h t or f l i g h t feeling). Sadness; b e l i e v e s she i s h e l p l e s s . TSE: T i g h t n e s s ; f a t i g u e ; no longer f e e l s drugged; needs t o r e s t ; wonders about p r o c e s s (how i t works). SE: Compassion f o r a s s a i l a n t . SE: Despair a t r e c o v e r i n g ; vague f l a s h b a c k or f a n t a s y of a s t a l k e r . SE: Wonders why i n c i d e n t happened. PE: R e l i v e s traumatic i n c i d e n t . SE: Anger. TSE: R e l u c t a n t t o look l e f t SE: ("too much pain.") Despair she won't r e c o v e r ; i d e n t i f i e s w i t h tragic figure (Hamlet). SE: Blank; wants s e s s i o n t o end. TSE: Exhaustion; nausea; t i g h t n e s s . TSE: F a t i g u e . TSE: Mental c o n f u s i o n ; d i f f i c u l t y f o l l o w i n g f i n g e r s ; p r e s s u r e on c h e s t . SE: Sadness f o r s e l f and SE: Thinks of s u i c i d e . world. 81 Set C l a s s i f i c a t i o n and D e s c r i p t i o n o f Experience 58: SE: G u i l t f o r having d i s c l o s e d . 59 SE: I n s i g h t ( i t was 60: SE: Increased anger; f r u s t r a t i o n a t l e n g t h of good t o d i s c l o s e ) . h e a l i n g process; two insights saved o t h e r s ; hasn't k i l l e d (she may have herself). 61: SE: Anger. 62: TSE: G r a t e f u l f o r t h e r a p i s t ' s comment. 63: TSE: Sees f i n g e r s as t o o l s t o r e c o v e r y . 64: TSE: Exhaustion; d i f f i c u l t y 65: TSE: Exhaustion. 66: TSE: Thoughts about t h e r a p i s t and 67: SE: Wonders, "Why me?"; articulating. insight process. (answers own question). TSE: Mental c o n f u s i o n and d i s o r g a n i z a t i o n . 68: TSE: Fatigue. Summary of Experiences bv Category P a r t i c i p a n t experiences. 1. P a s s i v e endurance of trauma. (a) R e l i v e s event; (b) p a s s i v e l y endures i n t r u s i v e r e - e x p e r i e n c i n g . 2. Narrowness of p e r s p e c t i v e . Momentary awareness does not extend beyond r e l i v e d experiences. 3. Immediacy of f o c a l Image. Image appears c l o s e and real. 82 4. I n t e n s i t y of emotion. Spectator (a) Fear; vulnerability. Experiences. 1. A c t i v e a l t e r a t i o n of experience. (b) f a n t a s i z e s a p e a c e f u l p l a c e ; h e r s e l f watch a f i l m ; place; (b) (a) F a n t a s i z e s revenge; (c) imagines watching (d) has c h i l d h o o d memory of s a f e (e) has vague f a n t a s y or f l a s h b a c k of a s t a l k e r . 2. Broadening of p e r s p e c t i v e . (a) B e l i e v e s she i s safe; f e e l s compassion f o r a s s a i l a n t ; (c) wonders why incident (b) happened; (d) contemplates s u i c i d e ; (e) f e e l s g u i l t y f o r having d i s c l o s e d ; (f) blames h e r s e l f ; (g) has p o s i t i v e insights ( i . e . , r e a l i z e s i t was wonders, "why me?"; good t o d i s c l o s e ) ; ( i ) i d e n t i f i e s with v a r i o u s (h) fictional characters. 3. D i s t a n c i n g of f o c a l image. (b) image comes as flash. 4. V a r i e t y of emotions. profound g r i e f ; t o laugh; (a) Cannot r e t r i e v e image; (a) Anger; (b) sadness; (d) r e l i e f ; (g) d e s p a i r a t Treatment s p e c i f i c (e) j o y ( e u p h o r i a ) ; (f) d e s i r e recovery. effects. 1. Momentary c o g n i t i v e impairment. mental c o n f u s i o n ; (c) (a) F e e l s drugged; (c) d i f f i c u l t y f o l l o w i n g f i n g e r s ; (e) d i f f i c u l t y a r t i c u l a t i n g her experience. (b) 83 2. Heightened p h y s i c a l awareness. (a) T i g h t c h e s t ; (b) d i f f i c u l t y b r e a t h i n g ; (c) p r e s s u r e on c h e s t ; relaxed; (d) f e e l s (e) head f e e l s heavy; (f) r i g h t s i d e o n l y o f head f e e l s heavy; (g) t e n s i o n moves from chest t o s k u l l ; (h) musculature t i g h t e n s and loosens; (i) f e e l s t i n g l y ; (j) muscles t w i t c h . 3. Change i n energy l e v e l . (a) F e e l s e n e r g i z e d ; (b) f e e l s exhausted; (c) r i g h t s i d e o f head f e e l s e n e r g i z e d ; (d) f e e l s sleepy. 4. Meta awareness o f process. working; (a) R e a l i z e s treatment i s (b) f r u s t r a t i o n a t h e r p r o c e s s ; (c) concerned with d i r e c t i o n o f t h e r a p i s t ' s f i n g e r movements; (d) aware o f f e e l i n g r e l u c t a n t t o look l e f t ; (e) angry a t s e l f f o r b e i n g sleepy; (f) embarrassed a t own p r o c e s s ; process (how i t works); (h) sees f i n g e r s as t o o l s t o recovery; (g) wonders about ( i ) w o r r i e s how she i s a f f e c t i n g t h e r a p i s t ; ( j ) g r a t e f u l f o r t h e r a p i s t ' s comments. Co-Researcher "C" During an i c e storm, approximately f i r s t EMDR s e s s i o n , "C 11 6 weeks p r i o r t o h e r had stopped her c a r i n o r d e r t o a s s i s t a man and h i s daughter, f l a g g i n g her f o r a s s i s t a n c e . whom she b e l i e v e d t o be 84 Immediately p r i o r t o e x i t i n g h e r v e h i c l e , another c a r c o l l i d e d w i t h h e r s , i n j u r i n g the man, and k i l l i n g h i s daughter. Although n o t i n j u r e d h e r s e l f , t h e c o - r e s e a r c h e r immediately began s u f f e r i n g emotional shock, w i t h which she coped by a t t e n d i n g t o the i n j u r e d p a r t i e s . As she was a nurse, and f a m i l i a r with emergency procedures, "C" attempted c h e s t compressions on the i n j u r e d young woman, b u t e v e n t u a l l y r e a l i z e d she c o u l d not save