THREE CO-RESEARCHERS' EXPERIENCES DURING THEIR FIRST SESSION OF EYE MOVEMENT DESENSITIZATION AND REPROCESSING by BRETT PETERSON B.A., The University of 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 thesis^as cpRforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA March 1996 © Brett Peterson In presenting this thesis in partial fulfilment of the requirements for an advanced degree, at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada Date f W IS l(o DE-6 (2/88) 1 1 ABSTRACT Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 1989a, 1989b, 1995) i s a r e l a t i v e l y new procedure used p r i m a r i l y for treating posttraumatic stress disorder (PTSD). This study i s the f i r s t to systematically investigate the moment-to moment experiences of PTSD victims during t h e i r f i r s t treatment session. Using variations of Interpersonal Process R e c a l l ( E l l i o t , 1994), and C o l a i z z i ' s (1978) phenomenological research methodology, findings confirmed many of Shapiro's (1995) descriptions of experience, with nothing of a disconfirming nature being discovered. Three d i s t i n c t patterns of co-researcher experience were i d e n t i f i e d , with one co-researcher reaching f u l l in-session r e s o l u t i o n of her baseline measures. Further, three broad categories of experience were discovered (Participant Experiences and Spectator Experiences [Cochran, 1990]; and Treatment S p e c i f i c E f f e c t s ) ; each of which was further found to consist of four dimensions, or components, of experience. Movement from the P a r t i c i p a n t to Spectator realm was consonant with co-researchers' working through, contextualizing and making meaning of trauma-related memories. I l l TABLE OF CONTENTS ABSTRACT . i i ACKNOWLEDGEMENTS v i i CHAPTER ONE: INTRODUCTION TO THE RESEARCH PROBLEM . .1 Purpose of the Study 4 CHAPTER TWO: LITERATURE REVIEW.. 5 The E f f e c t s of Trauma 5 Shattered Assumptions 5 Intrusion, Hyperarousal and Con s t r i c t i o n . . . . . . . . . 11 Intrusion. 11 Hyperarousal 14 Constriction 16 Current Treatments for Post Traumatic Stress Disorder.18 Imaginal Flooding 19 Cr i t i c i s m of Imaginal Flooding 20 Hypnosis 22 Cr i t i c i s m of Hypnosis 24 Systematic Desensitization 25 Cr i t i c i s m of Systematic Desensitization 25 Eye Movement Desensitization and Reprocessing 26 The O r i g i n a l Protocol 26 The Revised Protocol 28 Healing Mechanisms. 30 Previous Research into EMDR 32 Controlled Studies 33 Case Studies 37 C r i t i c i s m of EMDR Research 40 i v E t h i c a l Considerations. 41 Descriptive Accounts of EMDR 42 Single Memory Processing E f f e c t s 43 Multimemory Associative Processing Effects..45 CHAPTER THREE: METHOD. 48 Rational 48 Phenomenological Research 48 Interpersonal Process Recall 49 Overview of the Research Method 50 Selection of Co-Researchers 51 Selection C r i t e r i a 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 Analysis of the Data .55 CHAPTER FOUR: RESULTS 57 Categories of Experience.... 57 Participant Experiences. 57 Spectator Experiences 58 Treatment S p e c i f i c Effects 60 Dimensions of Cp-Researcher Experience 61 Participant Experiences 61 Passive Endurance of Trauma 61 Narrowness of Perspective 62 Immediacy of Focal Image 62 Intensity of Emotion 63 V Spectator Experiences. 63 Active A l t e r a t i o n of Experience 63 Broadening of Perspective 64 Distancing of the Focal Image 65 Variety of Emotional Experience ....65 Treatment S p e c i f i c Effects 66 Momentary Cognitive Impairment 66 Heightened Physical Sensations 66 Change i n Energy Level. 67 Meta Awareness of the Process 67 Co-Researchers' Experiences 68 Co-Researcher "A" 68 EMDR Expediences of Co-Researcher "A" 69 Sequential Experiences by Category 72 Summary of Experiences by Category 73 Co-Researcher " B" 75 EMDR Experiences of Co-Researcher "B" 76 Sequential Experiences by Category ....77 Summary of Experiences by Category 81 Co-Researcher "C" . 83 EMDR Experiences of Co-Researcher "C" 84 Sequential Experiences by Category 86 Summary of Experiences by Category 90 CHAPTER FIVE: DISCUSSION 92 Review. 92 Implications for Theory 94 Implications for Counselling 98 v i Implications for Research. 99 Limitations of the Study 100 Number of Subjects 100 Limitations of Verbal Communication 101 Researcher Bias and Influence 102 Therapist Style 102 Medication 103 Summary .103 REFERENCES 105 APPENDIX A: Consent Form 116 v i i ACKNOWLEDGEMENTS F i r s t , I would l i k e to express my deep appreciation to the three co-researchers who participated i n t h i s study. Their courage i s both moving and admirable; and without them, t h i s research would not have been possible. To Dr. Gary Ladd, for lending h i s time and expertise; to Dr. Du-Fay Der, for coming on board at the l a s t minute; to Dr. Marshall Wilensky, for p a r t i c i p a t i n g and imparting a small portion of hi s EMDR knowledge over several lunch hours; and f i n a l l y , to Dr. Larry Cochran, for his c l a r i t y , wisdom and pers i s t e n t encouragement to aim higher, I o f f e r my sincerest, h e a r t - f e l t appreciation. To my father, past and present; for h i s gracious, unending support and love. 1 CHAPTER ONE: INTRODUCTION TO THE RESEARCH PROBLEM That we should die i s inconceivable. That we should suddenly, without warning, be forced to touch the dark face of a n n i h i l a t i o n and remember, int o l e r a b l e . For i n such a case, to survive death i s not to escape i t , but to awaken an ineluctable shadow. I begin t h i s introduction to trauma and i t s treatments with a reference to death, as any encounter—even v i c a r i o u s --with a profoundly traumatic event, forces one to encounter one's own annihilation, frequently with severe psychological repercussions. Whether the traumatic event i s rape, war, natural disaster, or simply a witnessing thereof, as Janoff-Bulman writes a l l "traumatic events involve perhaps the most basic of threats, that to our very s u r v i v a l " (1992, p. 56). According to the Comprehensive Textbook of Psychiatry (Andreasen, 1985) the commonalty between a l l psychological trauma i s an experience of "intense fear, helplessness, loss of control, and threat of a n n i h i l a t i o n " (p. 921). The word "trauma" was o r i g i n a l l y derived from Greek verbs meaning "to pierce," or "wear out," and was used to denote a "wound," or "object damage" (Wernik, 1969). Freud (1888) extended t h i s meaning to include psychological 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 hysteria, melancholy and obsessive-compulsive disorder" (Benyakar et a l . , 1989, p. 432). He believed trauma to be a 2 consequence of an extensive breach being made i n the psychological "protective s h i e l d " against s t i m u l i (Freud, 1920) . This "breach" i s the r e s u l t of a sudden psychological assault on the s e l f too great to incorporate or withstand (Freud, 1920; Benyakar et a l . , 1989) and r e s u l t s i n the symptoms of posttraumatic stress disorder (PTSD; APA, 1994) and the concomitant "shattered assumptions" (Janoff-Bulman, 1992) and loss of meaning (Frankl, 1963). Just as i n the Greek myth of Persephone, i n which the protagonist, abducted from a state of r e l a t i v e naivete and raped i n the Underworld, henceforth must return repeatedly to the dark s i t e of her trauma, so too, many victims of trauma are "forced" by t h e i r intrusive symptoms to experience a frequent, unpredictable descent into t h e i r own private "underworld." The symptoms of PTSD (recurrent nightmares; flashbacks anxiety; hyper-arousal; avoidance of reminders of the o r i g i n a l trauma; APA, 1994) are notoriously d i f f i c u l t to t r e a t (Kleinknecht & Morgan, 1992; Spector & Huthwaite, 1993) ; with t r a d i t i o n a l trauma treatments such as flooding, (Stampfl and Levis, 1967); systematic d e s e n s i t i z a t i o n , (Wolpe, 1959, 1990); hypnosis, (Janet, 1919; Spiegal Hunt & Dondershine, 1988; Stutman & B l i s s , 1985); group therapy, (Yalom & Yalom, 1990); and pharmacotherapy, (Bleich et a l . 1986; Epstein, 1989;) being generally regarded as only p a r t i a l l y e f f e c t i v e (Janoff-Bulman, 1992; Shapiro, 1995). 3 Hence, with the advent of Eye Movement Desensitization and Reprocessing (Shapiro, 1989a; 1989b; 1995), comes new hope fo r victims of PTSD. Proponents have claimed that the normally treatment resis t a n t symptoms from a single-event trauma can be eradicated i n one to three sessions of EMDR (Shapiro, 1989a; 1989b; 1995). Further, some have declared i t e f f e c t i v e i n the treatment of a vari e t y of other diagnoses as well (Shapiro, 1995; Marquis, 1991). Since i t s inception i n 1989, research into EMDR has escalated to the point where "there are at present more p o s i t i v e controlled studies on EMDR than on any other method used i n the treatment of psychological trauma" (Shapiro, 1995, p. x). Yet no in-depth descriptive study focusing on the phenomenology of 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 provide relevant information to researchers, therapists and future c l i e n t s , and help elucidate the "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 not the intent of the author of t h i s study to affi r m or deny the claims of EMDR treatment e f f i c a c y ; such an undertaking would require a controlled experiment beyond the scope of a Master's thesis. Rather, as some of the extant EMDR l i t e r a t u r e claims use of the technique often leads to profound experiences of insight; memory r e t r i e v a l ; the emergence of a f f e c t i v e l y or semantically r e l a t e d 4 associations; and dramatic and swift a l l e v i a t i o n of symptoms (Kleinknecht & Morgan, 1992; McCann, 1992; Shapiro, 1989a, 1995), i t was hoped a close-up investigation of subjects' f i r s t session experiences of EMDR would help shed l i g h t on these phenomena (should they occur), and on what, exactly, occurs for subjects during t h e i r EMDR experience(s). 5 CHAPTER TWO: LITERATURE REVIEW The Effects of Trauma Shattered Assumptions When i t occurs to a man that Nature does not regard him as important, and that she f e e l s she would not maim the universe by disposing of him, he at f i r s t wishes to throw bricks at the temple, and he hates deeply the fact that there are no bricks and no temples. —Stephen Crane, "The Open Boat" E v i l has come though I expected good; I looked for l i g h t but there came darkness. . . . When I stop to think, I am f i l l e d with horror, and my whole body i s convulsed. — J o b In Stephen Crane's short story, "The Open Boat" (1960), a ship has sunk i n the open sea, leaving only four survivors i n a t i n y dinghy. Exhausted and t e r r i f i e d , they are tossed mercilessly by an endless procession of "snarling" waves, which threaten, with each thrust, to capsize and devour them, while a shark—equally hungry for t h e i r d e a t h — c i r c l e s repeatedly. Their sudden r e a l i z a t i o n of the randomness and meaninglessness of t h e i r s i t u a t i o n , and Nature's profound indifference to i t , i s intolerable. That there should be no 6 God, no benevolent Creator to save them at such a moment, or at l e a s t provide some meaning to t h e i r p l i g h t , i s overwhelming, and, i n t h e i r eyes, inexcusable. They, i n f r u s t r a t i o n and anger, want to complain and appeal t h e i r case to a higher authority; and, barring a favorable r u l i n g , "throw bricks" at the Temple of J u s t i c e ; but are even more distraught and demoralized upon r e a l i z i n g that "there are no bricks and no temples." So, attempting to restore order, and assuage t h e i r anxiety, they personify and blame Fate; as i f , by threatening or pleading with her, they might regain some control over t h e i r l i v e s , and s t i l l a f f e c t the outcome of t h e i r drama. In various ways they are t r y i n g to f i n d order and meaning i n , and make sense of, that which i s inherently random, bizarre and meaningless. S i m i l a r l y , the Bible's Job, renown as a "blameless and upright" man, "the greatest man i n a l l the East," cannot, despite the 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 why the God he loves and respects, and before whom he has behaved most piously, has v i s i t e d upon him the slaughter of h i s children, the loss of h i s livestock and shepherds, and smote him with "running sores from head to foot." He could well be i n the same boat with Crane's characters. For a l l are i n the process of experiencing one of the most profound effects of trauma: A shattering of one's basic assumptions about the s e l f and world. 7 According to Janoff-Bulman (1992), such i n d i v i d u a l s , i n the presence or aftermath of trauma, may s u f f e r the "shattering" or loss of three basic assumptions: 1. The world i s benevolent and good; and those who inhabit i t , " b a s i c a l l y kind, hel p f u l and caring" (p. 6). Events a f f e c t i n g us w i l l turn out well. Though we understand the p r i n c i p a l of bad things occurring i n the world, we expect they w i l l not happen to us. 2. The world i s meaningful. We can assure our ample rec e i p t of good things by our just behaviour: Bad happens only to those who behave badly. One gets what one deserves. Our fundamental assumption about meaning involves not simply b e l i e f s about why events happen i n our world, but, more s p e c i f i c a l l y , why these events happen to p a r t i c u l a r people. We seek to understand the " d i s t r i b u t i o n " of good and bad outcomes, and i n the service of meaning we recognize or impose seemingly natural contingencies between people and t h e i r outcomes (p. 8). We are deeply disturbed by the p o s s i b i l i t y that negative events could occur randomly to us (Lerner, 1970). We prefer to believe that she who was raped was deserving or wonton; he who i s i l l did not take care of himself; she who 8 was i n an automobile accident should have been more aware; and that i f we take the necessary precautions, we w i l l be safe 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 our death (a concept i n which we never r e a l l y believe; Becker, 1974) . 3. Self-Worth. The t h i r d of the basic pre-trauma assumptions i s that we are inherently good, moral and capable. Therefore, we believe, we are worthy of the rewards which we believe w i l l come to us. Our reasoning i s c i r c u l a r : We get rewarded and l i v e prosperously because we are good; and we must be good because our prosperity proves i t . In sum, the assumptions are as follows: My world i s benevolent. Even i n such a good world negative events happen, even i f r e l a t i v e l y infrequently. Yet when they occur they are not random, but rather are meaningfully d i s t r i b u t e d . They happen to people who deserve them, either because of who they are or what they did or f a i l e d to do. I am a good, competent, careful person. Bad things couldn't happen to me (p. 19). When such core assumptions, developed during infancy and childhood (Ainsworth, 1979; Bowlby, 1969; Marris, 1982) are "shattered" by the "shock" of trauma, the v i c t i m i s l e f t 9 f e e l i n g , among other things, vulnerable, helpless and confused (Janoff-Bulman, 1992; Herman, 1992); and through various defensive means, sets about to reconstruct the s e l f amid the r u b b l e — t o make sense out of the senseless; meaning out of the meaningless. V i c t o r Frankl (1963), who suffered greatly while a prisoner of war at Auschwitz, emphasized the importance of fin d i n g or creating meaning i n the face of trauma. According to Frankl, one can withstand almost any degree of suf f e r i n g i f meaning can be ascribed to i t , and he writes that "su f f e r i n g ceases to be suffering i n some way at the moment i t finds a meaning. . . " (p. 179). So important i s i t to us as human beings to ascribe meaning to events (put them i n emotional and i n t e l l e c t u a l perspective) that, as Benyakar, Kutz, Dasberg and Stern (1989) write, " c e r t a i n people w i l l choose to give up t h e i r l i v e s rather 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" (p. 438). However, as Spiegel (1988) writes, the very essence of trauma i s that " 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 or absence of meaning "sets victims on a search for some framework i n which to give the otherwise meaningless experience some sense of importance i n t h e i r l i f e " (p. 21), a task which can prove profoundly d i f f i c u l t . I f i t i s true, as interpersonal and object r e l a t i o n s t h e o r i s t s claim, that "we are our others" 10 (Cashdan, 1988, p. 4 7 ) — t h a t i s , who we believe ourselves to be i s the r e s u l t of our having incorporated and "metabolized" r e l a t i o n a l experiences and values, then i t follows that an encounter with, and incorporation of, the malicious "other" would lead to a profound d i s o r i e n t a t i o n of s e l f . Hence a shattering of our assumptive world i s mirrored by a sense of shattering, or fragmentation of the s e l f . This notion of a fractured or divided s e l f i s not new to psychology. From at least as f a r back as Freud and Janet, the predominant metaphors used to describe psychopathology and i t ' s symptoms are those of fragmentation. Terms such as "repression," "denial," "compartmentalization, 1 1 " s p l i t t i n g , " " d i s s o c i a t i o n , " "disintegration, "schizophrenic," "schizoid," "multiple personality," a l l imply associations between health and wholeness, i l l n e s s and fragmentation. Further, the goal of many forms of psychotherapy has t r a d i t i o n a l l y been conceptualized as the re-integration of that which has become disintegrated. That we equate health with wholeness, and a lack thereof with fragmentation, i s r e f l e c t e d i n our language. According to Metzner (1986), the English words "whole" and "wholesome,11 as well as " h o l i s t i c " and "holy," have t h e i r o r i g i n s i n Old English hal. which meant "healthy," "sound" as well as "complete." He writes that "wholeness, i n the sense of integration, overlaps considerably with the concept 11 of health" (p. 89). Further, our modern "crazy" comes from Middle English crasen, meaning "to