1: Who's Sitting Opposite You?
Phase 1 of the standard eye movement desensitization and reprocessing (
The Therapeutic Relationship—Back to Basics
Many practitioners who are new to
Therapists should ensure they are
Offering the core conditions of unconditional positive regard, empathy, and congruence (Rogers, 1995; see Chapter Resource 1.1: Roger’s Core Conditions)
Creating an environment, through the development of trust and rapport, in which the client is able and willing to be vulnerable
Being flexible according to the client’s needs and that they have a tool box of strategies
Attending to client safety (see Chapter Resources 1.2: Suicide Ideation and 1.3: Brief Suicide Counseling Model).
Table 1.1
The Conscious Competence Model
| Stage 1: Unconscious Incompetence | Stage 2: Conscious incompetence |
| Therapists are not aware of the existence or relevance of | Therapists become aware of the existence and relevance of If you are reading this book then you have made the commitment to learn and practice |
| Stage 3: Conscious competence | Stage 4: Unconscious competence |
| Therapists achieve “conscious competence” in a skill when they can perform it reliably at will. They still need to concentrate and think to perform the skill because the skill is not yet “second nature” or “automatic.” | Therapists become so practiced in their Do we ever really get there ….? |
This model provides a simple explanation of the process and stages of learning a new skill. The learner or trainee always begins at stage 1, “unconscious incompetence,” and moves through stages 2 and 3 to end at stage 4, “unconscious competence.”
All these are necessary before using
What Does the Client Need?
Clients need to be aware that the process of
Impairment in daily functioning
Unstable lifestyle
Inadequate coping style and resources
Few available significant others or reliance on one person alone
Uncooperative in prior psychiatric treatment or unreceptive to help
Chronic illness
Parasuicide acts or suicides within the family
Previous suicide attempts
Recent losses
Severe depression or hopelessness
Chronic abuse of alcohol/drugs
Unexplained improvement in clinical features.
Although highly effective,
Clients will need varying amounts of therapy time to create this resilience. You will need to explore your client’s ability to self-soothe, encourage their use of social support, and assess their control over any external stressors both current and likely to occur in the future. Other demands (such as upcoming exams, high workloads) will have an impact on the client’s finite resources. Systems issues may need to be addressed, for example, the therapist working with a victim of domestic violence should consider ongoing risks.
Perhaps because
Whatever You Do, Don’t Do This…
Claire came to therapy for an anxiety disorder. Her therapist introduced the concept of
“Oh, I think I’ve had that when I saw another counselor a couple of years ago. He didn’t say what it was though. It was our first meeting and I was talking about my problems when he just said ‘stop there a moment,’ came and sat right next to me and started waving his fingers in front of me. I don’t think it really worked….”
Common Pitfall The Client Is Not Ready for Therapy
On occasion, clients may have been “sent” to therapy by an employer, a well-meaning friend, relative, or a professional. Alternatively, they may have heard
It is important in such cases to establish in the history-taking phase what brought them to therapy, why now, what are their hopes and expectations, and what are their fears? What do they expect to be different once they have completed therapy and what do they understand the process to be? Eliciting this information early on in the relationship can prevent frustration and disappointment and create a transparency that allows the client to make a choice as to whether to engage. It is also important to carry out regular reviews to ensure the client maintains engagement.
Secondary Gain
For some clients there may be ambivalence about recovery from their dysfunction or distress. This may not always be something to which they give a conscious thought, and therapists should explore the possibilities of secondary gain in a sensitive and nonjudgmental manner. Common secondary gains include the loss or reduction of a compensation claim or disability pension. Others include the loss of their identity, particularly for veterans or survivors of abuse, or for clients who identify too closely with their symptoms and struggles with life.
Dissociative Disorders
It is strongly recommended that
Case ExampleSecondary Gain
Henry had reactive depression following serious bullying at work. During the subsequent internal investigation, he had felt unsupported by his managers and had left work to go on sickness absence due to raised levels of anxiety and disturbed sleep. An emerging secondary gain for him was that, if he recovered, he would have to return to the workplace. Additionally, he believed that he would be giving his employers the impression that he had not been that badly affected and they could forget what had happened to him—he needed to be seen to “suffer” for them to care. Recovery was equated with “forgive and forget,” and he was not ready for that to happen.
See chapter 3 for more information on
Cautions
Legal Issues
There are several legal issues that concern supervisees:
The use of
EMDR during ongoing litigation cases (see Frequently Asked Questions, concluding this chapter)Fears that a client may sue the therapist if previously dissociated material surfaces during
EMDR therapyFears that a lawyer will attempt to devalue or “rubbish”
EMDR or even suggest that the therapist has done harm.