her. B e l i e v i n g she may have caused the a c c i d e n t by s t o p p i n g her c a r , "C" had s i n c e been plagued w i t h g u i l t and o b s e s s i v e t h i n k i n g about t h e a c c i d e n t . E s p e c i a l l y t r o u b l i n g were i n t r u s i v e images o f the v i c t i m s ' f a c e s , and v i o l e n t nightmares i n v o l v i n g c a r crashes, s e r i a l k i l l e r s , and dismembered people and animals. car Although she had d r i v e n a s i n c e t h e t r a u m a t i c event, i t was always w i t h a s t r o n g sense o f t r e p i d a t i o n as she a n t i c i p a t e d another a c c i d e n t . P r i o r t o t h e EMDR s e s s i o n , she had d i f f i c u l t y s h a r i n g h e r f e e l i n g s about t h e event w i t h a l l accept h e r husband, who remained s u p p o r t i v e . At t h e time o f t h e c l a r i f i c a t i o n i n t e r v i e w "C" f e l t slightly tired. She was c l e a r l y i n p h y s i c a l p a i n r e s u l t i n g from her a c c i d e n t , and showed r e s t r a i n e d emotional vulnerability. EMDR Experiences o f Co-Researcher "C" Throughout the g r e a t e r p a r t o f h e r EMDR s e s s i o n , "C" r e - e x p e r i e n c e d , l a r g e l y i n sequence, h e r automobile 85 a c c i d e n t , and the events immediately afterward. That i s t o say, her t r a u m a t i c r e l i v i n g of the event began a t t h e moment of impact, and progressed, more or l e s s sequentially, forward through time, w i t h each s e t of saccades moving her a l i t t l e farther. She d e s c r i b e d her e x p e r i e n c e t h i s way: The f i r s t w h i l e . . . i t . . . almost went i n sequence of the a c t u a l a c c i d e n t . one t h i n g made me So, t h i n k i n g l e a d t o t h i n k about the next about thing. So, I worked through i t — t h e whole a c c i d e n t . Semantic and emotional threads l i n k one s e t t o the next. For example, i n s e t four, the anger she f e l t screaming woman, r e c u r r e d i n the f i f t h at a s e t ; but t h i s time d i r e c t e d toward the d r i v e r s of the a c c i d e n t v e h i c l e . The s i x t h s e t a g a i n brought an image of the same v e h i c l e , but t h i s time the focus was was wearing, on the d e t a i l s of the hat the woman and so on. C l a s s i f i c a t i o n of her experiences of g u i l t and was at f i r s t d i f f i c u l t . anger For, although one would n o r m a l l y t h i n k of these as secondary, and hence, S p e c t a t o r emotions, because they were re-experienced, as i f o c c u r r i n g i n the moment, they f i t t e d best i n t o the category of P a r t i c i p a n t Experiences. Throughout " C ' s f i r s t s e s s i o n , she d i d , by her admission, r e s i s t the urge t o emote. own Each time she f e l t impulse t o c r y , she stopped h e r s e l f , by choking back the the 86 f e e l i n g s , and stopping eye movements, s t a r i n g s t r a i g h t ahead, as i f f i x a t e d on something. T h i s impulse t o c r y she d e s c r i b e d as more profound and d i s t u r b i n g than mere sadness. At s e v e r a l p o i n t s d u r i n g treatment, "C" consecutive and why one Spectator Experiences; had among them, wondering how the event happened; a d e s i r e t o l e a v e f l o w e r s f o r o f the v i c t i m s , and a momentary sense o f r e l i e f r e a l i z i n g the a c c i d e n t wasn't her At s e s s i o n s end, i n her a n x i e t y fault. t h e r e had been o n l y a s l i g h t (SUDs) l e v e l , from 7.5 S e q u e n t i a l Experiences at to decrease 6.5. by Category Set C l a s s i f i c a t i o n and D e s c r i p t i o n of 01: TSE: Experience D i f f i c u l t y c o n c e n t r a t i n g ; not sure what t o do, d e s p i t e i n s t r u c t i o n s . 02: PE: R e l i v e s moment of impact; p a n i c , f e a r and guilt. TSE: S u r p r i s e d a t process; many images appear. 03: PE: Relives incident: nausea; f e a r ; shock. 04: PE: Relives incident: f e a r ; anger. TSE: D i f f i c u l t y c o n c e n t r a t i n g ; eye embarrassed a t her 05: l i d s get heavy; process. PE: Relives incident. SE: Anger. 06: PE: R e l i v e s i n c i d e n t ; remembers d e t a i l s . 07: PE: Relives incident. SE: Wants t o c r y ( b l o c k s ) . C l a s s i f i c a t i o n and D e s c r i p t i o n o f E x p e r i e n c e PE: R e l i v e s i n c i d e n t ; remembers d e t a i l s . SE: Wants t o c r y ( b l o c k s ) . TSE: Knot i n stomach. PE: R e l i v e s i n c i d e n t : remembers d e t a i l s . PE: R e l i v e s i n c i d e n t : f e e l s h e l p l e s s and vulnerable. SE: Increased awareness of remembered surroundings. PE: Relives incident: g u i l t . SE: Increased awareness of s u r r o u n d i n g s . TSE: Confuses past and present tenses; tension i n stomach f e e l s as i f i n t h r o a t ; shaky. PE: Relives incident. SE: Remembers f e e l i n g of r e l i e f t h a t she was not r e s p o n s i b l e f o r a c c i d e n t ; wants t o c r y (blocked). PE: Relives SE: Anger. (post i n c i d e n t ) . TSE: Nausea. PE: R e l i v e s : g u i l t and v u l n e r a b i l i t y . PE: Partial relive. PE: Partial relive. SE: Remembers f e e l i n g annoyed. PE: Partial SE: Wants t o c r y ( b l o c k s ) . TSE: Stomach relive. tight. 