break": "Insanity and psychosis, therefore, are related i n common language and thought to the notion of psychic fragmentation" (p. 91). Hence, when one i s "crazy", (suffering mental distress) one i s "broken" or fragmented; and conversely, when one i s healthy—emotionally and s p i r i t u a l l y — o n e i s whole, or as the modern vernacular might put i t , "together." Intrusion. Hyperarousal and Constriction The shattering or fragmentation of s e l f and one's assumptive world have three concomitant mental and physical manifestations recognized by The Diagnostic and S t a t i s t i c a l Manual of Mental Disorders, Fourth E d i t i o n (DSM IV; APA, 1994), which have become the defining c r i t e r i a f o r the diagnosis of PTSD: Intrusion, hyperarousal and c o n s t r i c t i o n . Intrusion. Unfortunately for those s u f f e r i n g from PTSD, the traumatic cognitive and a f f e c t i v e information which the victim r e f l e x i v e l y attempts to expel from awareness, does not remain i n e x i l e . Those meeting a DSM IV diagnosis of PTSD experience one or more of the following: (a) "recurrent and int 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, including images, thoughts, or perceptions"; (b) "recurrent d i s t r e s s i n g dreams of the event"; (c) a re-experiencing of the trauma, as i f i t were occurring i n the moment (flashbacks); or (d) "intense psychological d i s t r e s s at exposure to . . . cues"—be 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 aspect of the traumatic event" (APA, 1994, p. 209). Intrusive, traumatic memories are unlike our normal "narrative" memories—those which can be put into a story, and understood within a s p e c i f i c context. Rather, they are often encoded i n the form of v i v i d sensations and mental images, which possess a "frozen and wordless q u a l i t y " (Herman, 1992, p. 37; Janet, 1919); and often break spontaneously into consciousness, "both as flashbacks during waking states and as traumatic nightmares during sleep" (p. 37) . According to van der Kolk (1988), i n states of high sympathetic nervous system arousal experienced during trauma, the normal l i n g u i s t i c encoding of memory may become inactivated and replaced by sensory and i c o n i c forms of memory (similar to those found i n children) which then intrude into waking and dreaming states. Dreams re l a t e d to trauma often include exact r e p l i c a t i o n s of the o r i g i n a l traumatic event, and can occur outside of rapid eye movement (REM) sleep (Herman, 1992; Ross, B a l l & S u l l i v a n , 1989). The intr u s i v e re-experiencing of traumatic memories Freud (1958) termed a "re p e t i t i o n compulsion," which he conceptualized as an attempt to master that which was experienced as overwhelming and overpowering. S i m i l a r l y , Janet (1919) believed that because the trauma v i c t i m experienced a protracted sense of trauma-induced 13 helplessness, a sense of what we would now c a l l s e l f -e f f i c a c y i s seen as the antidote (Seligman, 1975). One former Vietnam veteran described h i s i n t r u s i v e experience t h i s way: At least twice a week for . . . years I had sustained the same recurring nightmares . . . [of being] back there facing the same dangers, witnessing the same incalculable suffering, waking suddenly a l e r t , sweating, scared. [At a meditation retreat] the nightmares did not occur during sleep, they f i l l e d the mind's eye during the day . . . . H o r r i f i c wartime flashbacks were superimposed over a quiet redwood grove at the retreat center. Sleepy students i n the dormitory became body parts strewn about a makeshift morgue on the DMZ (Kornfield, 1993). Horowitz (1976), believes that the r e p e t i t i v e , i n t r u s i v e thoughts and memories which haunt the trauma vi c t i m are an attempt by the mind to resolve the discrepancies between the new trauma-related information and incompatible e x i s t i n g schemata. The i n t r u s i v e r e -experiencing could be viewed as a biproduct of "active memory's" attempt to integrate troubling information which i s outside the realm of previously held b e l i e f s or schemata; that i s , to reconstruct "shattered assumptions." Completion ( i . e . , an abatement of intrusive symptoms) occurs when the 14 new disturbing information has been integrated into, or made compatible with, ex i s t i n g schemata; or conversely, when old schemata have been adjusted to allow for the integration of the new information. This l a t t e r idea i s s i m i l a r to Kuhn's (1962), notion of a paradigm s h i f t i n science, or Piaget'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 shattering of assumptions and s e l f , and the intrusion of disturbing memories, the p h y s i o l o g i c a l aspects are manifested by hyperarousal. And two or more of the following w i l l be experienced by the PTSD victim: (a) d i f f i c u l t y f a l l i n g or staying asleep; b) i r r i t a b i l i t y or outbursts of anger; (c) d i f f i c u l t y concentrating; (d) hypervigilance; (e) exaggerated s t a r t l e response (APA, 1994). As a r e s u l t of h i s work with World War II s o l d i e r s , Abram Kardiner (1947) coined the term phvsioneurosis to describe the continuously high lev e l s of autonomic nervous system stimulation he witnessed. I t appeared to him that these symptoms were indi c a t i v e of the body's almost chronic preparedness for what may be termed " f i g h t or f l i g h t . " S i m i l a r l y , Grinker and Spiegal (1945) observed that traumatized s o l d i e r s suffered from what seemed l i k e a "chronic stimulation of the sympathetic nervous system" (p. 219). More recently, researchers have been able to confirm extensive and enduring psychophysiological changes r e s u l t i n g from trauma. 15 According to van der Kolk (1987) due to prolonged or repeated exposure to traumata, the body's use of catecholamines (the neurotransmitters norepinephrine, epinephrine and dopamine) may exceed production, and a depletion may occur, leading to a neuronal h y p e r s e n s i t i v i t y to l a t e r stimulation by these same neurotransmitters. The r e s u l t i s that subsequent to trauma, even minor stressors or stimulation may trigger overarousal of the autonomic nervous system. Janoff-Bulmann writes that there i s now some evidence that a singl e case of overwhelming t e r r o r may be capable of changing brain chemistry such that some survivors are more s e n s i t i v e to adrenaline surges even decades l a t e r (1992, p. 68). Hyperarousal can p e r s i s t during the waking state, a f f e c t i n g concentration, causing hypervigilence, increased s t a r t l e response or angry reactions, etc.; as well as during 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 to f a l l asleep, awaken more frequently (Herman, 1992) and may experience a dysregulation of rapid eye movement REM sleep (Ross, B a l l & Sull i v a n , 1989) . Further, i t now appears that chronic, high l e v e l s of stress can r e s u l t i n st r u c t u r a l changes to the brain, 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 involve "a pe r s i s t e n t avoidance of s t i m u l i associated with the trauma and numbing of general responsiveness" (APA, p. 210). A PTSD vi c t i m w i l l exhibit one or more of the following: (a) an avoidance of thoughts or feelings associated with the trauma; an avoidance of (b) a c t i v i t i e s , places or people that arouse these feelings or thoughts; (c) amnesia f o r c e r t a i n aspects of the trauma; (d) a diminished i n t e r e s t i n p a r t i c i p a t i n g i n s i g n i f i c a n t a c t i v i t i e s ; (e) f e e l i n g s of detachment; (f) r e s t r i c t e d a f f e c t ; or (g) a sense of foreshortened future (p. 209). In the months following a traumatic event, as the i n t r u s i v e and hyperarousal symptoms tend to diminish somewhat, c o n s t r i c t i v e symptoms may begin to predominate (Herman, 1992, p. 48). The v i c t i m may begin to avoid people, places or things which he or she associates with the traumatic event, i n order not to experience p o t e n t i a l l y overwhelming r e l a t e d thoughts and feelings (Janoff-Bulman). In an attempt to gain control over what i s experienced, the v i c t i m may severely l i m i t h i s or her actions, thereby a f f e c t i n g "the e n t i r e f i e l d of purposeful action and i n i t i a t i v e " (Herman, p. 46). Just as a change i n victims' catecholamine production and s e n s i t i v i t y may occur aft e r trauma, leading to heightened anxiety states; so too may a dysregulation of endogenous opioids lead to si m i l a r feelings of anxiety and 17 emotional discomfort (Pitman, van der Kolk, & Orr, 1990). This i n turn may encourage those without the capacity for d i s s o c i a t i o n to self-medicate through the use of drugs or alcohol i n order to co n s t r i c t t h e i r range of negative a f f e c t . However, neither drugs nor conscious avoidance of negative s t i m u l i can ward off the persistent emotional and psychological post-trauma d i s t r e s s . Hence, the v i c t i m may u t i l i z e the "automatic denial process" (Janoff-Bulman, p. 97) of denial, which helps i n "turning o f f awareness of the event or i t s implications . . . [or] . . . shutting down the capacity to f e e l " (p. 97). Denial may serve a healing function i n helping the vi c t i m pace h i s or her recovery, by not allowing the organism to be overloaded with too much negative information at one time (Janoff-Bulman, 1992). However, as noted by Janet (1919) l a t e i n the l a s t century, a trauma victim can i s o l a t e traumatic information more or less completely from conscious awareness, i n what we today describe as fugue states, d i s s o c i a t i v e i d e n t i t y disorder (APA, 1994; previously known as multiple personality disorder, APA, 1987), or amnesia. In such d i s s o c i a t i v e states, although the traumatic information i s s p l i t from conscious awareness, i t does not disappear completely from the organism. Hence, the vi c t i m r e t a i n s a tendency to react to subsequent stressors i n inappropriate ways, as i f the trauma were recurring. Van der Kolk and 18 Kadish (1987) write that PTSD victims may experience "the emotional i n t e n s i t y of o r i g i n a l trauma without conscious awareness of the h i s t o r i c a l reference" (p. 7). These observations bring us f u l l c i r c l e to the notion of the fragmented or divided s e l f ; and lead us to the question of what therapeutic agent the psychotherapist might apply to return the trauma victim to a state of r e l a t i v e wholeness. Current Treatments for the E f f e c t s of Trauma Humpty Dumpty sat on a wall Humpty Dumpty had a great f a l l . A l l the King's horses and a l l the King's men Couldn't put him back together again. — T r a d i t i o n a l Nursery Rhyme As stated i n Ecclesiastes, there i s no new thing under the sun. Centuries b e f o r e the advent of modern psychology, t r a d i t i o n a l healers, known as shamans were attempting to heal the trauma victim through reintegration of fragmented parts of s e l f . They, however, unlike most modern therapists who concern themselves with the "mental" health ( i . e . , mind) of the victim, treated the soul, which they believed had at l e a s t p a r t i a l l y l e f t the victim's body during the traumatic experience (Ingerman, 1991). Healing was accomplished by the Shaman's venturing into the s p i r i t world i n an exercise known as "soul r e t r i e v a l . " To t h i s end, he employed such 19 t o o l s as r a t t l e s , "soul catchers," drums and hallucinogenic drugs (Ingerman, 1991; Achterberg, 1985). Although the tools of the modern "shaman," or psychologist, may seem to us less f a n c i f u l , they are not necessarily any more consistently e f f e c t i v e i n r e l i e v i n g a l l of the symptoms of PTSD than those of the Shaman. That i s , the concurrence of psychological 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 able, i n i t s e l f , or even i n combination with other treatments, to a l l e v i a t e consistently, a l l of the symptoms of PTSD (Herman, 1992; Shapiro, 1995), and put the c l i e n t "together again." The three treatments most frequently referr e d to i n the extant l i t e r a t u r e , and generally regarded as most e f f e c t i v e i n t r e a t i n g trauma are flooding, systematic des e n s i t i z a t i o n , and hypnosis (Herman, 1992; Shapiro, 1995). Imaginal Flooding Imaginal flooding (or implosive t h e r a p y — a v a r i a t i o n incorporating hypothesized cues) i s a technique whose ra t i o n a l e borrows from the seminal work of Pavlov (1927). Just as a dog—conditioned to s a l i v a t e at the sound of a b e l l (a conditioned stimulus [CS]) af t e r that b e l l i s repeatedly followed by food (the unconditioned stimulus [US])—can be taught to no longer do so i n the repeated absence of the US; so too can a trauma v i c t i m learn to respond to mental or tangible cues (the CS) with r e l a t i v e 20 n e u t r a l i t y , i n the repeated absence of r e a l threat (the US). Stampfl and Levis (1967) write the fundamental hypothesis i s that a s u f f i c i e n t condition for the extinction of anxiety i s to r e -present, reinstate, or symbolically reproduce the st i m u l i (cues) to which the anxiety response has been conditioned, i n absence of primary reenforcement (p. 499) . Pitman et a l . write, "The treatment i s no rose garden; i t i s s t r e s s f u l by design" (1991, p. 17). That i s , the 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 to e l i c i t a c l i e n t ' s anxiety, through a mental re-experiencing of a trauma-related event. Because t h i s re-experience occurs i n the absence of r e a l threat, i t i s deemed safe—even necessary—and i s repeated using increasingly anxiety-provoking cues, u n t i l anxiety i s s i g n i f i c a n t l y diminished. i C r i t i c i s m of imaqinal flooding. Pitman et a l . (1991) write that although flooding has been proven e f f i c a c i o u s i n the treatment of phobias and obsessive compulsive disorder, PTSD i s a more complex condition, often accompanied by comorbid mental disorders. Whereas the emotional disturbance i n phobias i s t y p i c a l l y limited to anxiety, PTSD patients often also suf f e r from sadness, anger, g u i l t , and/or shame 21 associated with the trauma . . . . I t i s not c l e a r whether these emotions obey the same law of e x t i n c t i o n as does anxiety, upon which the ra t i o n a l e f o r flooding i s t r a d i t i o n a l l y based (p. 17). They further suggest that i f a c l i e n t ' s emotional d i s t r e s s involves negative posttraumatic appraisals, repeated flooding may i n fact be exacerbating "the fee l i n g s of anger, shame, g u i l t , self-accusation, f e e l i n g s of f a i l u r e , and "What i f ? " (p. 19). They present cases i n which flooding led to worsened depression, relapse of alcohol abuse, and the advent of panic disorder. As one PTSD c l i e n t i s reported to have said i n reference to h i s treatment, "There was a l o t of flooding, but there wasn't much mopping up" (Pitman et a l . , p. 19). A further weakness i s that the e l i c i t a t i o n of extremely high l e v e l s of anxiety must be repeated over several to many sessions (Stampfl and Levis suggest between 1 and 15, 1-hr. sessions, "with t o t a l treatment time r a r e l y exceeding 30 implosive hr." (1967, p. 502). Further, flooding i s of limited therapeutic benefit. Although the most notable amelioration of symptoms occurs within the realm of intrusion symptoms, numbing and s o c i a l avoidance tend to remain unaffected (Lyons and Keane, 1989; Herman, 1992). According to Shapiro, (1989a) lacking are the cognitive elements necessary to complete treatment. 22 Hypnosis Use of hypnosis for the treatment of trauma dates at le a s t as f a r back as Freud (1958), who believed that the catharsis or abreaction induced during such al t e r e d states was s u f f i c i e n t for resolution of d i f f i c u l t i e s . This concept proved too simple (Spiegel, 1987), and he found that such abreaction alone could sometimes lead to the demoralization of the patient (p. 26), due to perceived lack of control over the traumatic material: The c l i e n t s were simply overwhelmed by, and powerless i n the face of, t h e i r emotion. Janet (1919) emphasized the need to help the patient not only re-experience but integrate traumatic information which had become s p l i t off from consciousness. Van der Hart, Brown and van der Kolk (1989) write Janet considered the i n a b i l i t y to integrate traumatic memories as the core issue i n post-traumatic syndromes: Treatment of psychological trauma always entailed an attempt to recover and integrate the memories of the trauma into the t o t a l i t y of people's i d e n t i t i e s (p. 380).. ' To t h i s end Janet pioneered p a r t i c u l a r hypnotic techniques, v a r i a t i o n s of which are s t i l l i n use today (van der Kolk & van der Hart, 1989). Under hypnosis, traumatic memories which the c l i e n t had repressed were retrieved and transformed or replaced by neutral or p o s i t i v e images and 23 f e e l i n g s (a technique anti c i p a t i n g the l a t e r work of Milton Erickson, 1980). The "frozen," i n t r u s i v e images which PTSD victims experience out of context and i n l i e u of "verbal" memory, were transformed into meaningful narratives. Presaging l a t e r flooding techniques, Janet employed a stepwise process of having the c l i e n t incrementally r e -experience and express t h e i r traumatic f e e l i n g s . Hypnotic age regression was also used where deemed appropriate. Since the time of Janet many authors have noted the 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 states occurring during and a f t e r trauma, and the hypnotic state. Bruer (1958) described d i s s o c i a t i o n as a "hypnoidal" state. Spiegel et a l . (1987) describe hypnotizability as "the fundamental capacity to experience d i s s o c i a t i o n i n a structured s e t t i n g " (p. 302). In fact, authors of recent studies (see Spiegal et a l . , 1988) have found a high c o r r e l a t i o n between hy p n o t i z a b i l i t y scores and the diagnosis of PTSD. Noting the d i s s o c i a t i v e nature of many PTSD symptoms, and the d i s s o c i a t i v e nature of hypnosis i t s e l f , Spiegel et a l . speculate that either the experience of trauma may enhance hy p n o t i z a b i l i t y ; or, conversely, highly hypnotizable i n d i v i d u a l s may be more susceptible to the a f t e r e f f e c t s of trauma (p. 304). I t i s further speculated that those in d i v i d u a l s who cannot spontaneously di s s o c i a t e i n the face of trauma, may induce d i s s o c i a t i o n through the use of drugs or alcohol (Spiegal, 1988). 