EMDR Within a Phase Model of Trauma-Informed Treatment

Ricky Greenwald

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136867163
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

A practical guide to learning and using EMDR Trauma is a potential source of most types of emotional or behavioral problems. Extensive research has shown EMDR to be an effective and efficient trauma treatment. EMDR Within a Phase Model of Trauma-Informed Treatment offers mental health professionals an accessible plain-language guide to this popular and successful method. The book also introduces the Fairy Tale Model as a way to understand and remember the essential phases of treatment and the tasks in each phase. This manual teaches a clear rationale and a systematic approach to trauma-informed treatment, including often-neglected elements of treatment that are essential to preparing clients for EMDR. The reader is led step by step through the treatment process, with scripted hands-on exercises to learn each skill. In addition to presenting the fundamental EMDR procedures, EMDR Within a Phase Model of Trauma-Informed Treatment teaches a treatment system that can be applied to a variety of cases. Using research-supported and proven-effective methods, this book takes you through the treatment process with easily-understood dialogues and examples. Explicitly guided exercises produce hands-on skills and familiarize you with ways to explain trauma to clients and prepare them for EMDR. You will also learn to problem-solve challenging cases using the trauma framework. EMDR Within a Phase Model of Trauma-Informed Treatment also includes an Instructor's Manual with:

• • sample syllabus
  • teaching tips
  • PowerPoint slides
  • test bank.
  Additional discussions address:
• why trauma matters
• posttraumatic symptoms
• the trauma wall
• the structure of trauma treatment
• the role of EMDR
• the eight phases of EMDR
• preparing clients for EMDR
• legal and medical issues in EMDR
• problem solving strategies in EMDR sessions
• treatment strategies for a variety of presenting problems
• using EMDR with children and adolescents
• use and application of the fairy tale model
• on-line and digital resources

Designed to be a comprehensive primer, companion/supplemental textbook, and valuable reference resource, EMDR Within a Phase Model of Trauma-Informed Treatment is ideal for clinicians already trained in EMDR, those actively learning EMDR, and mental health professionals interested in EMDR. Note that to practice EMDR requires formal supervised training.

SECTION II:

PHASE 1—CLIENT HISTORY AND TREATMENT PLANNING

From here on, the fairy tale model trauma-informed treatment approach will be outlined, step by step. This will be done in parallel with the phases of the EMDR protocol. Although it may be confusing at first to be working with both models at once, eventually you’ll get used to it, and you’ll be glad you did. It’s important to learn the EMDR terminology so that you’ll be able to communicate with other EMDR-trained clinicians. And it’s important to learn the fairy tale terminology because that will help you to remember to take your client through each step in the treatment. Fortunately, the EMDR and fairy tale models are consistent with one another and work well together.

Structured Treatment Approach

You will notice that this is a highly structured treatment approach. The reason for this is that you are the professional, and your client is contracting you for services so that he or she can achieve treatment-related goals. You are supposed to have the expertise to deliver the service effectively and efficiently. This is not to say that the client has no choice or input. To the contrary—the whole point of treatment is to accomplish the client’s goals. However, this does not mean that the therapist should rely on the client for technical guidance on how the treatment should be conducted. In other words, it’s not okay to just do what your client tells you to do, or to just “follow the client’s lead.” If you went to a doctor and said, “Just give me a prescription for penicillin” and your doctor did so, you should be going to another doctor. You want your doctor to pay attention to you, but also to make his or her own diagnosis and recommendations, and discuss it with you.

Another problem with just doing what your client wants to do, or talking about whatever your client happens to bring up, is that no informed consent exists. Your client is making decisions and guiding the treatment, but without the benefit of your professional advice. Your client should know what you know before he or she decides. This means that when your client tells you the presenting problem, or what memory he or she wants to work on, it’s up to you to figure out what you believe will be the best way to help. Then give your client adequate information— including the reason for your recommendation, as well as alternative options with pros and cons—to make an informed decision. Your job is to use your professional knowledge and skills, then your client’s job is to make decisions. You have to do your job for your client to be able to make the right choices. Much of the art of therapy is in helping your client to understand his or her problems with a perspective that will lead him or her to make beneficial choices.