88 C l a s s i f i c a t i o n and D e s c r i p t i o n of E x p e r i e n c e PE: Partial relive. SE: Wants t o c r y PE: Partial SE: Wants t o c r y PE: Partial relive: guilt; SE: Memory of r e l i e f i t wasn't her PE: Partial SE: Memory of r e l i e f i t wasn't her SE: Wonders how i n c i d e n t happened; wants c l o s u r e . SE: Wonders how i n c i d e n t happened; wants c l o s u r e ; (blocks). relive. (blocks). fear. fault. relive. fault. anger. TSE: Mind r a c i n g : many thoughts. SE: Fed up with p a i n ; wants c l o s u r e . PE: Relives incident impact): f e a r , (from immediately a f t e r panic. PE: Relives incident: shock: d i s s o c i a t i o n . PE: Relives incident. SE: Insight i n t o her p h y s i c a l v u l n e r a b i l i t y . PE: Partial relive. SE: Anger; i n s i g h t (she helped o t h e r s t o protect herself). PE: Partial relive. SE: Wants t o be taken care o f . PE: P a r t i a l r e l i v e : re-experiences d i s s o c i a t i v e quality; vivid SE: detail Swears she w i l l never forget. 89 Set C l a s s i f i c a t i o n and D e s c r i p t i o n o f E x p e r i e n c e 31: SE: F a n t a s i z e s l e a v i n g f l o w e r s f o r dead woman; wonders i f man blames her. 32: SE: Wonders how man i s ; wonders i f he blames her; g u i l t ; sadness; wants c l o s u r e . TSE: Fatigue 33: SE: begins. Flashes of man's f a c e ; wonders why he waved; image of him on ground; s e l f - c o a c h e s : Tells h e r s e l f she d i d the r i g h t t h i n g . 34: 35: PE: Partial relive. SE: Wonders why event happened. SE: I d e n t i f i e s with other v i c t i m s ; wonders how they cope. 36: PE: Relives incident; increased d e t a i l ; SE: Memory of being s u r p r i s e d a t her competence; insight 37: (from p s y c h o l o g i s t ' s fear. question). PE: R e l i v e s i n c i d e n t : g u i l t , shock. SE: I n s i g h t (she wasn't c a l l o u s ) . TSE: Mind r a c i n g ; many thoughts. 38: PE: Partial relive (post i n c i d e n t ) . SE: Remembers wanting comfort; wonders how cope. 39: PE: Partial relive (post i n c i d e n t ) ; d e t a i l s clearer. 40: SE: Wants t o c r y ( b l o c k s ) . PE: P a r t i a l r e l i v e of i n c i d e n t . SE: Experiences insight. others 90 Summary of Experiences by Category P a r t i c i p a n t experiences. 1. P a s s i v e endurance of trauma. (a) R e l i v e s event; (b) p a s s i v e l y endures r e - e x p e r i e n c i n g of t r a u m a t i c memories. 2. Narrowness of p e r s p e c t i v e ; Momentary awareness does not extend beyond r e l i v e d experiences. 3. Immediacy of f o c a l image: F o c a l image appears vivid and close; d e t a i l revealed. 4. I n t e n s i t y of emotion. Experiences (c) h e l p l e s s n e s s ; (d) v u l n e r a b i l i t y ; (f) anger (a) f e a r ; (e) g u i l t (b) shock; (relives); (relives). S p e c t a t o r experiences. 1. A c t i v e a l t e r a t i o n of experience. (a) F a n t a s i z e s l e a v i n g flowers. 2. Broadening of p e r s p e c t i v e . surroundings (of trauma s i t e ) ; (a) Increased awareness of (b) i n s i g h t i n t o her p l a y e d d u r i n g trauma; (c) wonders how wonders why event o c c u r r e d ; event occurred; (e) wonders how (f) i d e n t i f i e s w i t h other v i c t i m . 3. D i s t a n c i n g of f o c a l image. None. role (d) o t h e r s cope; 91 4. V a r i e t y o f emotions. ("more than sadness"); Feels (a) anger; (b) wants t o c r y (c) r e l i e f ; (d) f e e l s f e d up w i t h f e e l i n g bad. Treatment s p e c i f i c effects. 1. Momentary c o g n i t i v e impairment. concentrating; (b) mind r a c e s ; (a) D i f f i c u l t y (c) many images; (d) confuses p a s t and p r e s e n t t e n s e s . 2. Heightened p h y s i c a l awareness. (a) Nausea; become heavy; (d) f e e l s as i f h e r (c) knot i n stomach; stomach i s i n her t h r o a t ; 3. Change i n energy l e v e l . (e) f e e l s shaky. Fatigue. 4. Meta awareness o f process. process; (a) Embarrassed a t h e r own (b) s u r p r i s e d a t mind r a c i n g , number o f images. (b) e y e l i d s (c) s u r p r i s e d a t h i g h 92 CHAPTER FIVE: DISCUSSION Review To b r i e f l y summarize, i n f o r m a t i o n from a t o t a l o f s i x i n t e r v i e w t r a n s c r i p t s was analyzed and found consonant w i t h t h r e e broad c a t e g o r i e s , o r themes, o f experience, each o f which f u r t h e r contained f o u r dimensions o f e x p e r i e n c e . Two of t h e t h r e e broad c a t e g o r i e s — P a r t i c i p a n t E x p e r i e n c e s , and Spectator Experiences—were Cochran (1990). borrowed from t h e work o f P a r t i c i p a n t Experiences emphasize (a) t h e p a s s i v e nature o f the c o - r e s e a r c h e r s ' i n t r u s i v e r e experiencing; vivid, (b) the narrow p e r s p e c t i v e o r f o c u s ; (c) t h e immediacy of t h e f o c a l image; and (d) t h e h i g h i n t e n s i t y o f ( r e l i v e d ) emotion(s). Within t h i s category, the c l i e n t may be s a i d t o be r e - e x p e r i e n c i n g , t o some degree, t h e o r i g i n a l traumatic m a t e r i a l . The n o t i o n s o f narrow p e r s p e c t i v e , h i g h i n t e n s i t y o f emotion, and t h e h e l p l e s s nature o f r e - e x p e r i e n c i n g , a r e compatible DSM IV (APA, 1994) c a t e g o r i e s o f c o n s t r i c t i o n , and intrusion, with the hyperarousal respectively. S p e c t a t o r experiences suggest a movement away from t h e narrow, i n t e n s e r e - e x p e r i e n c i n g of t h e P a r t i c i p a n t , i n t o a realm i n which t h e co-researcher experiences (a) a p a r