24 An advantage of using hypnosis over other standard techniques i s that, due to the e f f e c t s of state-dependent memory (see Bower, 1981) the isolated, dissociated traumatic memories may 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 state (hypnosis). Although, as Freud found, simple abreaction under hypnosis (without integration) can prove counterproductive, a modulated re-experiencing can help foster i n the c l i e n t a sense of e f f i c a c y and control (Smith, 1989) . This perceived sense of control can arise when the c l i e n t — w i t h the therapist's h e l p — r e a l i z e s he or she has the power to slow down r e c a l l of the event(s), and re-experience only portions of the trauma, "drawing on the heightened capacity f o r physical and emotional control that the hypnotic state can provide" (Smith, p. 130). One hypnotic technique, c a l l e d the " a f f e c t bridge" (Watkins, 1971) i s used to help the c l i e n t r e t r i e v e previous traumatic information which i s si m i l a r i n a f f e c t i v e content to that of which the c l i e n t i s currently aware. In the " s p l i t screen" technique (see Spiegal, 1987) the c l i e n t simultaneously imagines the traumatic events appearing on one screen, while on another, what he or she d i d at the time to cope, thereby aiding the c l i e n t i n gaining a bigger, more integrated picture 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 f a c i l i t a t e s access to, and control over, dissociated states, as Spiegel writes, "There i s nothing that can be done with hypnosis 25 that could not be done without i t " (1987, p. 30). Further, despite the tendency toward increased h y p n o t i z a b i l i t y among PTSD victims, not a l l are hypnotizable. As noted by Janet (1919), some traumatized subjects take weeks or months before they can enter into a hypnotic state (presumably due to a fear of re-experiencing the trauma-related emotions), i f they enter at a l l . Spiegel (1987) notes the danger latent i n hypnotic transference: Patients may have the sense of being reassaulted (by an i n s e n s i t i v e therapist) during the hypnotic procedure. Systematic Desensitization Developed by Joseph Wolpe (see Wolpe, 1959, 1990), systematic desensitization i s based on the assumption that because an anxiety response i s learned or conditioned, " i t can be i n h i b i t e d by substituting an a c t i v i t y that i s antagonistic to the fear response" (Kanfer & Goldstein, 1991, p. 163). Hence, a therapist using t h i s technique exposes the c l i e n t , i n small graduated steps, to the disturbing memory, while having the c l i e n t experience emotions incompatible with anxiety ( i . e . , r e l a x a t i o n and calmness). An associative l i n k i s then formed between relaxation and the previously anxiety provoking memory. In other words, the c l i e n t learns to remain calm i n the face of that which once was disturbing. C r i t i c i s m of systematic desensitization. Although there i s some support for 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), several 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 for several reasons. F i r s t , systematic desensitization requires a h i e r a r c h i c a l ordering of anxiety related material (Wolpe, 1959) which i s inappropriate and often impossible to a t t a i n with PTSD symptoms (Shapiro, 1989a; Spector & Huthwaite, 1992). Second, i t tends to address only in t r u s i v e , and not c o n s t r i c t i v e , symptoms or inappropriate cognitions (Shapiro, 1989a). I t also has been c r i t i c i z e d due to length of treatment required (Shapiro, 1989a); and for subject non-compliance (Lyons & Kean, 1989). Eye Movement Desensitization and Reprocessing The Original Protocol As the reader i s possibly unfamiliar with t h i s r e l a t i v e l y new procedure, a b r i e f description w i l l be given (see Shapiro, 1989a, 1995 for complete d e t a i l s ) . In the o r i g i n a l protocol, treatment begins by having a traumatized c l i e n t focus on the troubling 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 suffering from PTSD from having been i n an automobile accident, he or she would picture the most anxiety provoking image of the accident and would covertly rehearse the concomitant cognitive b e l i e f , i . e . , "I'm going to d i e , " or "I should have done something," etc. Then, he or she rates the l e v e l of anxiety experienced i n doing t h i s , using the Subjective Units of Discomfort Scale (SUDs; Wolpe, 1982), an 11-point L i k e r t scale, with 0 being no anxiety, 27 and 10 representing extreme panic. The c l i e n t then imagines a preferred cognition, such as "I'm safe now," etc., 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 Scale (VOC; Shapiro, 1989a), a seven-point L i k e r t scale. The SUDs and VOC scores serve as baseline measures, against which any changes w i l l be compared. Then, while once again experiencing the disturbing image, f e e l i n g and cognition, the c l i e n t follows the therapist's index finger, which he or she moves horizontally, back and forth, across the c l i e n t ' s l i n e of v i s i o n , from extreme r i g h t to extreme l e f t , at a distance of 12-14 inches from the c l i e n t ' s face. Each back and f o r t h movement of the finger (a saccade) i s repeated 12-24 times (one se t ) . After each set of saccades, the c l i e n t relaxes and blanks out the picture. They then generate the picture and cognition once again and a new SUDs l e v e l i s taken. The procedure i s repeated u n t i l SUDs ratings reach one or zero. According to most published studies, a f t e r one to several sets of saccades, the disturbing image changes or disappears, and the concomitant anxiety also d i s s i p a t e s . Sometimes, before or afte r the f i r s t image i s desensitized, a d i f f e r e n t , but semantically 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 to desensitize i t . The procedure ends when a l l traumatic images have been desensitized. 28 The Revised Protocol As with most therapeutic techniques, the o r i g i n a l EMDR protocol has undergone an evolution which has l e d to al t e r a t i o n s i n the procedure. Most noticeably, i n the current protocol the c l i n i c i a n no longer has the c l i e n t remain focused only on the o r i g i n a l disturbing image throughout treatment, while i n s t i g a t i n g eye movements, but more gently follows the c l i e n t ' s evolving processing. For example, at the end of a set, the 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 hold the new image, f e e l i n g , thought, etc., i n mind through the next set of saccades (p. 37). Shapiro writes No matter how the information subjectively emerges, as long as processing has continued, the c l i e n t should simply be directed for the next set with the global statement "Think of i t . " In other words, the c l i n i c i a n needs to address the targeted memory i n whatever form i t a r i ses (1994, p. 77). Further, the revised EMDR protocol (see Shapiro, 1995, for d e t a i l s ) includes a complete treatment plan c o n s i s t i n g of eight phases: (a) Cli e n t history and treatment planning; (b) preparation; (c) assessment; (d) des e n s i t i z a t i o n (generally eye movements); (e) i n s t a l l a t i o n of p o s i t i v e cognition; (f) body scan; (g) closure; and (h) r e -29 evaluation; and an 11-step standard procedure which includes the following: 1. C l i e n t accesses an image which represents the e n t i r e traumatic event. 2. C l i e n t develops the negative "I am" self-statement, which conveys an underlying l i m i t i n g b e l i e f . 3. C l i e n t creates a desirable p o s i t i v e self-statement which (when possible) incorporates an in t e r n a l locus of co n t r o l . 4. C l i e n t determines the v a l i d i t y of the p o s i t i v e s e l f -statement (the V a l i d i t y of Cognition; VOC), on a scale of l to 7. 5. C l i e n t i d e n t i f i e s the disturbing emotion which l i n k i n g the image and negative cognition produce. 6. C l i e n t uses SUDs to determine the subjective l e v e l of disturbance when the memory of the traumatic event i s stimulated. 7. C l i e n t locates where the concomitant physical sensations i n the body are f e l t . 30 8. C l i e n t processes a l l disturbing information (using c l i n i c i a n - i n s t i g a t e d eye movements, etc.) 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 cognition. 10. C l i e n t mentally scans body for any re s i d u a l physical sensation, while holding event and p o s i t i v e cognition i n mind. 11. C l i n i c i a n ends session, insuring c l i e n t i s r e l a t i v e l y relaxed. Variations on the above standard protocol also e x i s t fo r the treatment of phobias (simple and complex); excessive g r i e f ; and i l l n e s s and somatic disorders (Shapiro, 1995). Shapiro (1995) notes that since 1990 those teaching EMDR have instructed students i n the use of not only eye movements, but hand taps and auditory cues; and that others have made use of flashing l i g h t s as well. She writes, that despite apparent e f f i c a c y , "further investigation may f i n d that eye movements have a unique status as a stimulus that i s also an observable inherent physiological manifestation of some types of cognitive processing" (p. 24). Healing Mechanisms In her seminal a r t i c l e (1989a) Shapiro c i t e s Pavlov's (1927) speculation that "traumatic overload" leads to pathological neural changes which keep the traumatic 31 information i n a "frozen state" (p. 220). Wolpe writes that i f e x c i t a t i o n and i n h i b i t i o n come into c o n f l i c t with each other at a given locus of the cortex, "the neural elements concerned may be unable to bear the s t r a i n and so undergo a pathological change . . . " (Wolpe, 1959). The EMDR technique (repeating eye movements while holding the memory i n awareness) purportedly f a c i l i t a t e s processing of t h i s "frozen" information (p. 220), thereby r e s t o r i n g neurological balance. Several early 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 rapid REM sleep, speculated that EMDR may provide an information processing function s i m i l a r to the putative processing mechanism of REM sleep (Shapiro, 1989a; Ross et a l . 1994). To make sense of EMDR's rapid healing e f f e c t s Shapiro's working hypothesis makes use of an "Accelerated Information Processing" model (Shapiro, 1995, p. 28). According to t h i s model, the information, which has become "frozen" due to traumatic overload, i s i s o l a t e d i n the nervous system i n i t s "distressing, excitatory state-s p e c i f i c form" (p. 30), and intrudes into consciousness i n the form of the intrusive symptoms discussed above. Shapiro (1995) writes In e f f e c t , the information i s frozen i n time, i s o l a t e d i n i t s own neuro network, and stored i n i t s o r i g i n a l l y 32 disturbing 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 receptors are unable to appropriately f a c i l i t a t e transmission between neural structures, the neuro network i n which the old 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 learning can take place because subsequent therapeutic information cannot l i n k a s s o c i a t i v e l y with i t (p. 40) . Hence, one may glean new, contradictory information from years of therapy or new l i f e experiences, but t h i s information may prove i n e f f e c t u a l , as i t i s stored i n i t s own neuro network, separate from the traumatic information. EMDR's eye-movements (or alternative stimuli) " t r i g g e r a phys i o l o g i c a l mechanism that activates the information-processing system" (p. 30), thereby l i n k i n g previously i s o l a t e d disturbing information with currently held adaptive b e l i e f s (p. 31). For now, the healing mechanisms of EMDR, remain speculative. Shapiro writes that "the actual neurological concomitants may not be discovered within t h i s generation" (1994, p. 3). Previous Research into Eye Movement Desensitization and Reprocessing In evaluating research into EMDR, the reader must keep i n mind that there ex i s t several extraneous variables which render evaluation d i f f i c u l t . F i r s t , there are, at present, a number of versions of EMD, or EMDR, currently being used 33 and tested. Those include Shapiro's o r i g i n a l EMD protocol (1989a, 1989b); the EMD o r i g i n a l l y taught by Shapiro i n 1990; the revised protocol taught by Shapiro since 1991 (see Shapiro, 1995); as well as therapists' own creative v a r i a t i o n s of the procedure (Greenwald, 1994). Controlled Studies The seminal study i n EMDR was done by Shapiro (1989a). After serendipitously observing that she could desensitize h e r s e l f to disturbing thoughts and feelings by r a p i d l y moving her eyes from side to side (Herbert & Mueser, 1992), she engaged i n c l i n i c a l experiments with the eye movement procedure on approximately 70 c l i e n t s and volunteers (Shapiro, 1989b). A systematic study was then undertaken involving 22 rape/molestation victims and Vietnam combat veterans, a l l of whom were diagnosed by t h e i r counsellors as having PTSD. Subjects were divided randomly into a treatment group, which received EMDR, and a control group, which received a modified flooding procedure. For e t h i c a l reasons, EMDR was administered to the control group a f t e r having p a r t i c i p a t e d i n the placebo condition. The r e s u l t s were as follows: In the treatment group, the mean SUDs score dropped from 7.45 (pretest) to 0.13 (post-test); and the mean VOC score (representing 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) rose from 3.95 to 6.75. In the placebo group, the mean SUDs ac t u a l l y increased from 6.77 to 8.31, u n t i l subjects received EMDR, after which t h e i r SUDs l e v e l dropped to a 34 n e g l i g i b l e l e v e l within several sets of saccades. Mean VOC scores i n t h i s group dropped from 2.95 to 2.36, and l a t e r increased from 2.36 to 6.77 after EMDR was administered. A l l subjects reported either a decrease or t o t a l elimination of t h e i r primary presenting problem, the e f f e c t s of which were maintained at a three month follow-up. Marquis (1991) undertook a study to " . . . explore the range of problems amenable to eye movement d e s e n s i t i z a t i o n " (p. 187). There were 78 subjects i n h i s study, 16 of whom suffered from PTSD. Some, but not a l l , of the other conditions treated i n the study included eating disorders, agoraphobia with panic disorder, simple phobias, r e l a t i o n s h i p problems, substance abuse, learning d i s a b i l i t i e s , and personality disorders. His r e s u l t s proved s i m i l a r to Shapiro's: Seventy-three subjects were apparently cured or had improved, and only f i v e were unimproved. Four of those suffered from severe self-esteem and s e l f - e f f i c a c y problems. The f i f t h was a woman who had been desensitized to her husband's " f e t i s h i s t i c a c t i v i t y , " and whose aversion to him was quickly re-established. Marquis reports that, "In general, sources of d i s t r e s s that are i n the past and isola t e d were e a s i l y desensitized. Themes that were d i f f u s e l y connected or highly generalized, or that represented mood-dependent states or addictions i n the broadest sense, were less successfully treated" (p. 189). The "ov e r a l l improvement r a t i n g " for PTSD was 2.9; 35 for agoraphobia, 2.8; and for simple phobias, 2.6 on a 0-3 scale. Sanderson and Carpenter (1992) compared EMDR to image confrontation (IC) i n a group of 58 phobic subjects (as compared to subjects suffering from PTSD). EMDR and IC (flooding) were used i n a single-session crossover t r i a l . Each procedure was given for seven sets of 20 seconds. Their r e s u l t s showed that both EMDR and IC s i g n i f i c a n t l y reduced SUDs scores, but that there was no s i g n i f i c a n t difference between the groups. The authors conclude that benefits of EMDR do not come from eye movements, but from exposure to the feared image (flooding/IC). Wilson, Covi, and Foster (1993) treated 18 in d i v i d u a l s s u f f e r i n g from traumatic memories i n a single session. Three groups (n = 6 each) included an EMDR treatment group, a group i n which thumb-taps were substituted f o r eye movements, and another group i n which eye movements were omitted. Besides SUDs and VOC scores, p h y s i o l o g i c a l measures were taken. The treatment group showed large and s i g n i f i c a n t improvements which were maintained at 3, 9 and 12 months. Recently, Boudewyns et a l . (1993) u t i l i z e d both ph y s i o l o g i c a l and standardized assessments f o r twenty Vietnam war veterans treated with either EMDR, imaginal exposure, or milieu therapy. The C l i n i c i a n Administered PTSD Scale (CAPS); the M i s s i s s i p p i Scale; the Impact of Event Scale (IES); therapist ratings of treatment 36 responsiveness; and SUDs were implemented, along with p h y s i o l o g i c a l assessments of heart-rate; electromyographic response (EMG); electrodermal response (EDR); and skin temperature. Interestingly, there was a greater reduction of SUDs l e v e l s f o r the EMDR group than f o r the exposure condition during treatment; yet no differences were found between groups, on SUDs or physiological ratings, during post treatment exposure to subject's i n i t i a l audiotaped des c r i p t i o n of the traumatic memory, nor on standardized post-treatment measures of PTSD. Wilson, Tinker and Becker (1994) undertook research on 80 in d i v i d u a l s who