Phase 1

Phase 1 of the EMDR protocol (see Shapiro, 2001, Chapters 3 & 4) is essentially the intake/evaluation phase of treatment. It begins with the first meeting (actually with the first contact) and ends when feedback on the evaluation has been provided, recommendations have been offered, and the client has decided, with the therapist’s guidance, how to respond to these. Typically this involves a treatment contract, that is, an agreement for the client to engage in specific treatment activities to address the issues raised in the evaluation. The evaluation should normally be scheduled to be completed as soon as possible, even within a single day, because:

• People tend to come for treatment in times of crisis.
• People in crisis are most willing to engage in treatment; when things have quieted down, they may be less interested (until the next crisis).
• Even though the evaluation should be beneficial in many ways, it is not called treatment. People in crisis should not be made to feel that they are being kept waiting for the official treatment to start.

In short, a rapid evaluation process will help clients to feel that their pressing concerns are being taken seriously and responded to quickly, and will increase the chances of clients choosing to engage in the recommended treatment.

Trauma-informed treatment—or any treatment—really starts with the first contact. It should go without saying that the person making the phone call or other initial contact should be treated with courtesy and respect and be given all necessary information in an understandable form, that some connection should be made even in a limited first contact, and that hope should be conveyed (see Greenwald, 2005, Chapter 3). This approach will maximize the likelihood that the client will show up for the first meeting.

It should also go without saying that every effort should be made to honor and take into account the relationships that the client forms with the helping professional(s) (see also Dworkin, 2005). Treatment does not arbitrarily begin after the “evaluation” has been completed and “treatment” starts. Treatment starts at the first contact. This is when the client (and family) begin to form a relationship with whomever they are interacting with.

A tweny-three-year-old woman who had been sexually assaulted went through the three-session assessment with the intake worker at the community mental health clinic. Her case was discussed at a staff meeting and then assigned to a therapist. The woman never showed for her therapy appointment. She told her friend, “I already talked to that one lady, I practically told her my life story. She’s the one I’ll talk to. I’m not going to start all over again with a stranger.”

Also, as the evaluation phase of treatment progresses, the client is telling his story, the therapist is giving feedback—much is happening. We may be tempted to underestimate how much treatment is really taking place even before we agree on a treatment plan and “begin.”

An eleven-year-old boy went through a two-hour evaluation following a school referral for disruptive behaviors and failing grades. The evaluator provided a trauma-informed case formulation and treatment recommendations to the boy and his parents. However, implementation of the recommendations (for treatment) was delayed by four weeks until after the plan was approved at his individualized education program meeting. When he returned to the same clinician to commence treatment, he said, “I don’t need to be here, I don’t have a problem anymore.” Indeed he was doing much better with his behaviors and his school performance. He explained, “Once you explained everything to me [at the end of the evaluation], I knew what to do about it.”

That so much may be accomplished during the initial intake/assessment phase of treatment is not accidental. We have much to accomplish at every phase of treatment. The following are the primary goals of the evaluation phase:

• Establish a sense of safety and predictability in the therapy.
• Enhance/reestablish primary attachment relationships.
• Provide trauma-related psychoeducation.
• Develop a case formulation.
• Identify goals and enhance hope in achieving them.
• Develop a trauma treatment contract.

The stated purpose of the evaluation phase is to learn about the client in order to understand what is wrong and how to fix it. However, the therapist can accomplish the remaining goals along the way, by behaving in a manner designed to instill a sense of safety and predictability, and by presenting information in a manner designed to increase understanding of the client, empathy toward the client, and hope for healing.

Remember, we can’t just say “trust me” or “you can feel safe now.” We have to do the work, to give clients experiences with us that will allow them to learn to trust us and to feel safe with us.

Chapter 4

The Initial Interview: From “Hello” to History

How does a trauma therapist say hello?

Actually, much goes into how we introduce ourselves and kick off the treatment relationship. The first goal is to establish a sense of safety and predictability in the therapy. We can do this by telling our clients what’s going on and what to expect. The trick here is to tell them the truth, and to offer a truth that is reasonably enticing.

Psychotherapy was initially considered suitable only for intelligent, articulate, psychologically oriented clients, but now we try to treat a much wider range of people. This brings special challenges. The psychotherapy literature tells us that clients from minority groups are more likely than others to drop out of therapy so quickly that treatment never gets a chance to work (Wierzbicki & Pekarik, 1993). The same is true for individuals who are not so intelligent, psychologically minded (i.e., insight-oriented), or verbal. This does not imply that these groups are similar, but both groups tend not to understand the appeal of the traditional unstructured talktherapy approach. Children in treatment have many similarities to these groups, in that children may not understand the purpose of unstructured talk, and they may not be particularly psychologically minded or verbal. So it’s important to understand that, along with many types of adults, children as a group may be difficult to engage.