Table 1.2
Cautions
| CONDITION | ACTION |
|---|---|
| Contact lenses | Client may experience discomfort with eye movements and should remove contact lenses during desensitization |
| Eye diseases, surgery | Seek advice from ophthalmology consultant; use alternative Never continue eye movements when client reports eye pain |
| Pregnancy | Seek physician advice and consider the appropriateness of avoiding high levels of arousal during the pregnancy |
| Heart condition Respiratory condition Severe physical impairment Trauma-related memories that involved severe physical sensations, for example, choking, drowning, intense pain/invasion | Seek physician advice and consider whether it is appropriate to treat as an inpatient or in a setting where medical assistance is readily accessible |
| Epilepsy | There is a very low probability of Consult with client’s neurologist as to whether increased affect or repetitive |
| Active drug/alcohol abuse | Consider what other support needs to be put in place. Therapists may work with such clients in partnership with professionals skilled in working with addictions. For nonactive drug/alcohol abuse, therapist and client may agree to a nonabuse contract for the duration of therapy. Clients need to be as stable as possible prior to desensitization and the risk of relapse actively monitored |
| Schizophrenia | Seek physician advice and assess the need for accessible medical assistance, restraint, and medication |
| Organic brain damage | Seek physician advice |
| Prescribed medication | Medication may be needed to stabilize the client during therapy and its efficacy and appropriateness should be monitored as progress is made by a suitably qualified professional. |
If in doubt, always seek advice from an appropriately qualified physician or consultant.
Therapists are less likely to encounter scrutiny of their use of
Pre-EMDR Questionnaire
At this point, supervisees are often wondering whether they will ever get a client who passes all the criteria for
Table 1.3
Pre-EMDR Questionnaire
| ADDITIONAL PRE- | |
|---|---|
| CHECK | ANY COMMENTS |
| Has the client got suicidal thoughts or intent? Has he/she previously attempted suicide? Has he/she reported current or previous self-harm? | |
| Does the client drink excessively, take drugs, gamble, or have any other comorbidity? | |
| What is the client’s score on the Dissociative Experiences Scale? (See chapter 3 for meanings) | |
| Are there previous critical events in the client’s history? | |
| Does the client know how to self-soothe? Can the client manage high affect? What coping skills are used regularly? | |
| Have you enhanced a safe place and does the client practice it regularly? | |
| If there is a current ongoing legal case, has legal advice been sought? | |
| Does the client have epilepsy? | |
| Any head injuries? | |
| Is the client pregnant? | |
| Any other medical condition? If so, does client need to see physician? | |
| Any medication? Prescription or otherwise | |
| Has client been given literature on | |
| What is the client’s understanding of | |
| What (if any) are the client’s expectations? | |
| What (if any) are the client’s fears? | |
| Informed consent form signed? | |
| Check out preference for | First choice: Second choice: |
| If using eye movements, does the client wear contact lenses/glasses? Has the client got any eye diseases or problems with his or her eyes other than refractory problems? | |
Case Study: Introducing Emma
Throughout this book, we will be illustrating common pitfalls as well as offering techniques and advice on how to avoid them. A variety of case examples will be shown in text boxes but we will also be taking readers through a complete case from start to finish. Emma’s is a composite case study, and information relating to her case will be described in text boxes so that readers can more easily follow her progress. A snapshot of Emma’s assessment below gives a rough guide as to the kind of information that should be gathered to determine suitability for
Case Study: Emma
Emma was 27 years old; she was of medium build with dark brown shoulder-length hair. Quietly spoken and very nervous on our first meeting, she could hardly look at me and her shoulders were bent forward as she sat on the edge of the seat. Emma was dressed in a grey shapeless jumper and baggy jeans that appeared to swamp her. She took a while to tell me that she had decided to seek therapy following a “bad experience with a boyfriend.” She began by telling me how stupid she was being and that she should not have got herself in this situation. She was clearly embarrassed about telling her story and needed reassurance that she would not be judged. It transpired that, 6 months ago, she had been out for the night with a new boyfriend, Duncan. She had seen him a couple of times previously and was enjoying his company. At the end of the night, they had shared a taxi home and she had invited him into her shared apartment for a coffee.
“I suppose I gave him the wrong impression. We were having a lovely evening talking and laughing, and I just wanted it to carry on a little longer.”
Emma became increasingly tearful as the story unfolded, and she expressed anger with herself. I just let her talk, focusing on providing a safe relationship for her to do so.