had been traumatized by a va r i e t y of experiences, including combat, rape, as well as physical and mental abuse. The traumatic event(s) had occurred from between three months and 54 years before the study began. Subjects were randomly assigned to one of two groups: One received the EMDR procedure; the other received no treatment of any kind for 30 days, aft e r which time, they too received EMDR. Following treatment, the EMDR group showed immediate, s i g n i f i c a n t improvement as measured by the Impact of Events Scale ( Horowitz, Wilner & Alavarez, 1979), SUDs (Wolpe, 1956), and the Anxiety dimension of the Symptom Check L i s t (SCL-90-R; Derogatis, 1992); whereas the delayed treatment group showed no improvement u n t i l EMDR was administered, at 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 protocol, Vaughn (1993) treated 10 individuals with a dual diagnosis of PTSD and substance abuse during 4 sessions. S i g n i f i c a n t and sustained improvement was found at post-treatment, and 4 month follow-up; yet the arousal subsale on the Hamilton anxiety scale, returned to near pre-treatment l e v e l s by four months. Vaughn (1993) also reported a study i n which he placed 36 PTSD subjects into one of three treatment groups (with members of each of those group either receiving treatment or being placed on a waiting l i s t ) , i n which they received either EMD (Shapiro, 1989a, 1989b), Anxiety Management Training (AMT; a relaxation technique), or Image Habituation Training (IHT; an exposure technique). A l l treatment groups showed greater improvement than w a i t - l i s t e d groups; with the EMD group showing most improvements. This group was followed by the AMT and IHT groups, respectively. F i n a l l y , regarding the sometimes contradictory findings of EMDR e f f i c a c y research, Greenwald, (1996) writes that discrepancies are due to "the substantial information gap between those who have and those who have not undergone the formal, supervised [EMDR] t r a i n i n g " (p. 67); and that "the c r i t i c a l variable appears to be f i d e l i t y to the EMDR protocol" (p. 69). Case Studies Greenwald writes that "as controlled studies begin to be reported, case studies play a diminished r o l e i n the 38 evaluation of EMDR's e f f i c a c y " (1994, p. 21). He goes on to note that while many of the case reports do include . . . standardized measures, behavioral indices, and long-term follow-up, most f a i l to meet the design standards expected of single-subject investigations (p. 21) . Puk (1991) reports treating a 23-year-old woman having disturbing dreams and s o c i a l anxiety as a r e s u l t of being raped, as well as a 33-year-old woman su f f e r i n g from frequent, int r u s i v e images of her dying s i s t e r , f o r whom she had cared during the f i n a l stages of cancer. Presenting symptoms for both women were eliminated a f t e r one session of EMDR, and benefits maintained at 12 months a f t e r treatment. Wolpe and Abrams (1991) also successfully treated a rape victim, a f t e r 15 sessions of t r a d i t i o n a l therapy had f a i l e d to a l l e v i a t e her fear of leaving her home. Lipke and Botkin (1992) used EMDR with f i v e hospitalized Vietnam combat veterans. Of the f i v e , two showed dramatic improvement. A t h i r d did not improve due to therapist error i n using the procedure. A fourth subject had w i l l f u l l y not complied with therapist's instructions; and the f i f t h , who suffered from bizarre thinking and temporal lobe epilepsy, asked to stop the procedure for fear that losing the image would r e s u l t i n harm to his family. Kleinknecht and Morgan (1992) successfully treated a 40-year-old male who had suffered 39 PTSD symptoms for eight years aft e r having been shot and l e f t to die. Similarly, McCann (1992) claimed success with a 41-year-old burn victim who also had displayed PTSD symptoms for eight years. Wernik (1993) reports having successfully treated 21- and 45-year-old males f o r premature ejac u l a t i o n and impotence, respectively. P e l l i c e r (1993) reports having successfully treated a ten-year-old g i r l who had suffered most of her l i f e from recurring nightmares of having snakes crawling i n her bed. She, as most subjects i n the above studies, was successfully treated i n only one session. Cocco and Sharpe (1993) report having used an auditory variant of EMDR with a four year, nine month old boy, "Sam," who had been experiencing nightmares, i n t r u s i v e thoughts and bedwetting, a f t e r having witnessed an armed robbery i n h i s home. The authors report that, af t e r one session, the subject "no longer evidenced any of the symptoms thought to be associated with intrusive thoughts", and that "there was a dramatic reduction i n the behavioural symptoms immediately following the session" (p. 375). Although asymptomatic at three month follow up, the c h i l d had returned to sleeping i n his parents' bed, and was a f r a i d to go to the t o i l e t alone l a t e at night. Kleinknecht (1993) reports t r e a t i n g a 21-year-old woman su f f e r i n g from an in j e c t i o n and blood phobia i n four t h i r t y -minute sessions. Self-report and physi o l o g i c a l measures 40 (blood pressure and heart rate) showed s i g n i f i c a n t improvement, which was maintained at 1, 14 and 24 weeks. Acierno Tremont, Last & Montgomery (1994) write of a 42-year-old female suffering from multiple simple phobias of images related to dead bodies ( i . e . , hearses, funeral homes, etc.) and darkness. EMDR was compared with a technique which was i d e n t i c a l i n a l l aspects, except that i t d i d not implement the normally prescribed eye movements. The two treatment conditions were administered "cumulatively and sequentially i n multiple-baseline design fashion across fear areas" (Acierno et a l . , 1994, p. 295). A t r i p a r t i t e evaluation of (a) motoric assessment (avoidance behaviour), (b) physiological responses and (c) standardized s e l f - r e p o r t measures (see Acierno et a l . , 1994 for d e t a i l s ) showed a s l i g h t EMDR performance advantage regarding avoidance behaviour related to dead bodies, but neither group proved superiour i n any other measures, including SUDs. C r i t i c i s m of EMDR Research Herbert and Mueser caution c l i n i c i a n s against the u n c r i t i c a l acceptance of EMDR, noting that the "research conducted i n t h i s area has serious methodological flaws, precluding d e f i n i t e conclusions regarding the effectiveness of the procedure" (1992, p. 169). Some of these flaws include (a) lack of standardized measurement used i n gathering baseline data and est a b l i s h i n g a PTSD diagnosis (Lohr et a l . , 1992); (b) subjects' 41 concurrently receiving treatment other than EMDR, which brings into question the causal r e l a t i o n s h i p between treatment,and outcome (Page & Crino, 1993); (c) the r a p i s t demand c h a r a c t e r i s t i c s (Page & Crino, 1993; Acierno et a l . , 1993) ; and (d) possible unintentional experimental bias (Acierno et a l . , 1993; Herbert & Mueser, 1992). E t h i c a l Considerations Page and Crino write "[EMDR] stands to challenge many fundamental b e l i e f s held by c l i n i c i a n s about the nature and treatment of PTSD, and may represent yet another technique about whose mechanism we must plead ignorance" (1993, p. 293). They go on to explore the e t h i c a l implications should such a simple and p o t e n t i a l l y rapid treatment prove to be widely e f f e c t i v e : F i r s t l y , what are the implications f o r claims f o r damages following traumatic events? For example, i f the psychological effects of rape can be r a p i d l y removed, w i l l the case for the prosecution be weakened? Secondly, should everyone be treated immediately? . . . F i n a l l y . . . i f [EMDR] were to successfully ameliorate g r i e f , should the di s t r e s s of bereavement be removed? (p. 293). Continuing i n t h i s vein, should a therapist attempt to r e l i e v e a 10-year-old of her recurring nightmares, i f they are a r e f l e c t i o n of a disturbed home l i f e ( P e l l i c e r , 1993)? 42 Descriptive Accounts of EMDR Experiences As mentioned i n the introduction, although several authors (see Greenwald, 1994; Kleinknecht & Morgan, 1992; McCann, 1992, for example) have noted p a r t i c u l a r phenomenological experiences described by t h e i r c l i e n t s during EMDR therapy, there has as yet been no systematic study i n t h i s area. In her book, Eye Movement Desensitization and Reprocessing: Basic P r i n c i p l e s . Protocols and Procedures (1995), Shapiro l i s t s some of the patterns of responses which she and other EMDR therapists have observed thus f a r . She writes, " C l i n i c a l observation indicates that approximately 40% of the time c l i e n t s experience a continual, progressive s h i f t toward a resolution of the target event" (p. 76). Processing i s always assessed i n r e l a t i o n to the target memory or memories. Because during treatment new memories may surface, or the c l i e n t may simply stay with the o r i g i n a l target memory, Shapiro divides such processing e f f e c t s into two categories: Single-memory processing e f f e c t s ; and Multimemory processing e f f e c t s . Single-Memory Processing E f f e c t s In cases where the attention does not s h i f t from the target memory, there may s t i l l be changes i n any of " f i v e d i s t i n c t aspects of the memory: image, sounds, cognition, emotion, or physical sensations" (p. 81). 43 Changes i n the Image The image may fade or s h i f t to a d i f f e r e n t aspect of the target event; and may even change i t s content or appearance (see also Kleinknecht & Morgan, 1992; O'Brian, 1993; Puk, 1991; Spector & Huthwaite, 1993). Shapiro gives the example of a face which the c l i e n t remembers as " l e e r i n g " changing to a "smiling one" (p. 81). She also notes that items such as weapons can "disappear" (p. 81) , and that the "scene" can expand to include more d e t a i l s of things the c l i e n t has forgotten, as the processing of the predominant a f f e c t which occurred at the time of trauma allows the c l i e n t to f i n a l l y see the event i n i t s larger context (p. 81). Hence, the more s e l f - a f f i r m i n g information such as "I did a l l I could," which has remained blocked i n the nervous system since the trauma, can now become integrated. Changes i n Sounds Shapiro writes that sounds may become louder or softer, or may completely disappear from the memory. Remembered dialogue may s h i f t ; and c l i e n t s may begin to spontaneously assert themselves with the remembered persons. Also, dialogue which was completely forgotten may emerge with changing images (p. 83). Changes i n Cognitions Shapiro notes that c l i e n t ' s l e v e l of i n s i g h t w i l l often increase from one set to another, with the c l i e n t ' s cognitions becoming "more adaptive as the information i s 44 processed" (p. 83). "Polar responses"—dramatic s h i f t s from a negative to a po s i t i v e cognition—may occur early on i n treatment (p. 83). For example, Shapiro writes that "a c l i e n t may s t a r t with the cognition "There i s something wrong with me: i n r e l a t i o n to s o c i a l s i t u a t i o n s and a f t e r a single set may s t a r t thinking, "I'm f i n e " (p. 83). Changes i n Emotions According to Shapiro, many c l i e n t s describe a change i n the emotion they are experiencing (see also Klienknecht & Morgan, 1992). That i s , they may begin f e e l i n g sad, and then become angry. Emotions may also diminish, or may become more profound before subsiding. She writes, The c l i e n t w i l l often report a progressive s h i f t toward more e c o l o g i c a l l y v a l i d , or appropriate, emotions. This 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 "layers" of emotion (e.g., from g u i l t to rage to sorrow to acceptance). Once again, each c l i e n t reacts uniquely . . . (p. 84). Further, some c l i e n t s may overtly manifest these emotions i n abreaction, others w i l l show l i t t l e overt display. Changes i n Physical Sensations According to Shapiro, "When a memory i s being processed, most c l i e n t s experience some manifestation of the information on a somatic l e v e l " (p. 84). There may be a release of physical sensations, leading to a decrease i n 45 i n t e n s i t y with each set; or conversely, there may be a temporary increase of somatic experiencing. The physical sensations experienced during the trauma may be r e -experienced i n the same part of the body as i f they were occurring i n present time. P a r t i c u l a r sensations may move through the body, from one location to another (p. 85) . Multimemory Associative Processing Shapiro writes that although memories may emerge during EMDR treatment, "no memory w i l l emerge that i s not i n some way associated with the target" (p. 78). As i n the above section, the following categories are hers (Shapiro, 1995). The Major Participant or Perpetrator The emergent memory may be linked by the common denominator of who the assailant or perpetrator was. For example, i f the target memory i s of an abusive parent molesting the c l i e n t , a related memory of the same father beating him or her may occur (p. 79). The Pronounced Stimuli For t h i s category, Shapiro gives the example of a Vietnam veteran processing the memory of an earthquake, who "may suddenly r e c a l l a combat experience i f the sounds of f a l l i n g objects or loud rumbling dominated both events" (p. 79). The dominant thread here may be the sensory experiences themselves, or the meaning which the v i c t i m ascribes to them (e.g., I am going to d i e ) . 46 The S p e c i f i c Event Here, "emerging memories may be linked to the targeted memory by the nature of the event i t s e l f " (p. 79). Hence, when the target memory i s a rape, memories of other rapes or molestations may occur. The Dominant Physical Sensations Because physical sensations are stored i n the nervous system at the time of each traumatization (p. 79), memories i n which the c l i e n t experienced related sensations may emerge during treatment. For example, Shapiro writes of one c l i e n t who reported having her hands t i e d to a bed while she was beaten with a broomstick by her mother. During processing, the sensations i n her hands brought to mind the memory of her hands being forced on her father's penis, and l a t e r again, of a r a p i s t holding her hands together during the attack (p. 80). The Dominant Emotions Memories may be linked not necessarily by context or sensations per se, but by the emotion(s) f e l t by the v i c t i m at the time of traumatization. Shapiro gives the example of a c l i e n t despairing at the memory of 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 or she was abandoned by a parent and f e l t the same subsequent emotion (p. 80). To r e i t e r a t e , although the above descriptions of c l i e n t experiences are he 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, s t i l l lacking 4 7 i n the l i t e r a t u r e i s any systematic, in-depth phenomenological investigation into i n d i v i d u a l s ' moment-to-moment EMDR experiences. 48 CHAPTER THREE: METHOD Rational In order to document co-researchers' moment-to-moment in-session EMDR experiences, the researcher combined va r i a t i o n s of two established research protocols: the phenomenological research protocol of C o l a i z z i (1978), which attempts to glean meaning from co-researchers' experiences; and Interpersonal Process Recall (IPR; E l l i o t , 1994) , a procedure used to cue co-researchers' memories, and document t h e i r in-session therapy experiences. Phenomenological Research Phenomenological research attempts to ascertain the meaning indivi d u a l s ascribe to t h e i r experiences ( C o l l a i z i , 1978; van Manen, 1992). The researcher investigates d e s c r i p t i v e l y , i n order to gain insight into the way indi 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 , without taxonomizing, c l a s s i f y i n g , or abstracting i t " (van Manen, 1992, p. 9). Subjects are seen by the researcher as partners, or "co-researchers, 1 1 i n the research endeavor, and given respect, t r u s t and empowerment, that they may better t e l l t h e i r story; thereby helping the researcher to glean a truer picture of the experiences being investigated (Mishler, 1988). According to C o l a i z z i , what i s needed i n the inves t i g a t i o n of human experience i s a method which 49 neither denies experience nor denigrates i t or transforms i t into operationally defined behavior; i t must be, i n short, a method that remains with human experience as i t i s experienced, one which t r i e s to sustain contact with experience as i t i s given (1978, p. 53). To a s s i s t i n the endeavor, Interpersonal Process R e c a l l was also used. Interpersonal Process Recall Interpersonal Process Recall (IPR; E l l i o t , 1994) i s an interview procedure i n which the therapist audiotapes the conversation between him- or herself and the subject (or "informant") and plays i t back immediately f o r the informant during a second interview. During what becomes a second interview, the informant i s asked to describe h i s or her moment-to-moment experiences, as remembered, of the f i r s t interview. E l l i o t writes that play back of the o r i g i n a l conversation acts as a cue to a s s i s t the par t i c i p a n t i n r e t r i e v i n g memory traces which would otherwise be l o s t i n the welter of i n t e r f e r i n g information generated during any communication episode (p. 505). 