The literature also tells us that certain therapist practices can mitigate this problem and help these people to stay in treatment (Sue, 1998; Nader, Dubrow, Stamm, & Hudnall, 1999). The therapist can acculturate the client by explaining what therapy is, what the procedures are, how it works (and why these procedures might help), and what is expected of the client. It is also helpful when the therapist’s style is directive, goal-oriented, and activity-focused rather than unstructured.

Acculturation

CLIENTs who are not “therapy-wise” do not generally understand why an undirected “talking about whatever you want” is supposed to help them. As one incarcerated thirty-year-old woman said, “They’ve been giving me counselors for years, but all that talking doesn’t make a difference. I still do what I do.” Clients want to know what to do to solve their problem, and they don’t see how this kind of talk will get results. When the therapist explains the therapy procedures and why these procedures can be expected to help the client, clients are more likely to engage and to stick around. Therapists can also tell the clients what to do—how to behave in order to be successful in treatment. Then clients know, and have a better chance of doing it.

Therapist Style

The other issue here is what actually happens in therapy. Just “talking about your feelings” doesn’t necessarily help (and might actually do harm if the feelings are overwhelming). The trauma-informed treatment approach consists of a series of tasks, and relies on a directive therapist to guide treatment accordingly, while also being sensitive and responsive to the client. When the client is helped to recognize the impact of his or her trauma (the dragon), to identify his or her goals (the princess), and to understand how the treatment plan might help him or her to overcome problems and achieve goals (personal training to slay the dragon and marry the princess), then the client is more likely to engage and to stick around.

Introducing Treatment

The therapist can start, then, by explaining what treatment is for and what is expected to happen in treatment. Here’s an example of what a therapist might say at the beginning of the first session:

THERAPIST: Why don’t you start by telling me in just a sentence or two: what brings you here?

CLIENT: Well, my wife’s kind of had it with my temper, there were a couple of times I got a little out of hand. I’m basically here because she insisted.

THERAPIST: Usually people come here because someone is worried about them, someone thinks that they could be feeling better, acting better, doing better in some way. My job is to learn a lot about you: what you care about, what you want for yourself, and what might be getting in your way. So I’ll be asking you a lot of questions. Then I’ll tell you what I learned. Then I’ll give you some suggestions for how to get what you want, what to do about the things that are in your way. Is this what you expected when you came?

CLIENT: Sort of. Not really.

Note that we are not focusing on the client’s problems at this point. We are acknowledging that problems exist and suggesting the possibility of solutions. However, the first focus is on acculturation, on what we’re doing here, why, and how we are going to do it. This continues with an explanation of the rules and expectations.

The Rules

THERAPIST: Before we get started with the questions, I want to tell you what the rules are for our meetings together. The first rule is that I don’t tell other people what you say. What you say here is private. But there are exceptions. One exception is if you give me permission to tell someone about a certain thing. Also, if I’m afraid someone’s in danger, the law says that I have to tell.

This is the place to go over all rules and expectations regarding confidentiality, payment, cancellation policy, and any other conditions that apply. Stating the rules makes them explicit. Therapy is a new setting for most people, and knowing the rules and expectations up front helps them to feel secure because then they know what to do and what will happen. Here is an important one:

Therapist: The next rule is about what you do and say. Your job is to take care of yourself, to make sure that you’re okay, and to let me know if there is something that’s making you uncomfortable. Also, you should not say anything in here, unless you decide you want to. So what if I ask you a question that you don’t want to answer, how do you follow this rule, what can you do?

Note that this rule is not phrased as “You don’t have to answer a question if you don’t want to.” That’s not a bad rule, but it carries the implication that the client can choose to not participate by not answering a question. That sets up both the client and the therapist to feel as if they have failed. This rule, “You may not speak unless you decide you want to,” carries the implication that the client is participating fully regardless of the choice. Later, when the client refuses to answer a question, the therapist can say, “I’m so glad you remembered my rule!” Thus both the client and the therapist remain successful.

Helping the client remain successful is a core element of trauma-informed treatment for a couple of reasons. First, in the fairy tale model, we are focused on personal training to help the client develop strength and skills. When failure becomes habitual...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• Section I: Trauma-Informed Treatment And EMDR
• Section II: Phase 1—Client History And Treatment Planning
• Section III: Phase 2—Client Preparation
• Section IV: Phases 3-8—Trauma Resolution
• Section V: Advanced EMDR Applications
• Appendix. EMDR and Trauma Treatment Resources Online
• References
• Index