Duncan had followed Emma into the kitchen, and although she had initially welcomed his advances, he became more insistent and had eventually forced her to have sex. Emma was devastated and blamed herself.
“He kept telling me I’d led him on, how he’d spent a fortune on a fancy restaurant, and now I was being selfish. He said I shouldn’t wear what I was wearing if I didn’t want sex. It was just a pretty summer dress—I’ve thrown it away now. Afterward he kissed me goodbye like nothing had ever happened. I must have missed all the warning signs. I thought he was a nice guy. Maybe it is my fault ….”
Emma was having difficulty with her reaction to what had happened. She explained that since it happened, she had become very withdrawn, would not venture out at night, had mood swings, and had lost her “sense of self.” She had also started to have panic attacks and was blaming herself for what had happened, so she had not reported it to the police.
“They’re not going to take it seriously. Let’s face it, they’ll just think I was stupid asking a man back when I’d had a few drinks. It’ll be my word against his and it probably was my fault. I just want to be able to put this behind me and move on.”
She was now complaining of poor concentration and being unable to sleep, and she spent most of her time at her mother’s home, not getting dressed all day as she was currently on sickness absence from work.
Emma’s Case Sheet
Name and reference number:
Emma Smith—07/ST
Address:
Currently resides at mother’s home
123 Rainbow Walk
San Francisco, CA
94111
Telephone No: (915) 555-5555
Occupation:
Human Resources Manager
Contract signed: Yes
Emergency contact—relationship, name, and telephone number: Mrs. Smith (mother)—as above
Family and significant others:
Parents: mother, Carol, 59 and father, Martin, 60 (lives 23 miles away)Both of good health and supportive but father unaware of situation Mother single; father remarried, no children with new wife Wendy ther, James, 34, lives 120 miles away and “busy with his family but we speak often.” Good relationship with his daughters, Maisie, 6 and Chloe, 10 Parents divorced 19 years ago Grandmother, Vera, 83, in nursing home Good friends, Kate, Susan, and Charlotte (unaware of whole story; Emma has isolated herself).
Psychological well-being prior to the incident (including suicide ideation, alcohol drug usage, previous counseling):
Good social network, lived happily and independently in an apartment. Works hard. No previous mental health issues. Social drinking only—none at all since incident. No previous suicide ideation or intention. Previously healthy diet and regular exercise. Hobbies included music, holidaying, and dancing.
Previous critical incidents or significant life events:
See lifeline
Postincident history and summary of current situation—last seen GP/medication?
Impact of Events-Revised Scale (Weiss & Marmar, 1996) completed: Yes Scores: avoidance = 16; intrusion = 21; hyperarousal = 24
Other information:
Emma had been to her physician 1 week ago and had been offered antidepressant medication, which she declined. Now just seeing GP for sickness absence certificates.
| Psychoeducation literature and explanation | Given |
| Leaflet on understanding trauma reactions | Session 1 |
| The body’s arousal system, the panic diagram, and dealing with hyperarousal | Session 1 |
| Self-nurturing activities leaflet | Session 2 |
| Fact sheet 1—Managing sleep disturbance | Session 1 |
| Fact sheet 2—Managing symptoms of reexperiencing | Session 2 |
| Fact sheet 3—Managing symptoms of avoidance and numbing | Session 2 |
Arrangements made with client:
Initial weekly contract for 10 sessions followed by review
Initial reflections:
Emma has good resources but needs to be encouraged to use them. She seemed committed to following the advice given regarding symptom management.
Systems control is reasonable. Her employers are not putting any pressure on her to resume work. However, this may change.
Themes from lifeline and assessment reflect safety, shame, being deserving, and blame (highlighted in bold).
Emma seems to have a need to work hard (school and employment), and I wonder what is driving this?
Does she have suppressed memories around divorce?
Is EMDR Suitable for the Client?
It can be tempting for therapists, particularly when they are fresh from basic training and keen to use
During history taking, the therapist needs to consider carefully any early memories that may be responsible for setting the groundwork for the current dysfunction, in addition to the present complaints and goals for the future. From the moment the client enters the consulting room, therapists can be listening attentively for negative self-evaluations and paying attention to the client’s unspoken communications. Sometimes stabilization work may be needed before getting a detailed history, particularly with more traumatized clients.
Impact of the Past
Because past events can often be responsible for current dysfunction, careful exploration needs to be made of the client’s history. It is equally important to be aware of the past because of the potential for these events to surface during desensitization. Never assume face validity. There is a variety of methods for exploring additional past occurrences, and therapists should be flexible in their approach. It is important never to assume anything about the clients’ presenting issues, therefore, whatever the therapist’s theoretical orientation, a structured in-depth assessment and/or detailed exploration of history and symptomatology is advised. Some clients will find it more difficult to provide a full history to the therapist. Reasons for this can include shame, feelings of overwhelm when they focus on all the negative events in their past, and difficulties articulating or organizing their thoughts.