50 Interpersonal Process Recall was chosen to help the researcher gather information about p a r t i c i p a n t s ' "subjective impressions which are missing from even the best t r a n s c r i p t i o n s or recordings of therapy sessions" ( E l l i o t , 1994, p. 505). The researcher deviated from the standard IPR protocol by playing back the in-session tape to the co-researcher, not immediately, but approximately 24 to 48 hours a f t e r the i n i t i a l taping. This was because immediate play back of the therapy session, as prescribed by IPR, would have been inappropriate; for, according to EMDR l i t e r a t u r e (Shapiro, 1995), some subjects experience extreme d i s t r e s s and fatigue during (and sometimes after) treatment. Hence, had the researcher d i r e c t l y followed a 1 1/2 hour EMDR session with a second interview, he would have risked taxing the emotional and physical resources of the co-researchers, which might have ultimately lead to a poorer q u a l i t y interview. As research into memory suggests that cued r e c a l l i s optimal within approximately 48 hours of 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 appropriate. Overview of the Research Method To r e i t e r a t e , researcher and co-researchers i n t h i s study were seen, by the former, as "partners" i n the endeavor; and interviews were conducted i n a context of respect, t r u s t and empowerment of the co-researcher, i n order to best glean t h e i r experiences, and the meaning they make of them. 51 Meaning, as i t i s used here, may be of broad or narrow import (Marris, 1982). I t may denote one's simply making sense of something (a sensation i n the stomach area may mean one i s hungry); or i t may have the broader d e f i n i t i o n of one's ascribing importance to something (as i n , "My wife means a l o t to me"). Both "types" of meaning were of relevance to the present investigation. The f i r s t step of inquiry into co-researchers' EMDR experiences involved the attending psychologist's tape-recording, followed by the researcher's t r a n s c r i b i n g of, the EMDR session. Subsequent to t h i s , the second, or " c l a r i f i c a t i o n interview" occurred, during which the researcher asked co-researchers to elaborate upon t h e i r i n -session EMDR experiences. This interview was also tape recorded. A tr a n s c r i p t i o n was made and compared to the f i r s t , i n order to gain the clearest possible p i c t u r e of each co-researcher's experiences. The researcher performed analysis of the data according to the procedure described on page 55 of t h i s t h e s i s . Selection of Co-Researchers Selection C r i t e r i a In order to q u a l i f y for p a r t i c i p a t i o n i n t h i s study, each co-researcher had to meet several c r i t e r i a , the f i r s t being a DSM IV (APA, 1994) diagnosis of PTSD, as determined by the attending psychologist. The c r i t e r i o n of a single diagnosis was imposed to l i m i t the number of possible confounding variables which a d i f f e r e n t i a l l y diagnosed population might 52 introduce. As EMDR was o r i g i n a l l y developed f o r , and tested on, a PTSD population (Shapiro, 1995), t h i s population was chosen. Second, co-researchers were required to be w i l l i n g to have t h e i r i n i t i a l EMDR session audio-taped by the p a r t i c i p a t i n g psychologist, and to be interviewed by the researcher within 48 hours of i t s occurrence. Third, co-researchers were required to possess s u f f i c i e n t verbal s k i l l s to adequately communicate t h e i r experiences. A l l co-researchers met these c r i t e r i a . Demographic Information A l l co-researchers were female, Caucasian, of the middle cl a s s , and in t h e i r early t h i r t i e s . Two of the three were married, with the t h i r d having been recently separated from her husband. Procedure Each co-researcher, having already entered therapy for PTSD, was informed of the study by her attending psychologist. The consent form (see Appendix A) required f o r p a r t i c i p a t i o n , f u l l y informed each of the nature of the study, and that, should they decide not to p a r t i c i p a t e , neither the therapeutic agenda, nor re l a t i o n s h i p , would be affected i n any way. Because the structure of the standard EMDR protocol (Shapiro, 1995) requires the therapist to follow each set with a question ( i . e . , "what did you get?"; 1995, p. 37); and requires the c l i e n t to answer (describe her experience), 5 3 i t may be said to constitute an interview. Hence, the audiotaped EMDR session i s here termed the "in-session interview." This was followed by the " c l a r i f i c a t i o n interview," during which the researcher interviewed the co-researcher about her moment-to-moment experiences, while playing her a tape recording of the f i r s t session to cue her memory. This second interview was also audio-taped. Each interview was conducted within 48 hours of the i n i t i a l EMDR session, with the exception of the interview with "C," which occurred a f t e r an in t e r v a l of approximately 72 hours, due to l o g i s t i c a l problems. The EMDR In-Session Interview Treatment was conducted exactly as i t would have been under non-research circumstances, except that the en t i r e session was audio-taped by the psychologist, with the awareness and approval of the co-researcher. A microphone was placed between the therapist and c l i e n t , i n order to record both of t h e i r voices; and the c l i e n t was al e r t e d when actual taping began and ended. The C l a r i f i c a t i o n Interview The second interview was conducted to c l a r i f y information gathered from the f i r s t . Following the EMDR session, the p a r t i c i p a t i n g psychologist telephoned the researcher to confirm that a session had taken place, and to provide information about how to contact the co-researcher. The researcher then contacted the co-researcher, and scheduled an appointment V 54 f o r the c l a r i f i c a t i o n interview. Each co-researcher was encouraged to choose a meeting place i n which she would f e e l comfortable, under the condition that i t be private enough to allow f o r undisrupted play-back and discussion of the audio-tape recording. Co-researcher "A" was interviewed at her home; "B," at a l o c a l beach of her choosing; and "C," at the home of the researcher. The researcher began the interview by requesting (a) p a r t i c u l a r demographic information; (b) information about the nature of the trauma experienced; (c) post-trauma symptoms; (d) information about current medications used; (e) post-session condition or experiences; and (f) any comments, of any sort, the co-researcher might l i k e to make about her EMDR experiences. The researcher then presented a t r a n s c r i p t of the EMDR session to the participant, and began play-back of the audio-tape. Both researcher and co-researcher had the opportunity to stop play-back at any time, i n order to ask questions, comment or elaborate upon what was being heard. The researcher asked mostly open-ended questions, such as, "could you t e l l me what was happening here?" or "could you t e l l me more about that?" as well as more s p e c i f i c questions relevant to pa r t i c u l a r co-researcher experiences. Due to r e l a t i v e inexperience, during the f i r s t interview with co-researcher "A," the researcher asked more pointed questions than, i n retrospect, seems desirable. 55 However, as information gleaned from the second interview was used to c l a r i f y the f i r s t , i t did not prove detrimental to the i n t e g r i t y of the study. Analysis of the Data Following the verbatim t r a n s c r i p t i o n of the c l a r i f i c a t i o n interview, transcriptions were analyzed phenomenologically, beginning with a v a r i a t i o n of the research protocol outlined by C o l a i z z i (1978). Each in-session t r a n s c r i p t was read several times i n order f o r the researcher to get a general f e e l i n g f o r each co-researcher's o v e r a l l EMDR experience ( C o l a i z z i , p. 59) . Following t h i s , the in-session t r a n s c r i p t s were c l a r i f i e d through examination of the " c l a r i f i c a t i o n interview" t r a n s c r i p t s . Because, each co-researcher had, by t h i s point, offered two accounts of her EMDR experiences, l i t t l e inference was required by the researcher. Once established, "moments of meaning" were placed on a time l i n e — a straight l i n e divided into even segments in d i c a t i n g movement through time. Therapist involvement was also tracked and placed at the appropriate places on the l i n e . The purpose of t h i s was for the researcher to gain a better sense of the o v e r a l l patterns of experience, both between, and among, the three co-researchers. Categories that were immediately evident, such as physical sensations, emotions, and cognitive experiences were colour-coded, to make them more r e a d i l y discernible to the eye. 5 6 Following t h i s , the laborious process of r e f i n i n g and categorizing the meaning of a l l experiences began. Some elements, as mentioned, seemed to lend themselves r e a d i l y to categorization; others remained uncategorized u n t i l a conceptual framework was discovered within which they could be understood. Descriptions which appeared s u p e r f i c i a l l y redundant were eliminated i n favour of a deeper commonality. For example, many of the physical sensations experienced by the co-researchers involved the common theme of tightening of the musculature; others, loosening. Hence, rather than merely l i s t i n g a l l such experiences taxonomically, those such as "knot i n the stomach," or "tension i n the shoulders" were placed i n one category; and those denoting a loosening or disappearance of such sensations, under another. Eventually, these became part of the dimension of experience e n t i t l e d "heightened physical awareness." In short, progressive attempts were made, through laborious and methodical contemplation, questioning, and t r i a l and error, to achieve a f i t t i n g organization of co-researchers' experience. Once completed, tr a n s c r i p t s were re-read several times i n l i g h t of the above categories, to check for inconsistencies, errors or oversights. 57 CHAPTER FOUR: RESULTS Categories of Experience Using the above methodology, i t was found that co-researchers' experiences could be grouped into one of three broad categories: Participant Experiences. Spectator Experiences or Treatment S p e c i f i c E f f e c t s . Participant and Spectator Experiences Pa r t i c i p a n t Experiences According to Cochran (1990), individuals can experience l i f e ' s dramas from the perspective of either a P a r t i c i p a n t or Spectator (also see Britton, 1970). In the r o l e of a Participant, an i n d i v i d u a l i s a c t i v e l y engaged with the a f f a i r s and events of the world; and focus i s l i m i t e d to the present moment. Cochran (1990) writes [The Participant] decides, plans, acts, and evaluates, a l l from the limited perspective of one who i s taking an active part i n the immediate s i t u a t i o n . . . " (p. 46; my emphasis). For the PTSD victim, the Participant r o l e emphasizes the i n d i v i d u a l ' s involuntary re-experiencing of the immediate s i t u a t i o n of trauma from what i s h i s or her extremely limited perspective; although lacking may be the same degree of i n t e n s i t y experienced during the o r i g i n a l 58 traumatic event (possibly due to the dual focus of past and present; Shapiro, 1995, p. 90). As already stated, some of the cardinal symptoms of PTSD include the intrusive r e l i v i n g of, or preoccupation with, p a r t i c u l a r aspects of the traumatic event (APA, 1994). The victim's nightmares, flashbacks, anxiety and reactions to otherwise neutral objects or events which have become emotional "triggers" for the victim, suggest he or she s t i l l experiences c o n t i n u a l l y — o r at least re-experiences continuously—the "immediate s i t u a t i o n " of her traumatic event. The c o n s t r i c t i v e PTSD symptoms (APA, 1994) are mirrored by the Participant's limited emotional and cognitive movement—her i n a b i l i t y to see from anything but her "l i m i t e d perspective." As an unwilling player i n an unfolding drama, she can gain no insight into the nature or si g n i f i c a n c e of her drama, any more than a novice actor could gain a broad perspective on the h i s t o r i c a l or a r t i s t i c s i g n i f i c a n c e of a play i n which she p a r t i c i p a t e s merely from reading her l i n e s . To acquire such a perspective, some distance i s required. The distance of a Spectator. Spectator Experiences Whereas the Participant i s engaged, or caught-up i n the action of an event, and thereby limited i n breadth of her perspective, the Spectator enjoys a freedom of mental movement not afforded the Participant. The Spectator can "play" and be creative with ideas i n t e g r a l or peripheral to 5 9 the actions of "the player." That i s , she i s able to see h e r s e l f and her actions considerably more o b j e c t i v e l y than she can as a Participant. As a Spectator she i s freer than as a P a r t i c i p a n t to experiment with or manipulate her thoughts and f e e l i n g s . In her mind, she may turn over the o r i g i n a l shape of her experience; toss i t about; reshape i t ; or juxtapose i t to, or j o i n i t with, other "shapes" of experience. The Spectator can "imaginatively re-enact the experience, inter p r e t i n g , adjusting expectation, a l t e r i n g v i s i o n , savoring p o t e n t i a l , and gaining insights" (Cochran, p. 47). Through such manipulations, the Spectator's r e l a t i o n s h i p to the problem or event changes, and so too, her concomitant feelings and reactions. Cochran writes . . . as a participant, one could be t e r r i f i e d , yet as a spectator upon one's experience, . . . f i n d i t to be extremely humorous. We can laugh at our own f o l l y , misery, and hardship, but not o r d i n a r i l y as a p a r t i c i p a n t . S i m i l a r l y , we can be saddened by our own gaiety, exuberance, or venturesomeness, but not o r d i n a r i l y as a participant. We need perspective to do t h i s , and breadth of perspective i s what the spectator r o l e o f f e r s (p. 46). From a narrative point of view, t h i s "breadth of perspective" involves the victim's contextualization of her 60 traumatic memory. No longer a frozen, wordless "prenarrative, 1 1 (Herman, 1992, p. 36), i t becomes a story; and i n the process, imbued with meaning. Conceptually, the co-researcher i s able to separate the author from the actor; that i s , the I, or witness, from the Me, or witnessed. Hermans and Hermans-Jansen (1995) write that, as a Spectator, or I, the co-researcher i s able to describe . . . herself as an actor. In t h i s configuration, the I can imaginatively construct a story with the Me as the protagonist. . . . Such narrative construction i s possible because the I can imagine the Me i n the future and can reconstruct the Me i n the past (p. 8). Inherent i n the structure of the new story, b u i l t from the wordless rubble of the victim's "shattered assumptions," are the p i l l a r s and beams of a new, more appropriate paradigm, which can now house the integrated trauma-related information (Britton, 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 to neither the c l a s s i f i c a t i o n of Spectator nor P a r t i c i p a n t (although they can occur simultaneously with e i t h e r of these experiences). They are, as the name suggests, p a r t i c u l a r to the treatment i t s e l f , and would not, i n a l l l i k e l i h o o d , be 61 occurring, were i t not for the subject's undergoing EMDR. This i s not to say that each such e f f e c t i s necessarily exclusive to EMDR, i n that i t could not, or does not, occur during other psychotherapeutic procedures. Rather, i t i s the frequency and context i n which these experiences occur which i d e n t i f y them as EMDR Treatment S p e c i f i c E f f e c t s . Such experiences have both physical and cognitive manifestations. Dimensions of Co-researchers' Experiences The categories of Participant Experiences, Spectator Experiences and Treatment S p e c i f i c E f f e c t s were found to contain a t o t a l of 12 subcategories, or dimensions, of co-researchers' experiences. Some dimensions contain items which arguably would be appropriate for more than one subcategory. In such cases, the researcher has chosen what he believes to be the most appropriate subcategory f o r the p a r t i c u l a r item. Participant Experiences Within the category of Participant Experiences, the following four dimensions of experience were i d e n t i f i e d : (a) passive endurance of trauma; (b) narrowness of perspective; (c) immediacy of fo c a l image; and (d) i n t e n s i t y of (relived) emotion; Passive Endurance of Trauma This category emphasizes the co-researcher's passive r e l a t i o n s h i p to her intrusive re-experiencing. Lacking i s a sense of agency to act upon her remembered experiences— 6 2 whether physical, emotional, cognitive or v i s u a l . Hence, she i s as i f t h e i r passive instrument, used at t h e i r w i l l . Narrowness of Perspective Awareness i s limited to 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 experience(s), including emotions, cognitions, physical sensations and images. The traumatic information remains unintegrated into a broader perspective or context. The event i s experienced through the co-researcher's "own eyes." As the Me has not yet emerged, she remains unable to see h e r s e l f i n the picture. Immediacy of Focal Image The " f o c a l image," (the picture imagined by the co-researcher) appears r e l a t i v e l y clear, v i v i d , and close i n proximity. The co-researcher may remember forgotten d e t a i l s of the image, such as a person's clothing or h a i r colour, as i f looking at a photograph or watching a f i l m . However, the nature of the new detailed information does not broaden the co-researcher's perspective, and does not lead to a cognitive or conceptual s h i f t i n r e l a t i o n to the trauma. One i s not looking at a new photograph, taken from a d i f f e r e n t perspective, as i t were, but simply n o t i c i n g the forgotten d e t a i l of a f a m i l i a r photograph. Co-researcher "C" described her experience t h i s way: I remember . . . everything around me, the d e t a i l , her gold earrings, what her face looked l i k e , what the 63 people looked l i k e . I probably didn't remember i t so intensely or so well u n t i l I was doing [the treatment]. Intensity of Emotion The co-researcher re-experiences the emotions