a d o x i c a l form o f agency, vaguely s i m i l a r t o dreaming, i n which t h e e x p e r i e n c e r i s both agent and instrument experience; (b) a broadening t r a u m a t i c event; o f her of p e r s p e c t i v e r e l a t i v e t o t h e (c) d i s t a n c i n g o f the f o c a l image; and (d) a v a r i e t y o f i n t e n s i t y and type o f emotion. I t i s within 93 t h i s category t h a t the s u r v i v o r begins t o m e n t a l l y a c t upon and c o n t e x t u a l i z e her experience; t o r e c o n s t r u c t t h e assumptions t h a t were " s h a t t e r e d " (Janoff-Bulman, 1992) as a r e s u l t o f her encounter w i t h the t r a u m a t i c . The category o f Treatment S p e c i f i c E f f e c t s , i n c l u d e s those experiences which would not, i n a l l p r o b a b i l i t y , be o c c u r r i n g , were i t not f o r the treatment itself. Various elements o f t h i s category were found t o occur a l o n g w i t h P a r t i c i p a n t and Spectator Experiences, as w e l l as on t h e i r own. They i n c l u d e (a) momentary c o g n i t i v e impairment; (b) somatic e x p e r i e n c e s ; energy (c) changes t o t h e c o - r e s e a r c h e r ' s l e v e l ; and (d) a meta awareness o f t h e c o - r e s e a r c h e r ' s own process. Each c o - r e s e a r c h e r manifested a s i g n i f i c a n t l y p a t t e r n o f experience. mentioned "approximately different "A" was among t h e p r e v i o u s l y 40%" o f i n d i v i d u a l s who e x p e r i e n c e a c o n t i n u a l , p r o g r e s s i v e movement toward i n - s e s s i o n r e s o l u t i o n o f t h e t a r g e t event (Shapiro, 1995, p. 76) . C l e a r l y , t h e m a j o r i t y of her experiences were o f t h e S p e c t a t o r and Treatment S p e c i f i c E f f e c t s v a r i e t y . No P a r t i c i p a n t Experiences occurred a f t e r 1/2 way through h e r f i r s t s e t o f eye movements. Co-researcher "B," a l t h o u g h spending much o f her time i n these same two c a t e g o r i e s , d i d have t h r e e P a r t i c i p a n t experiences, d u r i n g which she r e l i v e d , t o some extent, the h o r r o r o f her t r a u m a t i c event. Hers was a stormy voyage of a b r e a c t i o n , d r u g - l i k e euphoria, f a t i g u e , c o g n i t i v e i n s i g h t s , and p h y s i c a l t i g h t e n i n g and 94 loosening. Although, r e s o l u t i o n was not a t t a i n e d , s i g n i f i c a n t progress was made. Co-researcher "C," on t h e o t h e r hand, spent much o f her time i n t h e realm o f P a r t i c i p a n t Experiences, r e l i v i n g h e r trauma and t h e hours t h a t f o l l o w e d , g a i n i n g l i t t l e p e r s p e c t i v e beyond h e r narrow P a r t i c i p a n t focus. However, she d i d move t e m p o r a r i l y the S p e c t a t o r realm s e v e r a l times as t h e s e s s i o n into progressed: Among other t h i n g s , she questioned why and how h e r t r a u m a t i c event c o u l d have occurred, and imagined paying homage t o a woman k i l l e d a t t h e s i t e of her trauma. As w i t h "B," r e s o l u t i o n was not a t t a i n e d , a p p a r e n t l y due t o r e s i s t a n c e t o treatment. I m p l i c a t i o n s f o r Theory The g l e a n i n g and c l a s s i f i c a t i o n o f e x p e r i e n c e — e s p e c i a l l y remembered experience, which i s p a r t i a l l y o f r e l e v a n c e t o t h e present s t u d y — i s , a t best, a t r i c k y endeavor. Not o n l y i s t h e nature o f memory i t s e l f somewhat c r e a t i v e , and f a r from t h e "play back" mechanism we t y p i c a l l y imagine (Loftus & Hoffman, 1989); but, any attempt t o separate t h e v a r i o u s components o f experience ( c o g n i t i v e , a f f e c t i v e , somatic, sighted. fluoxetine e t c . ) , i s somewhat s u p e r f i c i a l and s h o r t One need only glance a t t h e c u r r e n t p o p u l a r i t y o f (Prozac), o r t h e e f f e c t s o f v a r i o u s forms o f "body work" (Upledger, 1990) on t h e mind and emotions t o r e a l i z e t h e i n t i m a t e and i n s e p a r a b l e r e l a t i o n s h i p ( o r , perhaps, " u n i t y " ) o f c o g n i t i o n / s o m a / a f f e c t . According t o 95 Damasio, (1994) our b e l i e f i n p u r e l y r a t i o n a l thought i s incorrect: The lower l e v e l s i n the n e u r a l e d i f i c e o f reason are t h e same ones t h a t r e g u l a t e t h e p r o c e s s i n g o f emotions and f e e l i n g s , along w i t h t h e body f u n c t i o n s necessary f o r an organism's survival. In t u r n , these lower l e v e l s maintain d i r e c t and mutual r e l a t i o n s h i p s w i t h v i r t u a l l y every b o d i l y organ, thus p l a c i n g t h e body d i r e c t l y w i t h i n the c h a i n o f o p e r a t i o n s t h a t generate t h e h i g h e s t reaches o f r e a s o n i n g . . . . Emotion, f e e l i n g , and b i o l o g i c a l r e g u l a t i o n a l l p l a y a r o l e i n human reason (p. x i i i ) . Hence, t o d e s c r i b e the upward m i g r a t i o n o f t i g h t n e s s i n "A"'s body as somatic. as i f devoid o f emotional o r c o g n i t i v e concomitants o r precedents; o r "B"'s a b r e a c t i o n as a f f e c t i v e , e x c l u s i v e o f t h e somatic o r r a t i o n a l , the same e r r o r as Descartes: i s t o make t h a t o f attempting t o d i v i d e the i n d i v i s i b l e wholeness of the e x p e r i e n c i