The Top Ten
Clients can be asked for the “top 10 significant events in their life.” It can be revealing to have the client include good and bad events in this. Some clients will struggle to come up with 10 events and may be better asked “what have been the worst/most challenging things you have experienced/witnessed in your life?”
Whatever You Do, Don’t Do This…
Peter came to therapy because he had been experiencing distressing nightmares in which he was horrifically attacked by a stranger wielding a machete. The nightmares had started around 2 years ago but were increasing in intensity and having a major impact on his waking day. He had become anxious and hypervigilant and was confused as to why he was suffering in this way.
Peter revealed no trigger for the onset of the nightmares. He was a social worker, and he enjoyed his work and had a settled home life. In fact, this was his motivation to sort out his problem as he was concerned that if he continued this downward spiral, then he could lose this.
The
“Oh, my neighbor is a therapist and she had been on an
And when was that…?
“Ooh, around 2 years ago…”
Sure enough, detailed history-taking sessions revealed that his neighbor’s “party trick” had uncovered traumatic material from his early childhood that, fortunately once reprocessed with
Creative Exploration
Clients and therapists may be more comfortable with creative exploratory exercises such as creating a lifeline. Using paper and pen, the client is encouraged to “plot” his or her lifeline. Starting at birth and ending with the present day, the client will mark significant markers along the way.
A similar exercise asks clients to depict their life on paper, as a corridor with doors on either side. Behind the doors are significant events and memories. The client does not need to open the door at this stage but can give each door a label. This serves to highlight to the therapist the existence of an event while keeping the client safe from its content until such time as sufficient trust and resources are present.
Common Pitfall The Client Talks Too Much or Too Little
One of the common complaints from supervisees is that “it’s like pulling teeth!” Some clients find it very hard to actually be in therapy and open up to a complete stranger. Some lack the ability to articulate their emotions or experiences. With many traumatic events there is an element of shame or fear of being judged.
It’s strange that, fresh from training, supervisees often forget or dismiss how they would usually handle this in their practice and get caught up in
Always ensure that the client is able to be open and vulnerable with you before tackling traumatic material in desensitization. Otherwise you will probably find that they somehow block their processing and you will both feel like failures.
Conversely, supervisees often bring the concern that the client is talking too much during the history taking, going off on tangents and overwhelming the therapist with fine detail. Things to remember here are:
This may be the first time that the client has ever been listened to—never underestimate the power of letting clients tell their various stories
Visual techniques such as lifelines and spider diagrams can be helpful to allow the client to focus
While clients are talking, they are offering up clues to the therapist about how they view themselves and others. For example, Harry could be awarded a gold medal for talking and the therapist was anxious to focus on the protocol. However, during this time Harry was feeling “heard” for the first time ever, thus building trust and rapport. His conversation was regularly dotted with phrases such as “they changed the goalposts,” “I never get what I need,” and “I’m on a treadmill.” Picking up on these themes helped later with the thorny subject of identifying negative cognitions.
Where the “verbal torrent” appears to be a defense mechanism, pushing the therapist away, this needs to be gently challenged.
In both the above cases, think “If I hadn’t done my
Maureen Kitchur’s Strategic Development Model for
An example of a mapping exercise is shown below for Emma.