present at the time of traumatization. Although t h i s p r i m a r i l y involves fear, other r e l i v e d emotions may also be present. For example, "C" re-experienced the g u i l t she had f e l t upon r e a l i z i n g she might have caused an automobile accident; and she again experienced the anger she had f e l t when a woman at the accident scene became h y s t e r i c a l . Whatever the emotion experienced by co-researchers, the l e v e l of emotional intensity i s high (although not necessarily as high as during the o r i g i n a l event). Concomitant physical manifestations (Treatment S p e c i f i c E f f e c t s ) , involve tightening of the musculature, (such as a knot i n the stomach; t i g h t shoulders; d i f f i c u l t y breathing; nausea; as well as " f i g h t or f l i g h t " t i n g l i n g ) . Spectator Experiences This category contains four dimensions of experience: (a) active a l t e r a t i o n of experience; (b) broadening of perspective; (c) distancing of f o c a l image; and (d) v a r i e t y of emotional experience. Active A l t e r a t i o n of Experience Whereas the Participant i s the passive instrument of her traumatic re-experiencing, the Spectator becomes an agent, acting upon the trauma-related information, and 64 putting i t into a larger context. However, a paradox e x i s t s ; f o r the co-researcher i s not a w i l l f u l agent of these processes, but i r o n i c a l l y , a passive one, i n much the same way a dreamer i s both the agent and instrument of h i s or her own dream. For example, when "B" imagines herself attacking her ass a i l a n t i n a ro l e reversal (suggesting agency), t h i s b r i e f drama of revenge appears to her spontaneously, but not w i l l f u l l y . She regards i t with as much delight and surprise as i f watching a clever t e l e v i s i o n advertisement f o r the f i r s t time. Although at one l e v e l , her "mind"—in the broadest s e n s e — i s a c t i v e l y engaged i n the process of understanding and integrating disturbing, novel information, her "ego," or sense of " I " i s passively experiencing i t . Fantasies or memories may a r i s e ; or the content of the f o c a l image may spontaneously change, or "morph," eithe r i n whole or i n part. For example, a h i s t o r i c a l l y accurate f a c i a l expression, such as one expressing fear, may change to one that i s calm and smiling. Broadening of Perspective The co-researcher begins to move outside the narrow sp o t l i g h t of her trauma. No longer the actor, compulsively replaying her traumatic scene, she becomes an audience member—a Spectator—able to muse and philosophize about the drama i n general, and the significance of the various players' roles within i t . From various new perspectives, she c r i t i q u e s and evaluates the drama i n ways she could not 65 as a Participant-Actor who lacked r e l a t i v e o b j e c t i v i t y . In p r a c t i c a l terms, she may see herself i n the picture f o r the f i r s t time, as i f a t h i r d party watching the incident from a distance. She may experience insight, or a cognitive s h i f t , i d e n t i f y i n g with others who have suffered s i m i l a r l y . Or she may f e e l compassion for her assailant. Distancing of the Focal Image The q u a l i t y of the f o c a l image i s diminished, as i f the co-researcher i s herself becoming emotionally d i s t a n t from the event. Lost i s the " l i v i n g " vividness found i n the Pa r t i c i p a n t experience of the f o c a l image. The image may appear faded; may alternate between being c l e a r or close, and being distant or faded; may appear momentarily, as i f i n a f l a s h ; or not appear at a l l , despite the co-researcher's e f f o r t to r e t r i e v e i t . Variety of Emotional Experience Whereas high in t e n s i t y of r e l i v e d emotions characterizes Participant experiences, greater v a r i e t y (of both i n t e n s i t y [high and low] and type) defines those of the Spectator. The co-researcher i s able to step outside the narrow sp o t l i g h t of trauma-related feelings, allowing f o r new emotions to emerge. She may grieve that which i s l o s t ; f e e l rage at an assailant for the i n j u s t i c e of an assault; or f e e l a sense of joy or euphoria at the absence of disturbing emotions and cognitions. Lacking are the emotions experienced during traumatization. 66 Whereas Participant emotional experiences are accompanied by a tightening of the musculature, emotions i n the Spectator category tend to be accompanied by a loosening; by alternating tightening and loosening; or by s h i f t s i n the location of physical sensations. Treatment S p e c i f i c E f f e c t s Four dimensions of experience were i d e n t i f i e d : (a) momentary cognitive impairment; (b) heightened physical awareness; (c) change i n energy l e v e l ; and (d) meta awareness of the process. Momentary Cognitive Impairment In t h i s dimension of experience, the co-researcher undergoes a momentary a l t e r a t i o n of her more f a m i l i a r cognitive state. For example, the speed at which she processes material may seem greatly accelerated; several or many thoughts may "race" through her mind, to the point where she can only r e t a i n a f r a c t i o n of t h e i r content i n memory. She may also experience a momentary, general confusion, or s l i g h t disorientation, as i f mildly intoxicated. For example, one co-researcher f e l t as i f drugged on morphine or Valium. Heightened Physical Sensations Co-researchers experiences physical sensations of varying i n t e n s i t y and type. These sensations do not remain constant, but s h i f t at various times throughout the treatment session. 67 When occurring with Participant Experiences, these physical experiences tend to involve a tightening of the musculature (tension i n the shoulder area; a "knot" i n the stomach; nausea), as i f the co-researcher were r e s i s t i n g p a i n f u l emotions. Conversely, as a Spectator, the musculature tends to loosen and relax, as one might expect, given that the co-researcher has, by d e f i n i t i o n , gained emotional distance from the perceived traumatic threat. The degree of tension may change throughout the session; as may i t s l o c a t i o n . The co-researcher may f e e l warmer, or experience 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 Level The co-researcher may f e e l fatigued or energized at various times during the treatment session, or may f e e l a l t e r n a t e l y fatigued and energized. This change i n energy l e v e l may be general, and include the ent i r e body, or may be f e l t i n only one s p e c i f i c location, such as one side of the s k u l l . Meta Awareness of the Process In t h i s dimension of experience, the co-researcher watches her own experience and has feelings or thoughts about i t . For example, i f she experiences her mind as racing, she may be surprised at t h i s process, wonder i f i t should be occurring, and worry about i t . Or the sudden, unexpected absence of fear may lead her to suspect that she i s blocking her feelings. She may wonder how her dramatic 6 8 cognitive and emotional changes could be occurring; that i s , she may ask herself, as one co-researcher did, what neurobiological changes are taking place i n the moment, to f a c i l i t a t e such unexpected changes. She may also experience thoughts and feelings about the therapist, i n r e l a t i o n to her treatment. Co-Researchers' Experiences In order,to help the reader better understand co-researchers' in-session EMDR experiences, a b r i e f synopsis of pre-treatment condition, as well as the nature and o r i g i n of the traumatic experiences, i s provided i n the following section. Co-Researcher "A" While working as a cashier at a liquor store 27 months p r i o r to treatment, "A" was robbed by two men wearing s k i masks, one of whom carried a shot gun. The armed man, whom "A" described as "crazy," removed hi s mask, started kicking the counter, and put his gun to the back of her head. T e r r i f i e d , "A" refused to look at either of the men, choosing instead to stand "scrunched up" with her eyes closed and f i s t s clenched; believing that, at any moment, the "crazy" 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 , while "A" was working i n the same store, a man entered, carrying a large knife i n the back of his pants. Again understandably t e r r i f i e d , "A" had to serve him af t e r he began to "scream" for service. Although no robbery or assault ensued, her previous assault 69 had l e f t her sensitized to the p o s s i b i l i t y of danger, and she afterward found herself "sobbing l i k e a baby." Her symptoms afte r the f i r s t trauma included nightmares of being chased by loud people with guns; and a f t e r the second, of being stabbed and s l i c e d by assa i l a n t s wielding knives. The frequency of the nightmares was from 1 to 3 nights per week. Further, she experienced fear at work whenever a customer entered. Similar public s i t u a t i o n s , such as standing i n a bank line-up, also evoked strong f e e l i n g s of anxiety. "A" also experienced recurring depression and anger that "someone had taken away [her] l i f e " ; and her anxiety profoundly affected her young daughter, who subsequently became a f r a i d to sleep alone. At the time of the c l a r i f i c a t i o n interview, the co-researcher f e l t t i r e d , and s l i g h t l y i l l , as i f she had "the f l u . " She described having had a dream i n which, f o r the f i r s t time, she turned and attacked her attacker. EMDR Experiences of Co-Researcher "A" Co-researcher "A" manifested a clear, unwavering movement toward in-session resolution of her baseline measures. Quite l i t e r a l l y , her only Part i c i p a n t experiences were those she brought with her into the therapeutic session (fear, narrow perspective of the event, physical tightness, etc.) which ended during the f i r s t set of eye movements. In other words, the fear, "knot" i n her stomach, and c l a r i t y of the disturbing f o c a l image, with which she began treatment, started to deteriorate within the f i r s t set of eye 70 movements. Half way through the set, she began to f e e l "relaxed" and "warm," as i f "wrapped i n a blanket," which seemed to protect her from the assailants who had, u n t i l t h i s point, been haunting her memory. This r e l i e f came with a momentary sensation of dizziness, and stayed with her "throughout the entire session." By the second set, her fear had s i g n i f i c a n t l y diminished; and by the t h i r d , the f o c a l image was more distant, and fading i n and out. As "A" described her experience, . . . I just couldn't believe what was happening. . . . I just f e l t l i k e laughing. I didn't f e e l frightened anymore. I didn't f e e l anxious. . . . I t ju s t seemed funny to me. The qu a l i t y of the fo c a l image continued to diminish, sometimes appearing i n "flashes"; at other times, fading i n and out. Although she occasionally saw seldom-remembered aspects of the traumatic event, t h i s new information was f l e e t i n g , and of a surreal quality, evoking i n her no emotional response but a sense of r e l i e f , and the impulse to laugh. At times, during the remaining sets, no image appeared to her, only the therapist's fingers: 71 I would just see the fingers. And I would concentrate on the fingers. And, you know, I saw h i s r i n g on h i s hand. . . . The image just disappeared. I t was ju 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 focusing on i t , "almost l i k e [the event] didn't happen." Several times the content of the f o c a l image changed. For example, at one point the assailant disappeared from behind her; at another, the worried face of her co-worker took on a calm, smiling demeanor. At times, "A" t r i e d to force the o r i g i n a l f o c a l image to mind, despite the therapist's instructions to "go with" whatever her experience happened to be. She also became preoccupied with the posit i v e changes which were occurring, and wondered about them. By the end of the session, her SUDs l e v e l was at 0, and her cognitive a t t r i b u t i o n , "I f e e l safe; he can't hurt me"; rated a 7 on the V a l i d i t y of Cognition scale, i n d i c a t i n g the highest measurable b e l i e f i n t h i s a t t r i b u t i o n . Sequential Experiences by Category In t h i s , and similar sections to follow, P a r t i c i p a n t Experiences (PE), Spectator Experiences (SE), and Treatment S p e c i f i c E f f e c t s (TSE) are presented i n the sequence i n which they occurred. C l a s s i f i c a t i o n and Description of Experience SE: Feels safe, as i f wrapped i n a blanket. TSE: f e e l s dizzy and warm SE: Decrease i n fear. SE: Image diminished; comes and goes. Sees therapist's fingers instead of f o c a l image. SE: Image faded; sees therapist's f i n g e r s . TSE: d i f f i c u l t y concentrating. SE: Sees image without fear; new information revealed; wants to laugh; f e e l s r e l i e f . SE: Sees image without fear; content of image changes. TSE: Has d i f f i c u l t y believing her experience. SE: Image diminished, comes and goes. Content of image changes. Sees herself i n image for f i r s t time. New information revealed. SE: Wants to laugh. TSE: Thinks urge to laugh i s "strange"; has d i f f i c u l t y concentrating. SE: Image i s reduced to flashes. New information revealed. SE: Feels calm; sees a b r i e f p i c t ure. TSE: Has d i f f i c u l t y believing her experience; wonders i f she i s "blocking." 73 Set C l a s s i f i c a t i o n and Description of Experience 11: SE: Increased d i f f i c u l t y seeing image; increased relaxation. TSE: Knot moved from stomach to upper chest; fe e l s "drained." 12: TSE: Knot disappeared; d i f f i c u l t y concentrating. 13: SE: Cannot ret r i e v e image; sees only therapist's fingers; feels calm. 14: SE: Feels present and safe, without fear. TSE: Has d i f f i c u l t y believing her EMDR experience. 15: SE: Sees herself i n picture, without fear; wants to laugh. TSE: Wonders about the process (how i t works). 16: SE: No image; incident 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 bring to 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 (how i t works). Summary of Experiences by Category Participant experiences. Co-researcher "A" had no Pa r t i c i p a n t experiences which extended beyond 1/2 way through the f i r s t set of saccades. Spectator experiences. 1. Active 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 perspective: (a) New information revealed; (b) f e e l s present; (c) r e a l i z e s danger i s over (she i s safe); (d) sees herself i n the picture for the f i r s t time. 3. Distancing of f o c a l image: The image (a) comes and goes; (b) diminishes; (c) does not appear (despite e f f o r t to r e t r i e v e i t ) ; (d) appears i n flashes; (e) i s replaced by therapist's fingers. 4 . Variety of emotional experience. (a) R e l i e f ; (b) decrease i n fear; (c) desire to laugh. Treatment s p e c i f i c e f f e c t s . 1. Momentary cognitive impairment: (a) Dizziness; (b) d i f f i c u l t y concentrating. 2. Heightened physical awareness: (a) warmth; (b) tension migrates upwards; (c) musculature loosens; (d) tension disappears. 3. Change i n energy l e v e l : Feels fatigued. 4 . Meta awareness of the process: (a) Has d i f f i c u l t y b e l i e v i n g her experience; (b) judges her urge to laugh; (c) wonders i f she i s "blocking"; (d) wonders about how her experiences are occurring. 75 Co-Researcher B The trauma history of "B" was, perhaps, the most extensive and complicated of the three co-researchers. Eighteen months p r i o r to treatment, P a r t i c i p a n t "B" had been sexually assaulted while a patient at a l o c a l h o s p i t a l , by a radiographer employed by the h o s p i t a l . This was the second such assault she had endured, the f i r s t having occurred when she was thirteen. I r o n i c a l l y , both occurred at the same hospit a l , by a man of the same minority race. Further adding to her traumatized state 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 , during which information about the f i r s t assault was made publ i c . Approximately s i x months p r i o r to the second assault, "B" had attempted to become pregnant through i n v i t r o f e r t i l i z a t i o n . She " l o s t the baby" and suffered acute depression. Approximately one year a f t e r the assault, the p a r t i c i p a n t and her husband separated. To complicate matters, there existed other repressed traumatic information (revealed i n subsequent sessions) not known to c l i e n t or therapist during the f i r s t EMDR session, which might have affected treatment. Her symptoms included intrusive r e c o l l e c t i o n s of the assault (a metaphorical image of the assailant crawling on her back); severe depression and anxiety; diminished sexual desire; and d i f f i c u l t y maintaining normal friendships. Her sense of t r u s t i n others had been severely injured; and she 76 had been unable to work for several months. As "B" suc c i n c t l y said of the ef f e c t of her second sexual assault: " I t j u s t b a s i c a l l y changed my entire l i f e . " At the time of the c l a r i f i c a t i o n interview "B" was ph y s i c a l l y exhausted, and appeared emotionally f r a g i l e . EMDR Experiences of Co-Researcher "B" If co-researcher "A" could be said to have moved more or less s t e a d i l y down a gentle slope toward r e s o l u t i o n of her traumatic condition, "B"'s tra j e c t o r y was clo s e r to that of a ship on stormy waters, as she was tossed dramatically up and down through profoundly d i f f e r e n t emotional states: Anger, fear, sadness, joy (euphoria), and g u i l t were a l l experienced, as were the concomitant physical manifestations of nausea, tightening and loosening of the musculature, extreme fatigue, rejuvenation, t i n g l i n g , and the experience of f e e l i n g as i f she were drugged on Valium, a medication with which she was fa m i l i a r . She has two Participant experiences, during which she r e l i v e d the traumatic incident. In the realm of fantasy, "B" imagines gaining revenge from the as s a i l a n t through r o l e r e v e r s a l , violence and conviction for h i s crime. She i d e n t i f i e s with three f i c t i o n a l characters: one from l i t e r a t u r e (Hamlet, whom she sees as t r a g i c ) ; another from a children's' story (a very sad g i r l ) ; and f i n a l l y , one from f i l m (the protagonist i n It's a Wonderful L i f e ) . During the l a t t e r , she watches herself watching the f i l m i n " r e a l time," at a point when the protagonist find's h i s daughter 77 Zu Zu's flower petals i n his pocket, and r e a l i z e he has not k i l l e d himself. During the c l a r i f i c a t i o n interview, "B" r e a l i z e d the significance of t h i s for her: She had survived, and not k i l l e d herself. The several insights she displays, and her new compassion f o r the assailant, suggest some working through of her trauma occurs; however, complete re s o l u t i o n of her symptoms i s not reached. By the end of her session, "B" i s exhausted, and somewhat mentally disoriented. Both therapist and she agree there i s more work to be done i n future sessions. Her SUDs l e v e l , which began at "between nine and ten," i s now "sevenish—eight." Sequential Experiences by Category Set C l a s s i f i c a t i o n and Description of Experience 01: SE: Anger. 