n g organism (Damasio, 1994). That t o which we a s s i g n l a b e l s such as " a f f e c t i v e , " "cognitive, 11 e t c . , i s simply t h e most s a l i e n t a s p e c t o f a g r e a t e r wholeness o f experience a f f e c t i n g t h e e n t i r e person. The above caveat being s t a t e d , t h e r e was much found i n t h i s study which confirms Shapiro's (1995) d e s c r i p t i o n s o f c l i e n t experiences. Although not every e x p e r i e n c e d e s c r i b e d 96 by Shapiro o c c u r r e d (nor would one expect them t o , g i v e n t h e s m a l l sample i n v o l v e d ) , no experiences o c c u r r e d which h e r t e x t had n o t a n t i c i p a t e d . In f a c t , some o f the more unusual EMDR e x p e r i e n c e s , such as p h y s i c a l s e n s a t i o n s , changes t o the f o c a l image, p o l a r i z e d c o g n i t i v e s h i f t s and so on, seemed taken almost verbatim from h e r t e x t . F o r example, both "A" and "B" experienced the upward m i g r a t i o n o f p h y s i c a l t i g h t n e s s ; "B," from her c h e s t t o h e r head; and "A," from her stomach t o h e r chest, whence i t disappeared, " l i k e i t d i d n ' t want t o be t h e r e anymore." Of t h i s type o f s h i f t i n g s e n s a t i o n , Shapiro w r i t e s , "a c l i e n t may i n i t i a l l y i n d i c a t e a t i g h t n e s s i n the stomach, but w i t h each s e t t h e s e n s a t i o n s may seem t o move upward (to the c h e s t , t h r o a t , o r head) how 11 (p. 85). Regarding the f o c a l image, S h a p i r o w r i t e s "a l e e r i n g f a c e can change t o a s m i l i n g one . . ." (p. 81), which o c c u r r e d when "A" saw the f a c e o f h e r co-worker, which had p r e v i o u s l y looked worried, appear calm and smiling. Other (but not a l l ) c o - r e s e a r c h e r e x p e r i e n c e s which confirmed Shapiro's d e s c r i p t i o n s i n c l u d e changes i n cognition (p. 83); l e s s i n t e n s e r e l i v i n g o f e x p e r i e n c e (p. 90); and changes i n emotions (p. 84). M i c r o p a t t e r n s o f experiences were a l s o a n t i c i p a t e d by Shapiro, i n c l u d i n g "C"'s b l o c k i n g (p. 77), and "B"'s profound a b r e a c t i o n s (p. 168). The p r e s e n t study extends p r e v i o u s EMDR t h e o r y by o f f e r i n g a conceptual framework f o r c l a s s i f y i n g and 97 understanding type and movement o f c o - r e s e a r c h e r experience, which i s c o n s i s t e n t w i t h e x i s t i n g p e r s p e c t i v e s on PTSD (APA, 1994; Shapiro, 1995; Herman, 1992), " s h a t t e r e d assumptions" (Janoff-Bulman, 1992), and n a r r a t i v e t h e r a p i e s (Hermans & Hermans-Jansen, 1995). Whereas Shapiro's (1995) a c c e l e r a t e d i n f o r m a t i o n p r o c e s s i n g model p r o v i d e s a metaphorical and b i o l o g i c a l "working h y p o t h e s i s " (p. 29) of how EMDR b r i n g s about changes t o t h e organism, the c u r r e n t study o f f e r s a framework f o r c o n c e p t u a l i z i n g and understanding t h e s i g n i f i c a n c e o f these changes themselves. To d e s c r i b e movement away from t h e P a r t i c i p a n t realm, t o t h a t o f a Spectator i s not only t o say one i s working through t h e t r a u m a t i c m a t e r i a l , but a l s o t o say what t h e s i g n i f i c a n c e and meaning o f such movement i s . When, f o r example, "A" sees h e r s e l f i n t h e p i c t u r e f o r t h e f i r s t it time, i s not o n l y a s i g n t h a t "two neuro networks [ a r e l i n k i n g ] up w i t h each o t h e r " (Shapiro, 1995, p. 41), but, j u s t as important, i t i s an i n d i c a t i o n o f what t h e c o - r e s e a r c h e r , i n her p a r a d o x i c a l l y a g e n t i v e / p a s s i v e r o l e i s i n t h e p r o c e s s o f doing: c o n t e x t u a l i z i n g , n a r r a t i n g , and hence, making meaning o f her p r e v i o u s l y meaningless, memory. wordless, traumatic I t i s t h i s n e g o t i a t i o n and r e c o n s t r u c t i o n o f meaning which allows the traumatic e p i s o d e — n o w a s t o r y — t o be removed from " a c t i v e memory" (Horowitz, rest. 1976) and l a i d t o 98 The dimensions o f experience, (largely bipolar i n the realms o f P a r t i c i p a n t and Spectator) i n d i c a t e t h e dynamics, or components, i n v o l v e d i n t h e s h i f t from t h e p r e n a r r a t i v e (Herman, 1992) t o t h e n a r r a t i v e (Hermans & Hermans-Jansen, 1995); from s t a s i s (Shapiro, 1995; Janet, ( F r a n k l , 1963); from fragmentation integration (Janet, 1919) t o meaning (Janoff-Bulmann, 1992) t o 1919). T h i s c o n c e p t u a l i z a t i o n i s o f f e r e d by t h e author, n o t as an a l t e r n a t i v e t o t h e a c c e l e r a t e d i n f o r m a t i o n model, b u t an adjunct, processing adding a g r e a t e r depth t o our understanding o f t h e s i g n i f i c a n c e o f c o - r e s e a r c h e r experiences. Implications f o r Counselling There a r e s e v e r a l p o i n t s t o be made r e g a r d i n g implications f o r counselling. F i r s t , although t h e f i n d i n g s of t h i s study do n o t suggest a need f o r a l t e r a t i o n o f t h e standard EMDR p r o t o c o l (Shapiro, 1995), t h e c o n c e p t u a l i z a t i o n s o f f e r e d may be o f v a l u e t o t h e r a p i s t s by i n c r e a s i n g awareness o f t h e dynamics i n v o l v e d i n c l i e