Case Study: Emma’S Lifeline
| AGE | EVENT | CLIENT’S COMMENTS |
|---|---|---|
| 0–5 | Happy childhood | We lived in a nice town and I’ve got lots of happy memories, stuff like picnics and having friends round to the house. |
| 5–11 | Loved school, “my haven” | My teacher, Mrs. Jones, was really kind, and I remember she always used to put my artwork up on the wall. I think my parents were going through a bit of a hard time then so school was my haven. I always looked forward to it. I don’t remember any friction at home, but my brother James tells me there was a lot. |
| 9 | Parents divorced Went to stay with aunt for a while with two older cousins | I don’t remember much about the divorce other than that my mum lost her temper with me and James once. It must have been hard for her, and we were probably being a nuisance. |
| 11 | Friend of her cousin molests her during summer holiday | He was a lot older I think—about 17—he grabbed me and touched my breasts. I was an early developer, and I was ashamed and scared. My cousin came in the room, and I ran back to my aunt’s house. My aunt went mad when I told her. She said I shouldn’t have been hanging around with the older boys. |
| 11 | Moved to new area and starts secondary school | We moved to the town where we live now, and I started a new school. I didn’t really like it much, being the new girl, and it was very different from my old school. I worked hard though and did well. |
| 11–16 | Settling into new school | I was the quiet one, but I got a good circle of friends and didn’t have any problems with bullying or anything like that. |
| 18–21 | Went to college studying | I loved college. I felt grown up at last and I enjoyed my course. |
| 21– to date | Got taken on by current employer | I was lucky to get the job. I think they decided to take a chance on me. |
| 25 | Promoted | I’ve been very lucky. |
| 26 | Minor road traffic accident | Just glad it wasn’t my fault and no one was hurt |
| 27 | Index event |
Assessment Tools
There are various diagnostic tools that have been devised to identify
Common Pitfall Clients Are Overwhelmed by Negative Experiences and Unable to Find Anything Positive About Their Lives
Occasionally clients can present in therapy with such an overwhelming history of negative events that it can be difficult to draw on anything positive that has happened in their lives. In such cases, it is important during the first phase to be aware and to focus and highlight the clients strengths and resources, what they put in place to survive these events, how the events ended (did their actions contribute to this?), and whether they protected other people. Emphasize the courage it takes to come to therapy and face their fears. Check out how they might view someone else who had come through similar experiences and was, for example, holding down a job, raising a family, and living day to day.
These tests can be helpful in determining various features of posttraumatic stress and can also have the added advantage of validating a client’s symptoms. However, if clients are ill-prepared prior to completing the appropriate questionnaires, they can be left feeling more helpless and/or hopeless. It is important therefore to be sensitive to preparation for, and timing of, the test as well as to normalize the client’s current experiencing of reactions. Some of the questions may be open to different interpretations by both the client and the therapist, and, depending on the levels of trust and rapport, the client may not be ready to be totally honest with the therapist. Conversely, some clients may find it easier to disclose a past traumatic event in writing rather than verbally. Flexibility is the key.
Because the effects of a traumatic incident can be wide ranging, it can be argued that some tests can be deficient and may omit certain idiosyncrasies. Thus, an individual may fall “under the radar” of the diagnostic tests by not falling neatly into the
There is a danger that by using one trauma-specific diagnostic tool, other diagnoses could be overlooked. It is important that such tools are not used in isolation but rather used as part of a comprehensive approach.
Presenting Problems
It may seem obvious to state that the therapist needs to know what has brought the client to therapy, yet occasionally supervisees will neglect to spend sufficient time on this clarification as they focus on the event(s) that is “crying out” for desensitization.
Clients may describe their problems in a variety of ways including their symptoms of distress, dysfunctional behaviors, negative emotions, or feeling held back from a fulfilled life. The therapist needs to explore with the client the latter’s perception of the initial cause and duration of symptoms along with the frequency and intensity. Current triggers for distress should be identified. It is important to ask about other complaints that the client may or may not feel to be related so as to ensure as complete an understanding as possible of the whole picture (Chapter Resources 1.5: Mapping Exercise and 1.6: Identifying Symptomatology Using the Film Script).
At this point, it may be appropriate to offer psychoeducation and normalization of symptoms, and this in itself can prove of great relief to a client.
Goals for the Future
It is important to elicit the client’s desired future state and goals for therapy. A simple question such as “If you had a magic wand and you could use it to change your life tonight, how would you know this had happened when you woke up the next day?” Although this may seem obvious, in cases of bereavement the therapist may need to acknowledge the reality that the person who died cannot come back before asking the question.
Defining goals using the
For example, the client who states “I just want to be happy …”
Case Example Symptom Clarification
Jane complained of not sleeping very well. The therapist explored this with her.
Therapist: So could you perhaps describe a typical night, in terms of what time you go to bed, how long it takes to get to sleep…
Jane: Well, I generally go to bed around 10:30 p.m., but it takes me a couple of hours to get to sleep.
Therapist: What’s happening in those 2 hours?
Jane: I tend to toss and turn, I’m very fidgety and my mind then starts obsessing about things.
Therapist: Like?
Jane: Well, it can be things that happened during the day, or thinking about (the incident), worrying about what I’ve got to do next week.
Therapist: How much time is thinking about general worries and how much about (the incident)?
Jane: I suppose about 60% general stuff and 40% (the incident). It tends to be a spiral—I start worrying about the day-to-day stuff and move on to the incident.
Therapist: And then what happens?
Jane: Well, sometimes I get up and make a cup of coffee and other times I’m just so tired I eventually fall asleep.