02: SE: Anger. TSE: Tight chest; d i f f i c u l t y breathing. 03: PE: Relives event; f e e l s vulnerable. SE: Feels enough distance for sadness. TSE: Realizes treatment i s working. 04: SE: R e l i e f she i s safe. 05: SE: Anger. 06: SE: Anger; sadness. 07: SE: Anger. 78 C l a s s i f i c a t i o n and Description of Experience SE: Blank (no image); fantasizes going to safe place (beach). TSE: Feels exhausted. SE: Positive insight; believes she i s strong. TSE: Feels energized; body relaxed; f e e l s more i n control of body. SE: Revenge fantasy (assaulting a s s a i l a n t ) . SE: Revenge fantasy (role r e v e r s a l ) ; anger. SE: Blank (no image). TSE: Frustration at her process; body relaxed. 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 children's story. SE: Too distraught to continue. Asks f o r break; comforts s e l f with s e l f - t a l k . TSE: Feels negatively effected by therapist's change i n d i r e c t i o n of finger movements. SE: Revenge fantasy (assailant being punished). SE: Revenge fantasy (continuation of above). TSE: Head fe e l s heavy ("as i f on morphine."); wonders about (neurophysiology of) process; wonders i f she i s upsetting t h e r a p i s t . TSE: Right side of "brain" f e e l s energized. SE: Feels euphoric; wants to laugh. TSE: Feels fatigued. SE: Cannot retrieve image; imagines safe place. 7 9 Set C l a s s i f i c a t i o n and Description of Experience 23: SE: Complete mental and emotional peace; f e e l s "wrapped i n a cocoon." 24: TSE: Right side of brain f e e l s heavy; increased physical awareness. 25: TSE: Tension migrated from chest to s k u l l ; f e e l s drugged, sleepy. 26: TSE: Fingers f e e l t i n g l y . 27: TSE: Body relaxed. 28: TSE: Muscles twitching. 29: TSE: Sleepy; angry at s e l f for being sleepy; tightness increases and decreases. 30: TSE: D i s l i k e s perceived change i n finger movements. Perceives therapist as relaxed. 31: SE: Fantasized watching herself watch a movie. TSE: F e l l s drugged and relaxed. 32: SE: Wants to be alone. 33: TSE: Fatigued; increased physical awareness. 34: TSE: Perceives fingers as "Grim Reaper", pointing. 35: SE: Blank. TSE: Right side of brain s t i l l f e e l s drugged. 36: SE: Childhood memory of hiding i n safe place. 37: SE: Sadness; wants to f e e l safe again. TSE: Nausea; fatigue; embarrassed at own process. 38: TSE: Tight chest; d i f f i c u l t y breathing. 39: TSE: Tension; exhaustion. 40: PE: Anticipates traumatic event. 80 C l a s s i f i c a t i o n and Description of Experience SE: Anger. SE: Insight (into metaphorical f o c a l image). SE: Self blame (she couldn't stop i n c i d e n t ) . TSE: Tight chest. SE: Anger. TSE: Feels t i n g l y (fight or f l i g h t f e e l i n g ) . SE: Sadness; believes she i s helpless. TSE: Tightness; fatigue; no longer f e e l s drugged; needs to rest; wonders about process (how i t works). SE: Compassion for assailant. SE: Despair at recovering; vague flashback or fantasy of a stalker. SE: Wonders why incident happened. PE: Relives traumatic incident. SE: Anger. TSE: Reluctant to look l e f t ("too much pain.") SE: Despair she won't recover; i d e n t i f i e s with t r a g i c figure (Hamlet). SE: Blank; wants session to end. TSE: Exhaustion; nausea; tightness. TSE: Fatigue. TSE: Mental confusion; d i f f i c u l t y following fingers; pressure on chest. SE: Sadness for s e l f and world. SE: Thinks of suicide. 81 Set C l a s s i f i c a t i o n and Description of Experience 58: SE: G u i l t for having disclosed. 59 SE: Insight ( i t was good to d i s c l o s e ) . 60: SE: Increased anger; f r u s t r a t i o n at length of healing process; two insights (she may have saved others; hasn't k i l l e d h e r s e l f ) . 61: SE: Anger. 62: TSE: Grateful for therapist's comment. 63: TSE: Sees fingers as tools to recovery. 64: TSE: Exhaustion; d i f f i c u l t y a r t i c u l a t i n g . 65: TSE: Exhaustion. 66: TSE: Thoughts about therapist and process. 67: SE: Wonders, "Why me?"; insight (answers own question). TSE: Mental confusion and disorganization. 68: TSE: Fatigue. Summary of Experiences bv Category Pa r t i c i p a n t experiences. 1. Passive endurance of trauma. (a) Relives event; (b) passively endures intrusive re-experiencing. 2. Narrowness of perspective. 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 close and r e a l . 82 4. Intensity of emotion. (a) Fear; (b) v u l n e r a b i l i t y . Spectator Experiences. 1. Active a l t e r a t i o n of experience. (a) Fantasizes revenge; (b) fantasizes a peaceful place; (c) imagines watching her s e l f watch a f i l m ; (d) has childhood memory of safe place; (e) has vague fantasy or flashback of a s t a l k e r . 2. Broadening of perspective. (a) Believes she i s safe; (b) f e e l s compassion for assailant; (c) wonders why incident happened; (d) contemplates suicide; (e) f e e l s g u i l t y f o r having disclosed; (f) blames herself; (g) has p o s i t i v e ins i g h t s ( i . e . , r e a l i z e s i t was good to d i s c l o s e ) ; (h) wonders, "why me?"; (i) i d e n t i f i e s with various f i c t i o n a l characters. 3. Distancing of f o c a l image. (a) Cannot r e t r i e v e image; (b) image comes as f l a s h . 4. Variety of emotions. (a) Anger; (b) sadness; (c) profound g r i e f ; (d) r e l i e f ; (e) joy (euphoria); (f) desire to laugh; (g) despair at recovery. Treatment s p e c i f i c e f f e c t s . 1. Momentary cognitive impairment. (a) Feels drugged; (b) mental confusion; (c) d i f f i c u l t y following 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. 83 2. Heightened physical awareness. (a) Tight chest; (b) d i f f i c u l t y breathing; (c) pressure on chest; (d) f e e l s relaxed; (e) head f e e l s heavy; (f) r i g h t side only of head f e e l s heavy; (g) tension moves from chest to s k u l l ; (h) musculature tightens and loosens; (i) f e e l s t i n g l y ; (j) muscles twitch. 3. Change i n energy l e v e l . (a) Feels energized; (b) fe e l s exhausted; (c) r i g h t side of head fe e l s energized; (d) f e e l s sleepy. 4. Meta awareness of process. (a) Realizes treatment i s working; (b) f r u s t r a t i o n at her process; (c) concerned with d i r e c t i o n of therapist's finger movements; (d) aware of fe e l i n g reluctant to look l e f t ; (e) angry at s e l f f o r being sleepy; (f) embarrassed at own process; (g) wonders about process (how i t works); (h) sees fingers as to o l s to recovery; (i) worries how she i s a f f e c t i n g t h e r a p i s t ; (j) gra t e f u l for therapist's comments. Co-Researcher "C" During an ice storm, approximately 6 weeks p r i o r to her f i r s t EMDR session, "C11 had stopped her car i n order to a s s i s t a man and his daughter, whom she believed to be flagging her for assistance. 84 Immediately p r i o r to exi t i n g her vehicle, another car c o l l i d e d with hers, i n j u r i n g the man, and k i l l i n g h i s daughter. Although not injured herself, the co-researcher immediately began suffering emotional shock, with which she coped by attending to the injured 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 chest compressions on the injured young woman, but eventually r e a l i z e d she could not save her. Believing she may have caused the accident by stopping her car, "C" had since been plagued with g u i l t and obsessive thinking about the accident. Esp e c i a l l y t r o u b l i n g were in t r u s i v e images of the victims' faces, and v i o l e n t nightmares involving car crashes, s e r i a l k i l l e r s , and dismembered people and animals. Although she had driven a car since the traumatic event, i t was always with a strong sense of trepidation as she anticipated another accident. P r i o r to the EMDR session, she had d i f f i c u l t y sharing her feel i n g s about the event with a l l accept her husband, who remained supportive. At the time of the c l a r i f i c a t i o n interview "C" f e l t s l i g h t l y t i r e d . She was c l e a r l y i n physical pain r e s u l t i n g from her accident, and showed restrained emotional v u l n e r a b i l i t y . EMDR Experiences of Co-Researcher "C" Throughout the greater part of her EMDR session, "C" re-experienced, largely i n sequence, her automobile 85 accident, and the events immediately afterward. That i s to say, her traumatic r e l i v i n g of the event began at the moment of impact, and progressed, more or less sequentially, forward through time, with each set of saccades moving her a l i t t l e farther. She described her experience t h i s way: The f i r s t while . . . i t . . . almost went i n sequence of the actual accident. So, thinking about one thing made me lead to think about the next thing. So, I worked through i t — t h e whole accident. Semantic and emotional threads l i n k one set to the next. For example, i n set four, the anger she f e l t at a screaming woman, recurred i n the f i f t h set; but t h i s time directed toward the drivers of the accident v e h i c l e . The s i x t h set again brought an image of the same veh i c l e , but t h i s time the focus was on the d e t a i l s of the hat the woman was wearing, 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 anger was at f i r s t d i f f i c u l t . For, although one would normally think of these as secondary, and hence, Spectator emotions, because they were re-experienced, as i f occurring i n the moment, they f i t t e d best into the category of P a r t i c i p a n t Experiences. Throughout "C's f i r s t session, she did, by her own admission, r e s i s t the urge to emote. Each time she f e l t the impulse to cry, she stopped herself, by choking back the 86 fe e l i n g s , and stopping eye movements, star i n g s t r a i g h t ahead, as i f fixated on something. This impulse to cry she described as more profound and disturbing than mere sadness. At several points during treatment, "C" had consecutive Spectator Experiences; among them, wondering how and why the event happened; a desire to leave flowers f o r one of the victims, and a momentary sense of r e l i e f at r e a l i z i n g the accident wasn't her f a u l t . At sessions end, there had been only a s l i g h t decrease i n her anxiety (SUDs) l e v e l , from 7.5 to 6.5. Sequential Experiences by Category Set C l a s s i f i c a t i o n and Description of Experience 01: TSE: D i f f i c u l t y concentrating; not sure what to do, despite instructions. 02: PE: Relives moment of impact; panic, fear and g u i l t . TSE: Surprised at process; many images appear. 03: PE: Relives incident: nausea; fear; shock. 04: PE: Relives incident: fear; anger. TSE: D i f f i c u l t y concentrating; eye l i d s get heavy; embarrassed at her process. 05: PE: Relives incident. SE: Anger. 06: PE: Relives incident; remembers d e t a i l s . 07: PE: Relives incident. SE: Wants to cry (blocks). C l a s s i f i c a t i o n and Description of Experience PE: Relives incident; remembers d e t a i l s . SE: Wants to cry (blocks). TSE: Knot i n stomach. PE: Relives incident: remembers d e t a i l s . PE: Relives incident: f e e l s helpless and vulnerable. SE: Increased awareness of remembered surroundings. PE: Relives incident: g u i l t . SE: Increased awareness of surroundings. TSE: Confuses past and present tenses; tension i n stomach f e e l s as i f i n throat; shaky. PE: Relives incident. SE: Remembers f e e l i n g of r e l i e f that she was not responsible for accident; wants to cry (blocked). PE: Relives (post incident). SE: Anger. TSE: Nausea. PE: Relives: g u i l t and v u l n e r a b i l i t y . PE: P a r t i a l r e l i v e . PE: P a r t i a l r e l i v e . SE: Remembers fe e l i n g annoyed. PE: P a r t i a l r e l i v e . SE: Wants to cry (blocks). TSE: Stomach t i g h t . 88 C l a s s i f i c a t i o n and Description of Experience PE: P a r t i a l r e l i v e . SE: Wants to cry (blocks). PE: P a r t i a l r e l i v e . SE: Wants to cry (blocks). PE: P a r t i a l r e l i v e : g u i l t ; fear. SE: Memory of r e l i e f i t wasn't her f a u l t . PE: P a r t i a l r e l i v e . SE: Memory of r e l i e f i t wasn't her f a u l t . SE: Wonders how incident happened; wants closure. SE: Wonders how incident happened; wants closure; anger. TSE: Mind racing: many thoughts. SE: Fed up with pain; wants closure. PE: Relives incident (from immediately a f t e r impact): fear, panic. PE: Relives incident: shock: d i s s o c i a t i o n . PE: Relives incident. SE: Insight into her physical v u l n e r a b i l i t y . PE: P a r t i a l r e l i v e . SE: Anger; insight (she helped others to protect h e r s e l f ) . PE: P a r t i a l r e l i v e . SE: Wants to be taken care of. 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; v i v i d d e t a i l SE: 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 Description of Experience 31: SE: Fantasizes leaving flowers for 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 closure. TSE: Fatigue begins. 33: SE: Flashes of man's face; wonders why he waved; image of him on ground; self-coaches: T e l l s herself she did the r i g h t thing. 34: PE: P a r t i a l r e l i v e . SE: Wonders why event happened. 35: SE: I d e n t i f i e s with other victims; wonders how they cope. 36: PE: Relives incident; increased d e t a i l ; fear. SE: Memory of being surprised at her competence; insight (from psychologist's question). 37: PE: Relives incident: g u i l t , shock. SE: Insight (she wasn't c a l l o u s ) . TSE: Mind racing; many thoughts. 38: PE: P a r t i a l r e l i v e (post incident). SE: Remembers wanting comfort; wonders how others cope. 39: PE: P a r t i a l r e l i v e (post i n c i d e n t ) ; d e t a i l s clearer. SE: Wants to cry (blocks). 40: PE: P a r t i a l r e l i v e of incident. SE: Experiences insight. 90 Summary of Experiences by Category Participant experiences. 1. Passive endurance of trauma. (a) Relives event; (b) passively endures re-experiencing of traumatic memories. 2. Narrowness of perspective; Momentary awareness does not extend beyond r e l i v e d experiences. 3. Immediacy of f o c a l image: Focal image appears v i v i d and close; d e t a i l revealed. 4. Intensity of emotion. Experiences (a) fear; (b) shock; (c) helplessness; (d) v u l n e r a b i l i t y ; (e) g u i l t ( r e l i v e s ) ; (f) anger ( r e l i v e s ) . Spectator experiences. 1. Active a l t e r a t i o n of experience. (a) Fantasizes leaving flowers. 2. Broadening of perspective. (a) Increased awareness of surroundings (of trauma s i t e ) ; (b) insight into her r o l e played during trauma; (c) wonders how event occurred; (d) wonders why event occurred; (e) wonders how others cope; (f) i d e n t i f i e s with other victim. 3. Distancing of f o c a l image. None. 91 4. Variety of emotions. Feels (a) anger; (b) wants to cry ("more than sadness"); (c) r e l i e f ; (d) f e e l s fed up with f e e l i n g bad. Treatment s p e c i f i c e f f e c t s . 1. Momentary cognitive impairment. (a) D i f f i c u l t y concentrating; (b) mind races; (c) many images; (d) confuses past and present tenses. 2. Heightened physical awareness. (a) Nausea; (b) eyelids become heavy; (c) knot i n stomach; (d) f e e l s as i f her stomach i s i n her throat; (e) fe e l s shaky. 3. Change i n energy l e v e l . Fatigue. 4. Meta awareness of process. (a) Embarrassed at her own process; (b) surprised at mind racing, (c) surprised at high number of images. 