n t s ' movement toward r e s o l u t i o n and meaning m a k i n g — t h e being an a p p a r e n t l y As EMDR continues i n t e g r a l p a r t o f t h e EMDR latter experience. t o evolve, t h i s awareness may e v e n t u a l l y l e a d t o s u b t l e changes i n how some t h e r a p i s t s approach t h e o v e r a l l context o f EMDR therapy, p l a c i n g a g r e a t e r on meaning and s t o r y . The second p o i n t i n v o l v e s t h e l e v e l o f f a t i g u e experienced by a l l co-researchers (during and a f t e r emphasis 99 therapy). A t h e r a p i s t ' s emphasizing t o a c l i e n t i n advance t h a t he o r she may experience -and some degree o f f a t i g u e d u r i n g - especially after—treatment, would seem e t h i c a l l y r e s p o n s i b l e , i n t h a t the c l i e n t c o u l d p l a n h i s o r h e r p o s t s e s s i o n time a c c o r d i n g l y . T h e r a p i s t s should be aware t h a t i n - s e s s i o n f a t i g u e , c o g n i t i v e impairment, o r t h e e f f e c t s o f a b r e a c t i o n may r e q u i r e c l i e n t s t o r e s t b r i e f l y , as d i d "B," when overwhelmed by her experiences. T h i r d , as two o f the t h r e e c o - r e s e a r c h e r s were, a t some p o i n t , unsure o f what t o do, d e s p i t e t h e r a p i s t ' s previous i n s t r u c t i o n s , a r e - e v a l u a t i o n o f how and what i n s t r u c t i o n s are g i v e n might be h e l p f u l . F i n a l l y , r e g a r d i n g the t h e r a p e u t i c r e l a t i o n s h i p , i t would appear t h a t , as i n most t h e r a p i e s , encouragement can p l a y an important r o l e f o r c l i e n t s i n d i s t r e s s . Given t h e h i g h l e v e l o f meta awareness c l i e n t s d i s p l a y e d , arid t h e i r f e e l i n g s o f s u r p r i s e r e g a r d i n g t h e process, i t would seem t h a t t h e r a p i s t s should continue c l i e n t s that treatment i s proceeding t o reassure w e l l , i f such i s t h e case. For some c l i e n t s , such as "C," who d i d not y e t f e e l s a f e emoting i n f r o n t o f her t h e r a p i s t — a n d , i n essence, blocked h e r treatment as a r e s u l t — g r e a t e r time and a t t e n t i o n might need t o be p a i d t o developing treatment the t h e r a p e u t i c r e l a t i o n s h i p b e f o r e begins. I m p l i c a t i o n s f o r Research As e f f i c a c y r e s e a r c h continues usefulness t o confirm the o f EMDR i n the treatment of PTSD and o t h e r 100 conditions (Shapiro, 1995; Greenwald, 1994, 1996), i t would seem u s e f u l f o r r e s e a r c h e r s t o begin t o conduct f u r t h e r q u a l i t a t i v e i n v e s t i g a t i o n s into co-researcher experiences, e s p e c i a l l y r e g a r d i n g the dynamics o f meaning c r e a t i o n w i t h i n the t h e r a p e u t i c s e s s i o n ( s ) . To t h i s end, i t i s hoped t h e c o n c e p t u a l s t r u c t u r e s i d e n t i f i e d i n t h i s study w i l l be o f h e u r i s t i c value. As t h i s was t h e f i r s t systematic i n v e s t i g a t i o n o f t h e phenomenology o f EMDR, t h e r e remains a g r e a t d e a l t o be explored. R e p l i c a t i o n o f t h i s study w i t h a much l a r g e r sample, might v a l i d a t e the a p p r o p r i a t e n e s s , o r l a c k t h e r e o f , of t h e c a t e g o r i e s and dimensions h e r e i n d e s c r i b e d . L i m i t a t i o n s o f t h e Study Number o f S u b j e c t s Perhaps the most g l a r i n g l i m i t a t i o n o f t h i s study i s the i n c l u s i o n o f only t h r e e s u b j e c t s , o r c o - r e s e a r c h e r s . Had every c o - r e s e a r c h e r manifested a s i m i l a r p a t t e r n o f experience, i t would s t i l l have remained d i f f i c u l t t o g e n e r a l i z e t h e r e s u l t s beyond t h i s study. each c o - r e s e a r c h e r manifested a d i f f e r e n t The f a c t t h a t experiential p a t t e r n renders any such g e n e r a l i z a t i o n t h a t much l e s s certain. For t h e t h r e e p a t t e r n s i d e n t i f i e d do, i n a l l p r o b a b i l i t y , r e p r e s e n t only a s m a l l sample o f t h e many possible patterns. G e n e r a l i z a t i o n i s f u r t h e r c o m p l i c a t e d by the f a c t t h a t , although a l l c o - r e s e a r c h e r s shared a common DSM IV d i a g n o s i s o f PTSD (APA, 1994), "A" was b e i n g t r e a t e d for a s i n g l e event trauma; "B" f o r a t l e a s t two; and "C," 101 a l t h o u g h t r e a t e d p r i m a r i l y f o r a s i n g l e trauma, was, by h e r own admission, r e s i s t i n g t h e treatment, so as n o t t o f e e l overwhelmed. L i m i t a t i o n s o f V e r b a l Communication Even w i t h t h e use of I n t e r p e r s o n a l Process R e c a l l t o cue c o - r e s e a r c h e r s ' memories, i t i s presumed t h a t n o t a l l o f the i n - s e s s i o n i n f o r m a t i o n c o u l d be r e t r i e v e d by t h e researcher or co-researcher. For such i s t h e n a t u r e o f memory and v e r b a l communication t h a t , even i f one possessed u n l i m i t e d time t o remember and d e s c r i b e one's e x p e r i e n c e (which c o - r e s e a r c h e r s d i d n o t ) , a p r e c i s e r e p r e s e n t a t i o n i s unlikely. Some experiences may be o u t s i d e t h e realm o f language. A l a n Watts w r i t e s t h a t words can express no more than a t i n y fragment o f human knowledge, f o r what we can say and t h i n k i s always immeasurably l e s s than what we e x p e r i e n c e . T h i s i s not o n l y because t h e r e a r e no l i m i t s t o t h e e x h a u s t i v e d e s c r i p t i o n o f an event, as t h e r e a r e no l i m i t s t o t h e p o s s i b l e d i v i s i o n s o f an i n c h ; i t i s a l s o because t h e r e are experiences which defy t h e v e r y s t r u c t u r e o f our language, as water cannot be c a r r i e d i n a s i e v e (1983, p. 3 ) . Further, the f a l l i b i l i t y o f memory i t s e l f may u l t i m a t e l y render a l l accounts o f remembered e x p e r i e n c e a t l e a s t m a r g i n a l l y suspect ( L o f t u s & Hoffman, 1989) . 