Therapist: And what happens next?
Jane: Most nights I have bad dreams where I’m being chased or someone’s in the house. Usually this wakes me up, and I have to get up and put the lights on.
Therapist: How often?
Jane: Well, this week I’ve had dreams every night, last night was bad because I knew we had this session & I’d say I get up four nights out of the week.
Therapist: When you do get up, what do you do after you’ve put the lights on?
Jane: Usually read some of my books or watch TV until I’ve calmed down. Quite often I can fall asleep when it starts getting light outside. Then I sleep in until about 10 a.m., if I can.
Therapist: Does this have an impact on your daily functioning?
Jane: Oh yes! I’ve got in trouble at work for being late or I’m bad tempered all day because I’m tired and then I feel bad. Sometimes I get on the couch for an hour when I get home and just have a cat nap.
Therapist: What time is that generally?
Jane: About 5 p.m. I only work short days thank goodness, 11 a.m. until 4:30, otherwise I don’t know how I’d cope.
Therapist: Can you tell me a bit about your bedtime routine? What time do you eat your evening meal?
Jane: About 8 p.m. I go to the gym most nights as I’ve heard that exercise helps so I eat quite late. Then I watch TV and have a hot bath around 10 before I go to bed with my book.
Therapist: What do you have to drink in the evening?
Jane: I have to admit to a couple of glasses of wine—they help me sleep, but I have a pint of water before my bath so I’m not dehydrated. I’m really trying to do the right things…
Following this clarification, primary therapeutic goals included teaching the client basic sleep hygiene and techniques for managing nightmares. Without clarifying the symptom, these may have been missed as necessary. Jane was trying hard to do the right things but unfortunately many of her efforts were counterproductive. Providing psychoeducation gave her choices and empowered her to make positive changes that would underpin her further treatment.
Specific
What does happy mean to you? What are happy people like? Whom do you know who are happy (role model)?
Measurable
What would be different if you were happy? What would you see, do, feel? Who would be the first to notice and what would they see differently?
Achievable
Avoid goals where happiness depends on external influences that are out of the client’s control or dependent on other’s reactions, for example, if my parent no longer criticized me. Equally, the goal of being a 75-year-old ballerina may need some gentle challenging.
Realistic
Requests to win the lottery or to be happy 100% for the rest of their lives are perhaps not realistic.
Time Framed
This will give an indication of the client’s willingness to participate actively in the therapy, offer a reality check, and inspire hope.
Although this can be an empowering process for most clients, some may find it hard to imagine things being improved ever. A balance is needed between inspiring hope for recovery and making false promises. As with any other psychotherapeutic approach, goals should be set collaboratively and neither too low nor too high.
Particularly in cases of complex trauma, it is helpful to review these goals regularly as they may change as the client does.
Treatment Plan
By this stage, the therapist should have as complete a picture as possible and, only when this is done is it possible to begin conceptualizing the treatment plan.
The treatment plan identifies specific targets for reprocessing. These include the past memories that appeared to have set the pathology in process, the present situations that exacerbate this dysfunction, and the desired future response. Where clients have identified groups of memories with parallel cues (e.g. similar negative cognitions, emotional or physical reactions) these may be clustered to maximize the generalization effect.
This can be a complex area, yet is fundamental to the effectiveness of
Frequently Asked Questions
Q: My client is a police officer involved with a major court case in which he is to be called as a witness to a serious assault on a child. Because he wasn’t the victim, is it okay to use
A: Providing
Q: My client only wants to deal with a later trauma but she was abused as a child. She says she’s dealt with that. Is it OK to proceed?
A: This raises several questions. Firstly, there is no way of preventing dissociated or unresolved material from surfacing during desensitization. For this reason, the client needs to be fully informed that her earlier abuse may come up. Additionally, it may be helpful to gently challenge the client about any reluctance to discuss all past trauma. This could indicate that the therapeutic relationship needs strengthening or that the client is using avoidance techniques. Finally, links to earlier trauma may not always be apparent but it may not be possible to fully address later trauma if its foundation lies in these earlier issues.
Q: Do I need to take a full history for every client? One of my clients has come for
A: Yes. In the authors’ opinion, this is probably the most important phase and is the foundation for later work. Get this wrong and you will most certainly encounter problems later. This also avoids a “fishing expedition” and allows the client some control and understanding of his or her current reactions. Using a gardening metaphor, it is helpful to explain to the client that the presenting problem is rather like an insidious weed. The roots need to be completely removed in order to prevent its return. It is strongly urged that the therapist does not assume that the presenting problem, for example flying phobia, has only face validity. The memory network may contain other earlier experiences besides those involving flying, possibly associations to feeling out of control or unsafe.