92 CHAPTER FIVE: DISCUSSION Review To b r i e f l y summarize, information from a t o t a l of s i x interview t r a n s c r i p t s was analyzed and found consonant with three broad categories, or themes, of experience, each of which further contained four dimensions of experience. Two of the three broad c a t e g o r i e s — P a r t i c i p a n t Experiences, and Spectator Experiences—were borrowed from the work of Cochran (1990). Participant Experiences emphasize (a) the passive nature of the co-researchers' i n t r u s i v e r e -experiencing; (b) the narrow perspective or focus; (c) the v i v i d , immediacy of the f o c a l image; and (d) the high i n t e n s i t y of (relived) emotion(s). Within t h i s category, the c l i e n t may be said to be re-experiencing, to some degree, the o r i g i n a l traumatic material. The notions of narrow perspective, high in t e n s i t y of emotion, and the helpless nature of re-experiencing, are compatible with the DSM IV (APA, 1994) categories of c o n s t r i c t i o n , hyperarousal and intrusion, respectively. Spectator experiences suggest a movement away from the narrow, intense re-experiencing of the Participant, into a realm i n which the co-researcher experiences (a) a paradoxical form of agency, vaguely s i m i l a r to dreaming, i n which the experiencer i s both agent and instrument of her experience; (b) a broadening of perspective r e l a t i v e to the traumatic event; (c) distancing of the f o c a l image; and (d) a v a r i e t y of int e n s i t y and type of emotion. I t i s within 93 t h i s category that the survivor begins to mentally act upon and contextualize her experience; to reconstruct the assumptions that were "shattered" (Janoff-Bulman, 1992) as a r e s u l t of her encounter with the traumatic. The category of Treatment S p e c i f i c E f f e c t s , includes those experiences which would not, i n a l l p r o b a b i l i t y , be occurring, were i t not for the treatment i t s e l f . Various elements of t h i s category were found to occur along with Pa r t i c i p a n t and Spectator Experiences, as well as on t h e i r own. They include (a) momentary cognitive impairment; (b) somatic experiences; (c) changes to the co-researcher's energy l e v e l ; and (d) a meta awareness of the co-researcher's own process. Each co-researcher manifested a s i g n i f i c a n t l y d i f f e r e n t pattern of experience. "A" was among the previously mentioned "approximately 40%" of individuals who experience a continual, progressive movement toward in-session r e s o l u t i o n of the target event (Shapiro, 1995, p. 76) . Clear l y , the majority of her experiences were of the Spectator 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 Partic i p a n t Experiences occurred a f t e r 1/2 way through her f i r s t set of eye movements. Co-researcher "B," although spending much of her time i n these same two categories, d i d have three Participant experiences, during which she r e l i v e d , to some extent, the horror of her traumatic event. Hers was a stormy voyage of abreaction, drug-like euphoria, fatigue, cognitive insights, and physical tightening and 94 loosening. Although, resolution was not attained, s i g n i f i c a n t progress was made. Co-researcher "C," on the other hand, spent much of her time i n the realm of Part i c i p a n t Experiences, r e l i v i n g her trauma and the hours that followed, gaining l i t t l e perspective beyond her narrow Par t i c i p a n t focus. However, she did move temporarily into the Spectator realm several times as the session progressed: Among other things, she questioned why and how her traumatic event could have occurred, and imagined paying homage to a woman k i l l e d at the s i t e of her trauma. As with "B," reso l u t i o n was not attained, apparently due to resistance to treatment. Implications for Theory The gleaning and c l a s s i f i c a t i o n of experience— e s p e c i a l l y remembered experience, which i s p a r t i a l l y of relevance to the present s t u d y — i s , at best, a t r i c k y endeavor. Not only i s the nature of memory i t s e l f somewhat creative, and far from the "play back" mechanism we t y p i c a l l y imagine (Loftus & Hoffman, 1989); but, any attempt to separate the various components of experience (cognitive, a f f e c t i v e , somatic, etc.), i s somewhat s u p e r f i c i a l and short sighted. One need only glance at the current popularity of fluoxetine (Prozac), or the eff e c t s of various forms of "body work" (Upledger, 1990) on the mind and emotions to r e a l i z e the intimate and inseparable r e l a t i o n s h i p (or, perhaps, "unity") of cognition/soma/affect. According to 95 Damasio, (1994) our b e l i e f i n purely r a t i o n a l thought i s incorrect: The lower levels i n the neural e d i f i c e of reason are the same ones that regulate the processing of emotions and feelings, along with the body functions necessary for an organism's s u r v i v a l . In turn, 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 with v i r t u a l l y every bodily organ, thus placing the body d i r e c t l y within the chain of operations that generate the highest reaches of reasoning. . . . Emotion, f e e l i n g , and b i o l o g i c a l regulation a l l play a r o l e i n human reason (p. x i i i ) . Hence, to describe the upward migration of tightness i n "A"'s body as somatic. as i f devoid of emotional or cognitive concomitants or precedents; or "B"'s abreaction as a f f e c t i v e , exclusive of the somatic or r a t i o n a l , i s to make the same error as Descartes: that of attempting to divide the i n d i v i s i b l e wholeness of the experiencing organism (Damasio, 1994). That to which we assign labels such as " a f f e c t i v e , " "cognitive, 1 1 etc., i s simply the most s a l i e n t aspect of a greater wholeness of experience a f f e c t i n g the ent i r e person. The above caveat being stated, there was much found i n t h i s study which confirms Shapiro's (1995) descriptions of c l i e n t experiences. Although not every experience described 96 by Shapiro occurred (nor would one expect them to, given the small sample involved), no experiences occurred which her text had not anticipated. In fact, some of the more unusual EMDR experiences, such as physical sensations, changes to the f o c a l image, polarized cognitive s h i f t s and so on, seemed taken almost verbatim from her text. For example, both "A" and "B" experienced the upward migration of physical tightness; "B," from her chest to her head; and "A," from her stomach to her chest, whence i t disappeared, " l i k e i t didn't want to be there anymore." Of t h i s type of s h i f t i n g sensation, Shapiro writes, "a c l i e n t may i n i t i a l l y i ndicate a tightness i n the stomach, but with each set the sensations may seem to move upward (to the chest, throat, or head) 1 1 (p. 85). Regarding the f o c a l image, Shapiro writes how "a leer i n g face can change to a smiling one . . ." (p. 81), which occurred when "A" saw the face of her co-worker, which had previously looked worried, appear calm and smiling. Other (but not a l l ) co-researcher experiences which confirmed Shapiro's descriptions include changes i n cognition (p. 83); less intense r e l i v i n g of experience (p. 90); and changes i n emotions (p. 84). Micro patterns of experiences were also anticipated by Shapiro, including "C"'s blocking (p. 77), and "B"'s profound abreactions (p. 168). The present study extends previous EMDR theory by of f e r i n g a conceptual framework for c l a s s i f y i n g and 97 understanding type and movement of co-researcher experience, which i s consistent with ex i s t i n g perspectives on PTSD (APA, 1994; Shapiro, 1995; Herman, 1992), "shattered assumptions" (Janoff-Bulman, 1992), and narrative therapies (Hermans & Hermans-Jansen, 1995). Whereas Shapiro's (1995) accelerated information processing model provides a metaphorical and b i o l o g i c a l "working hypothesis" (p. 29) of how EMDR brings about changes to the organism, the current study o f f e r s a framework for conceptualizing and understanding the si g n i f i c a n c e of these changes themselves. To describe movement away from the Pa r t i c i p a n t realm, to that of a Spectator i s not only to say one i s working through the traumatic material, but also to say what the si g n i f i c a n c e and meaning of such movement i s . When, for example, "A" sees herself i n the picture f o r the f i r s t time, i t i s not only a sign that "two neuro networks [are linking] up with each other" (Shapiro, 1995, p. 41), but, j u s t as important, i t i s an indication of what the co-researcher, i n her paradoxically agentive/passive r o l e i s i n the process of doing: contextualizing, narrating, and hence, making meaning of her previously meaningless, wordless, traumatic memory. I t i s t h i s negotiation and reconstruction of meaning which allows the traumatic episode—now a s t o r y — t o be removed from "active memory" (Horowitz, 1976) and l a i d to re s t . 98 The dimensions of experience, (largely b i p o l a r i n the realms of Participant and Spectator) indicate the dynamics, or components, involved i n the s h i f t from the prenarrative (Herman, 1992) to the narrative (Hermans & Hermans-Jansen, 1995); from s t a s i s (Shapiro, 1995; Janet, 1919) to meaning (Frankl, 1963); from fragmentation (Janoff-Bulmann, 1992) to integration (Janet, 1919). This conceptualization i s offered by the author, not as an a l t e r n a t i v e to the accelerated information processing model, but an adjunct, adding a greater depth to our understanding of the significance of co-researcher experiences. Implications for Counselling There are several points to be made regarding implications for counselling. F i r s t , although the findings of t h i s study do not suggest a need for a l t e r a t i o n of the standard EMDR protocol (Shapiro, 1995), the conceptualizations offered may be of value to therapists by increasing awareness of the dynamics involved i n c l i e n t s ' movement toward resolution and meaning making—the l a t t e r being an apparently i n t e g r a l part of the EMDR experience. As EMDR continues to evolve, t h i s awareness may eventually lead to subtle changes i n how some therapists approach the o v e r a l l context of EMDR therapy, placing a greater emphasis on meaning and story. The second point involves the l e v e l of fatigue experienced by a l l co-researchers (during and a f t e r 99 therapy). A therapist's emphasizing to a c l i e n t i n advance that he or she may experience some degree of fatigue during--and e s p e c i a l l y after—treatment, would seem e t h i c a l l y responsible, i n that the c l i e n t could plan h i s or her post-session time accordingly. Therapists should be aware that in-session fatigue, cognitive impairment, or the e f f e c t s of abreaction may require c l i e n t s to rest b r i e f l y , as d i d "B," when overwhelmed by her experiences. Third, as two of the three co-researchers were, at some point, unsure of what to do, despite therapist's previous inst r u c t i o n s , a re-evaluation of how and what i n s t r u c t i o n s are given might be h e l p f u l . F i n a l l y , regarding the therapeutic r e l a t i o n s h i p , i t would appear that, as i n most therapies, encouragement can play an important r o l e for c l i e n t s i n d i s t r e s s . Given the high l e v e l of meta awareness c l i e n t s displayed, arid t h e i r f e e l i n g s of surprise regarding the process, i t would seem that therapists should continue to reassure c l i e n t s that treatment i s proceeding well, i f such i s the case. For some c l i e n t s , such as "C," who did not yet f e e l safe emoting i n front of her ther a p i s t — a n d , i n essence, blocked her treatment as a r e s u l t — g r e a t e r time and attention might need to be paid to developing the therapeutic r e l a t i o n s h i p before treatment begins. Implications for Research As e f f i c a c y research continues to confirm the usefulness of EMDR i n the treatment of PTSD and other 100 conditions (Shapiro, 1995; Greenwald, 1994, 1996), i t would seem useful for researchers to begin to conduct further q u a l i t a t i v e investigations into co-researcher experiences, e s p e c i a l l y regarding the dynamics of meaning creation within the therapeutic session(s). To t h i s end, i t i s hoped the conceptual structures i d e n t i f i e d i n t h i s study w i l l be of h e u r i s t i c value. As t h i s was the f i r s t systematic i n v e s t i g a t i o n of the phenomenology of EMDR, there remains a great deal to be explored. Replication of t h i s study with a much larger sample, might validate the appropriateness, or lack thereof, of the categories and dimensions herein described. Limitations of the Study Number of Subjects Perhaps the most glaring l i m i t a t i o n of t h i s study i s the i n c l u s i o n of only three subjects, or co-researchers. Had every co-researcher manifested a s i m i l a r pattern of experience, i t would s t i l l have remained d i f f i c u l t to generalize the res u l t s beyond t h i s study. The f a c t that each co-researcher manifested a d i f f e r e n t e x p e r i e n t i a l pattern renders any such generalization that much les s c e r t a i n . For the three patterns 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 , represent only a small sample of the many possible patterns. Generalization i s further complicated by the f a c t that, although a l l co-researchers shared a common DSM IV diagnosis of PTSD (APA, 1994), "A" was being treated for a single event trauma; "B" for at least two; and "C," 101 although treated primarily for a single trauma, was, by her own admission, r e s i s t i n g the treatment, so as not to f e e l overwhelmed. Limitations of Verbal Communication Even with the use of Interpersonal Process R e c a l l to cue co-researchers' memories, i t i s presumed that not a l l of the in-session information could be retrieved by the researcher or co-researcher. For such i s the nature of memory and verbal communication that, even i f one possessed unlimited time to remember and describe one's experience (which co-researchers did not), a precise representation i s un l i k e l y . Some experiences may be outside the realm of language. Alan Watts writes that words can express no more than a t i n y fragment of human knowledge, for what we can say and think i s always immeasurably less than what we experience. This i s not only because there are no l i m i t s to the exhaustive description of an event, as there are no l i m i t s to the possible d i v i s i o n s of an inch; i t i s also because there are experiences which defy the very structure of our language, as water cannot be carr i e d i n a sieve (1983, p. 3). Further, the f a l l i b i l i t y of memory i t s e l f may ultimately render a l l accounts of remembered experience at lea s t marginally suspect (Loftus & Hoffman, 1989) . 102 Researcher Bias and Influence Despite the researcher's attempt to wade into the large body of co-researcher experience without preconceptions or expectations, i t would be naive to assume such a neutral approach to research i s possible (Kuhn, 1962; Laing, 1967). For one cannot help but interpret through the f i l t e r of one's previous t r a i n i n g and experience. Further, although the author has attempted to investigate each co-researcher's "experience as i t i s experienced" ( C o l a i z z i , 1978, p. 53), as R. D. Laing writes, i t i s f a l l a c i o u s to believe we can investigate or i n t e r p r e t the experience of another, without becoming part of, and hence, influencing, the very thing we are attempting to investigate. S o c i a l phenomenology i s the science of my own and of others' experience. I t i s concerned with the r e l a t i o n between my experience of you and your experience of me. That i s , with interexperience (1967, p. 5) Therapist Style Both of the psychologists who graciously p a r t i c i p a t e d i n t h i s study, although following standard EMDR protocol (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 how they interacted with t h e i r c l i e n t s . 103 The psychologist who treated "B" performed over twice as many sets as the mean number of h i s colleague, who treated both "A" and "C." The former also placed considerably more emphasis on somatic experiences than the l a t t e r , by more frequently asking h i s c l i e n t to "scan her body." I t i s d i f f i c u l t to say how these differences might have affected c l i e n t experience, i f at a l l . Medication Use of medications was not consistent across a l l co-researchers. At the time of the i n i t i a l EMDR session, "B" was using alprazolam (Xanax; a benzodiazepine); "C," n o r t r i p t y l i n e (a t r i c y c l i c ) ; and "A" no medication whatsoever. Regarding the eff e c t s of medications on treatment, Shapiro writes that "so far , no medications appear to completely block EMDR processing, although the benzodiazepines have been reported to reduce treatment e f f i c a c y " (1995, p. 100). I t remains d i f f i c u l t to speculate confidently how d i f f e r e n t i a l medications might have affected co-researcher experience i n t h i s study. Summary This study i s the f i r s t to systematically investigate the moment-to-moment experiences of three co-researchers rec e i v i n g t h e i r f i r s t session of EMDR. Using a va r i a t i o n of both Interpersonal Process Recall (IPR; E l l i o t , 1994) and C o l a i z z i ' s (1978) phenomenological research methodology, findings confirmed many descriptions 104 of experience offered by Shapiro (1995); with nothing of a disconfirming nature being discovered. 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Journal of Consulting and C l i n i c a l Psychology. 50(3) , 407-414. 116 APPENDIX A 117 Dear C l i e n t : I am a Master's student i n Counselling Psychology at UBC, i n v i t i n g you to par t i c i p a t e i n a research study I am conducting, for my thesis, into Eye Movement Desensitization And Reprocessing (EMDR), a procedure you are about to experience. I am gathering information about the experiences i n d i v i d u a l s have during t h e i r f i r s t session of EMDR. Such information w i l l be useful to future c l i e n t s , by giving them a sense of what they might expect during t h e i r own EMDR treatment. Should you par t i c i p a t e , Dr. Wilensky w i l l tape record your i n i t i a l 90 minute session. Then, at your convenience (preferably within 48 hours), I w i l l arrange to interview you about your experiences using the tape recording to help you remember. A f i n a l interview w i l l be arranged at a l a t e r date, during which I w i l l show you what I have written, and ask for your feedback as to i t s accuracy and completeness. The t o t a l time required of you (not including your i n i t i a l session with Dr. Wilensky) w i l l be between three and four hours. Your i d e n t i t y w i l l remain co n f i d e n t i a l during and a f t e r the study, with your name being omitted and replaced by a numerical code. A l l tapes w i l l be erased immediately a f t e r the project i s completed. Please note that you may refuse to p a r t i c i p a t e i n t h i s study, and may withdraw at any time, without, i n any way, af f e c t i n g your therapeutic relationship with Dr. Wilensky. Should you have any questions regarding the project, please contact me at the telephone number below. Research T i t l e : Six Participants' Experiences of Their F i r s t Session of Eye Movement Desensitization and Reprocessing. Brett Peterson 731-3457 Faculty Supervisor: Larry Cochran, Ph.D. 822-6139 I consent to pa r t i c i p a t e i n t h i s study, and acknowledge rec e i p t of a copy of 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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