102 Researcher B i a s and I n f l u e n c e D e s p i t e the r e s e a r c h e r ' s attempt t o wade i n t o t h e l a r g e body of c o - r e s e a r c h e r experience without p r e c o n c e p t i o n s or e x p e c t a t i o n s , i t would be naive t o assume such a n e u t r a l approach t o r e s e a r c h i s p o s s i b l e (Kuhn, 1962; L a i n g , 1967). For one cannot h e l p but i n t e r p r e t through the f i l t e r one's p r e v i o u s t r a i n i n g and of experience. F u r t h e r , although the author has attempted to i n v e s t i g a t e each c o - r e s e a r c h e r ' s "experience as i t i s experienced" it ( C o l a i z z i , 1978, p. 53), as R. D. L a i n g w r i t e s , i s f a l l a c i o u s t o b e l i e v e we can i n v e s t i g a t e or interpret the experience of another, without becoming p a r t o f , and hence, i n f l u e n c i n g , the very t h i n g we are attempting to investigate. S o c i a l phenomenology i s the s c i e n c e of my of o t h e r s ' experience. r e l a t i o n between my experience of me. p. I t i s concerned own and w i t h the experience of you and your That i s , w i t h i n t e r e x p e r i e n c e (1967, 5) Therapist Style Both of the p s y c h o l o g i s t s who graciously participated i n t h i s study, although f o l l o w i n g standard EMDR p r o t o c o l (Shapiro, 1995), manifested s l i g h t l y d i f f e r e n t s t y l e s i n they i n t e r a c t e d w i t h t h e i r clients. how 103 The p s y c h o l o g i s t who t r e a t e d "B" performed over t w i c e as many s e t s as the mean number o f h i s c o l l e a g u e , who t r e a t e d both "A" and "C." The former a l s o p l a c e d c o n s i d e r a b l y more emphasis on somatic e x p e r i e n c e s than t h e l a t t e r , by more f r e q u e n t l y a s k i n g h i s c l i e n t t o "scan h e r body." Iti sdifficult t o say how these d i f f e r e n c e s might have a f f e c t e d c l i e n t experience, i f a t a l l . Medication Use o f medications was not c o n s i s t e n t a c r o s s a l l c o researchers. A t t h e time o f t h e i n i t i a l EMDR s e s s i o n , "B" was u s i n g a l p r a z o l a m (Xanax; a b e n z o d i a z e p i n e ) ; "C," nortriptyline whatsoever. treatment, (a t r i c y c l i c ) ; and "A" no m e d i c a t i o n Regarding t h e e f f e c t s o f m e d i c a t i o n s on Shapiro w r i t e s t h a t "so f a r , no m e d i c a t i o n s appear t o completely b l o c k EMDR p r o c e s s i n g , a l t h o u g h t h e benzodiazepines have been r e p o r t e d t o reduce efficacy" treatment (1995, p. 100). I t remains d i f f i c u l t t o speculate c o n f i d e n t l y how d i f f e r e n t i a l medications might have a f f e c t e d c o - r e s e a r c h e r experience i n t h i s study. Summary T h i s study i s t h e f i r s t t o s y s t e m a t i c a l l y investigate the moment-to-moment experiences o f t h r e e c o - r e s e a r c h e r s r e c e i v i n g t h e i r f i r s t s e s s i o n o f EMDR. Using a v a r i a t i o n o f both I n t e r p e r s o n a l P r o c e s s R e c a l l (IPR; E l l i o t , 1994) and C o l a i z z i ' s (1978) phenomenological r e s e a r c h methodology, f i n d i n g s confirmed many d e s c r i p t i o n s 104 of experience o f f e r e d by Shapiro (1995); w i t h n o t h i n g of a d i s c o n f i r m i n g nature being d i s c o v e r e d . Three d i s t i n c t p a t t e r n s of c o - r e s e a r c h e r were determined, experience with one c o - r e s e a r c h e r a t t a i n i n g f u l l i n - s e s s i o n r e s o l u t i o n of her b a s e l i n e measures. Three broad c a t e g o r i e s of experience were a l s o identified ( P a r t i c i p a n t Experiences, S p e c t a t o r Experiences and Treatment S p e c i f i c E f f e c t s ) each of which were found t o c o n s i s t of f o u r dimensions, or components, of e x p e r i e n c e . Movement from the P a r t i c i p a n t t o S p e c t a t o r realm was t o be c o n s i s t e n t with working through and of t r a u m a - r e l a t e d memories. found contextualization 105 References A c i e r n o , R., Meuser, K. T. Hersen, M., (1994). Van H a s s e l t , Tremont, G., Review of the v a l i d a t i o n d i s s e m i n a t i o n o f eye-movement d e s e n s i t i z a t i o n reprocessing: A scientific & and and and e t h i c a l dilemma. 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(1989a). d e s e n s i t i z a t i o n procedure memories. Freeman. E f f i c a c y o f t h e eye movement i n t h e treatment J o u r n a l of Traumatic Shapiro, F. (1989b). new treatment On d e p r e s s i o n , of traumatic S t r e s s . 2. 