Q: How do we know if we’ve got all the information from the history taking? I’m worried that my client may not disclose something relevant or may not even be aware of dissociated material.
A: It is important to explain the rationale for taking the client’s history so that the client can take responsibility for what he or she discloses. At some point we have to trust that the clients are doing this and we have given them sufficient opportunity to build a safe relationship in which he/she can do this. However, some memories may be preverbal or dissociated. The therapist needs to remain alert to new material and have ensured that the client is fully prepared for this eventuality. The informed consent form will help with this awareness, but the preparation phase is crucial. As we know from experience, many clients will identify additional memories as treatment progresses.
Q: Is
A:
Some of the indications that
Intrusive imagery or other “stuck” sensory material such as smells or sounds
Repetitive dreams and nightmares
Where the client rationally knows that something is untrue (e.g., I’m safe) but emotionally/behaviorally disagrees with this
A strong negative self-evaluation that is unjustified
Unexplained somatic symptoms
It is equally important to be aware of the appropriateness of education, marital therapy, assertiveness, anger management training, and problem solving when a client enters therapy.
Learning Summary
You should feel confident that you are able to:
Begin to build the therapeutic relationship
Assess whether the client is ready for therapy and, in particular, to consider the following:
A risk assessment of client safety
Any potential secondary gain issues
Screening for
DD (see chapter 2)Any physical contraindications
Legal issues
Client’s ability to self-soothe and access social support
The existence (or likelihood) of external stressors and their potential to have a negative impact on the client
Take a full history from the client including:
Past events that may be unresolved or contributing to the current presenting problems
Present dysfunction
Their goals for the future.
Resources
Carl Roger’s Core Conditions
1.1:Carl Rogers (1995) said that there are three core conditions: respect (also known as unconditional positive regard), genuineness, and empathy. He suggested that the three conditions are “core” because they are necessary for development to take place.
Respect is about valuing the other person as a human being. This does not involve approving of all of the other person’s behavior, but appreciating the other as a person. Each person is unique, and therefore has something to contribute to the experiences of others. Whether this contribution is regarded as positive or negative, it stems from the values of the perceiver. Being nonjudgmental is an important characteristic of therapy. Although the therapist will have his or her own values, it is not part of therapy to make judgments about the client. Acceptance is another term that is sometimes used for this core condition.
Genuineness is a characteristic of the therapist in the relationship. Rogers said that he aims to be “transparent” in this relationship. In other words, there is nothing that he is feeling or thinking that he wished to hide from the client. If, for example, there is some aspect of the client’s behavior that Rogers finds difficult or disagreeable, then he would aim to find a way to share this with the client. It is arguable that if these perceptions are not shared, then they will still be present and influence the therapist’s behavior in his or her relationship with the client. Openness is preferable, and in the long run, more therapeutic for the client.
Empathy is a characteristic that the therapist brings to the relationship. It involves being able to perceive a situation as the client perceives it. This is sometimes referred to as being within the client’s “frame of reference.” The therapist is able to see things as the client does. It is very different from sympathy. Sympathy is concerned with appreciating how someone else feels because that is the way you would feel in that situation. Because we are unique, this cannot precisely be the case; we can only approximately know how someone else feels in or about a particular situation. Often we may think that we know, but fall wide of the mark.
Suicide Ideation and Intent
1.2:It is not true that most people who complete suicide do not tell anyone. Eighty percent of the people who kill themselves have communicated their intention. Probably the biggest indicator of suicide is hopelessness. Other indicators can include stating goodbyes and putting affairs in order. The suicidal person’s ambivalence can lead to vague references to suicide and an expectation that the helper will inevitably understand these communications.
Therapists should always explore throwaway comments such as “I’ve had enough, they’d be better off without me, I can’t stand this.”
It is not true that if you mention it you may put the idea into his mind. If the idea isn’t there you will get told that he has no intention of doing that. If it is there, he will feel able to be more open about thoughts that he may have felt ashamed to admit. The opportunity to discuss suicidal thoughts can give relief and enable a person to put thought between impulse and action. The greater risk is that the idea becomes shameful and increases a sense of low worth and isolation.
It is not true that people who make suicidal gestures never do kill themselves. Some of them do kill themselves. Even if they may have half-hoped that they would be found, if they are very unlucky they still end up dead.