199-223. Eye movement d e s e n s i t i z a t i o n : f o r post-traumatic s t r e s s d i s o r d e r . A Journal of Behavior And Experimental P s y c h i a t r y . 20. 211-217. Shapiro, F. (1994, S p r i n g ) . S t r a y thoughts. Network Newsletter. 1, 1-4. Shapiro, R. (1995). reprocessing: New York: The EMDR Eye movement d e s e n s i t i z a t i o n and B a s i c p r i n c i p l e s , p r o t o c o l s , and procedures. The G u i l f o r d Press. 113 Smith, W. H. (1989). stress disorder: Antecedents of p o s t t r a u m a t i c Wasn't being raped enough? American J o u r n a l o f P s y c h i a t r y . 142(6). 129-133. Spector, J . , & Huthwaite, M. (1993). 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J o u r n a l o f C o n s u l t i n g and C l i n i c a l Psychology. 50(3) , 407414. 116 APPENDIX A 117 Dear C l i e n t : I am a Master's student i n C o u n s e l l i n g Psychology a t UBC, i n v i t i n g you t o p a r t i c i p a t e i n a r e s e a r c h study I am conducting, f o r my t h e s i s , i n t o Eye Movement D e s e n s i t i z a t i o n And Reprocessing (EMDR), a procedure you are about t o experience. I am g a t h e r i n g i n f o r m a t i o n about the e x p e r i e n c e s i n d i v i d u a l s have d u r i n g t h e i r f i r s t s e s s i o n o f EMDR. Such i n f o r m a t i o n w i l l be u s e f u l t o f u t u r e c l i e n t s , by g i v i n g them a sense o f what they might expect d u r i n g t h e i r own EMDR treatment. Should you p a r t i c i p a t e , Dr. Wilensky w i l l tape r e c o r d your i n i t i a l 90 minute s e s s i o n . Then, a t your convenience ( p r e f e r a b l y w i t h i n 48 hours), I w i l l arrange t o i n t e r v i e w you about your experiences u s i n g the tape r e c o r d i n g t o h e l p you remember. A f i n a l i n t e r v i e w w i l l be arranged a t a l a t e r date, d u r i n g which I w i l l show you what I have w r i t t e n , and ask f o r your feedback as t o i t s accuracy and completeness. The t o t a l time r e q u i r e d o f you (not i n c l u d i n g your i n i t i a l s e s s i o n w i t h Dr. Wilensky) w i l l be between t h r e e and f o u r hours. Your i d e n t i t y w i l l remain c o n f i d e n t i a l d u r i n g and a f t e r t h e study, w i t h your name being omitted and r e p l a c e d by a n u m e r i c a l code. A l l tapes w i l l be erased immediately a f t e r t h e p r o j e c t i s completed. P l e a s e note t h a t you may r e f u s e t o p a r t i c i p a t e i n t h i s study, and may withdraw a t any time, without, i n any way, a f f e c t i n g your t h e r a p e u t i c r e l a t i o n s h i p w i t h Dr. Wilensky. Should you have any q u e s t i o n s r e g a r d i n g the p r o j e c t , p l e a s e c o n t a c t me a t the telephone number below. Research T i t l e : S i x P a r t i c i p a n t s ' Experiences o f T h e i r F i r s t S e s s i o n o f Eye Movement D e s e n s i t i z a t i o n and Reprocessing. B r e t t Peterson 731-3457 F a c u l t y S u p e r v i s o r : L a r r y Cochran, Ph.D. 822-6139 I consent t o p a r t i c i p a t e i n t h i s study, and acknowledge r e c e i p t o f a copy o f t h i s form. NAME: ADDRESS: PHONE NUMBER: SIGNATURE: DATE:
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Three co-researchers’ experiences during their first session of eye movement desensitization and reprocessing Peterson, Brett 1996
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Title | Three co-researchers’ experiences during their first session of eye movement desensitization and reprocessing |
Creator |
Peterson, Brett |
Date Issued | 1996 |
Description | Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 1989a, 1989b, 1995) is a relatively new procedure used primarily for treating posttraumatic stress disorder (PTSD). This study is the first to systematically investigate the moment-to moment experiences of PTSD victims during their first treatment session. Using variations of Interpersonal Process Recall (Elliot, 1994), and Colaizzi's (1978) phenomenological research methodology, findings confirmed many of Shapiro's (1995) descriptions of experience, with nothing of a disconfirming nature being discovered. Three distinct patterns of co-researcher experience were identified, with one co-researcher reaching full in-session resolution of her baseline measures. Further, three broad categories of experience were discovered (Participant Experiences and Spectator Experiences [Cochran, 1990]; and Treatment Specific Effects); each of which was further found to consist of four dimensions, or components, of experience. Movement from the Participant to Spectator realm was consonant with co-researchers' working through, contextualizing and making meaning of trauma-related memories. |
Extent | 4602954 bytes |
Genre |
Thesis/Dissertation |
Type |
Text |
File Format | application/pdf |
Language | eng |
Date Available | 2009-02-17 |
Provider | Vancouver : University of British Columbia Library |
Rights | For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use. |
DOI | 10.14288/1.0054094 |
URI | http://hdl.handle.net/2429/4643 |
Degree |
Master of Arts - MA |
Program |
Counselling Psychology |
Affiliation |
Education, Faculty of Educational and Counselling Psychology, and Special Education (ECPS), Department of |
Degree Grantor | University of British Columbia |
Graduation Date | 1996-05 |
Campus |
UBCV |
Scholarly Level | Graduate |
Aggregated Source Repository | DSpace |
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