If the means of completing suicide are removed, then suicide rates will drop. As more cars are fitted with catalytic converters, asphyxiations by car fumes will drop. The suicide rate dropped significantly in the 1960s when British homes switched to natural gas. A government initiative in the 1990s made buying large quantities of paracetamol more difficult in an attempt to reduce overdoses. Where there is suicide ideation, the therapist should explore the extent of plans to carry this out.
| LOW RISK | MODERATE RISK | HIGH RISK | |
|---|---|---|---|
| Method | Undecided | Decided | Decided |
| Availability of method | No | Yes | Yes |
| Time and place | Not specific | Not specific | Specific |
| Lethality | Low | Moderate | High |
| Final arrangements | None | Some planning | Written notes, wills, possessions given away |
It is untrue that people who really want to die will find a way or that it would not help to try and stop them. The impulse to commit suicide is generally an acute, transient experience that often passes if delayed. Most suicidal people are highly ambivalent about suicide—often simultaneously desiring death, while desperately wishing to be rescued.
It is not true that if someone survives a suicide attempt it must have been a manipulative act. People usually have complex reasons for attempting suicide, and manipulation by itself is usually insufficient reason.
Brief Suicide Counseling Process
1.3:Recognize the risk
Listen actively
Look out for hints and desperate words
Look at the whole person; body language, demeanor, self-care
Explore the risk
Important to maintain Roger’s Core Conditions
Use explicit language
Accept depth of feelings. The current crisis may be caused by something that seems almost trivial, but in reality this may be the final straw, often a culmination of events.
Assess the level of risk
Assess short-term and historical risk factors
Interrupt the process
Gently challenge cognitive distortions
Instill hope
Build relationship
Delay action on impulses
Help with problem solving
Establish reasons for living/not dying
Mobilize internal resources
Close session
Mobilize external resources
Refer on
Help with time structuring and contract setting
Look After Yourself
Self-care and supervision: Take a few minutes after dealing with the situation to calm down. It is very normal to feel anxious, sad, or “fired up” after this kind of intervention. If you can, get some fresh air, speak to a colleague or your supervisor, have a cup of tea, or move away from the environment you were in. Do not throw yourself headlong into another intensive piece of work until you feel calmer.
Consider self-use of
Mapping Exercise
1.4:In their model of posttraumatic stress counseling, Bourne and Oliver (1999) described the importance of helping the client to survey the full effects of the traumatic incident. The client is encouraged to “map out” these effects in visual terms, for example, using paper and pen, and to think about what has changed, what remains the same, what has been lost, and what has been introduced since the incident?
Case Example
Mary was involved in an armed attack at the superstore where she worked. She has been off work with high anxiety for the last 2 months. Her completed mapping exercise is shown below:
| EMPLOYMENT | HOME LIFE |
|---|---|
| No longer going to work Occupational health nurse ringing weekly Visiting GP for sick notes Lost my good sickness record Colleagues are ringing me for progress reports Still getting paid No focus/structure to week/day I miss the lunch breaks and camaraderie Feel panic at the thought of returning | Children have been a continuous strength, and I enjoy spending time with them
Doing the school run is unchanged I’m doing more housework Relationship with grandmother is unchanged Feel let down by husband and defensive when he talks about work Parents are fussing, and my mum doesn’t talk about her own problems any more I like being at home (but not alone) |
| See work as risky now, particularly thoughts of being around money or stock-taking when store is closed I worry about my capability for managing conflict like customer complaints Supervisors/culture changes seem threatening No longer feel valued by work | Don’t watch TV now Would like to go away for a holiday but scared Don’t want sex but want lots of cuddles—hubby doesn’t know the difference so this causes conflict Okay about driving with kids but must put music on and lock the doors |
| SOCIAL LIFE | TIME ALONE |
| Friends are sympathetic but awkward Not as much face-to-face contact with work friends Strangers appear threatening People at school gossip—feel labeled No longer going to the gym Feel okay about having people round to the house so long as they don’t want to go over the robbery Feel okay in crowds—never used to but I seek company out (so long as they don’t ask questions about why I’m not at work) Am only able to go shopping with a companion | Don’t like open spaces Taking pills and have panic attacks I flit from one job to another, sometimes I clean like mad as a distraction Still like spending time with my children Jumpy at front door bell/telephone Don’t like being alone—used to Uncomfortable about coming back to house especially after dropping kids at school Comfort eating—put on 1 stone Unhappy with self-image Nightmares |
Identifying Symptomatology Using the Film Script
1.5:Using the metaphor of writing a film script, the client is asked to consider how life was before, during, and since the incident. This will include symptomatology, lifestyle, and any ways that his or her life has changed—the exercise should help provide a detailed narrative of life in the client’s shoes, past and present.
