In 1974, Hiroo Onoda, a Japanese soldier, came out of the jungle in the Philippines and was surprised to learn that World War II, which actually ended in 1945, was now over. This man had been caught in a time warp, stuck in a “reality” that no longer existed, with intense but unfortunate loyalties to people and institutions long gone. His situation resembled that of many adult psychotherapy clients suffering from complex posttraumatic stress disorder (Complex PTSD) and dissociative personality structure. For many of these individuals, who come to us with hope and even some degree of trust that we will help them, the war is not yet over. They are attempting to live life in a way that other people deem to be “appropriate” and “normal,” while also frequently experiencing “relivings” of a past trauma world—a world that, in many cases, no longer exists.

Many clients come to therapy with “issues” and emotional problems that do not fall clearly into the category of single-incident PTSD. Oftentimes, a client’s clinical picture might include significant psychological defenses, problems in forming and maintaining relationships with others, addictive disorders, and dissociative separation between personality parts. This is a book for therapists who are trained and experienced in using standard eye movement desensitization and reprocessing (EMDR; as taught in the basic Eye Movement Desensitization and Reprocessing International Association [EMDRIA]-approved trainings), but who are stymied sometimes about how to structure therapy sessions to help clients with more complex emotional problems. The methods described in the chapters that follow are meant to supplement, not replace, standard EMDR procedures (Shapiro, 1995, 2018). The standard procedures are extremely useful and effective (Maxfield & Hyer, 2002) with a wide variety of clinical presentations that originate in or include disturbing traumatic memories. However, for some clients, those who have suffered early, complex, and prolonged abuse or neglect, additional therapy “tools”—conceptual models and specific therapy interventions—can significantly extend the therapeutic power of EMDR-related methods.

I began using EMDR in 1992. At that time, I had a practice as a therapist for several decades, with the particular focus of treating complex emotional problems—personality disorders, addictive disorders, clients with “thought disorders” and poor reality contact, and clients with histories of childhood abuse. EMDR met a need that had repeatedly come up in my work with clients. Many people who had been in therapy over the years had developed cognitive understanding of why they were unhappy, and this had helped, but part of the affective element of their initial problem had remained. One person said, “I know why I am nervous around my father, after everything that happened when I was a kid. I know all that, but when he calls on the phone, I still feel anxious, like I am 10 years old, all over again!” For many clients who endured sexual abuse or sexual assaults, the therapy process was very arduous, and for those who had gained insight into their history, but still had intense feeling of shame or fear, all I could suggest was continuing exposure to these irrational affects, either in my office or when these feelings arose between sessions.

EMDR was a solution to this problem. It was a way to break through, relatively quickly, and help these individuals tame the flashbacks and the disturbing emotions that had resulted from their prior life experience. My enthusiasm for EMDR was channeled into several research projects, work with the Trauma Recovery/EMDR Humanitarian Assistance Program, and, in my practice and in writing, exploration of ways that EMDR-related procedures could be used in the treatment of the more complex psychological disorders.

Therapists who are trained and experienced in the use of EMDR often report a particular phenomenon during the first year after their training. The composition of the therapist’s clinical practice is likely to significantly change. Those clients with simple, single-incident posttraumatic disturbance—a traumatic event that the person was depressed or anxious about, and was reliving mentally—were able to finish therapy fairly quickly, say “Thank you very much!” and be on their way. Consequently, within the practice of a newly trained EMDR therapist, there tends to be a shift to an increasing proportion of clients with more complexity in their clinical picture. The great majority of clients come to therapy with “issues,” not just of troubling memories but also of interpersonal problems and significantly problematic personality structure. Oftentimes, that is when additional conceptual models and additional procedures—additional therapy tools—are needed.

This book has two main goals: to provide descriptions of specific EMDR therapeutic “tools” and, by incorporating these tools, to develop an overview of an Adaptive Information Processing (AIP) model of the treatment of Complex PTSD. The development of EMDR-related tools has been ongoing since the introduction of EMDR three decades ago (Shapiro, 1989). Since that time, many advanced applications and extentions of the EMDR Therapy approach have been developed. What will EMDR be in 2030? Unfortunately, our field—the field of psychotherapy for trauma-related disorders—has at times had a kind of dissociative disorder. Some therapists identify with one theoretical approach, and others are strong adherents of another identity. Often, these two “identities” do not communicate sufficiently, and sometimes they mistakenly think they have to fight with each other. Clearly, my primary identification as a therapist is with EMDR-related methods based on an AIP approach, but in each of the following chapters, I am also attempting to integrate the concepts and methods of cognitive approaches—approaches that are not only useful, but at times essential in the treatment of dissociative clients.

The use of the word “tools” is intended here to be metaphorical: a person who builds houses for a living needs to use power tools, but that person also needs to know, in general, how to build houses! A contractor or carpenter needs to know how to put up drywall, read blueprints, put in the electricity and plumbing, and so on. The tools I will be describing in this book are meant to be blended, for the reader, with other skills previously acquired as a psychotherapist.

Many EMDR therapists are quite aware of the need in their work for additional concepts and interventions, particularly when working with clients who have extensive trauma histories going back to childhood abuse and neglect. Some new EMDR therapists take the approach of alternating between “doing psychotherapy” and then putting their psychotherapy skills on the shelf so that they can “do EMDR.” Often, therapists will attempt to create a “hybrid” therapy, combining elements of EMDR with whatever therapy model the therapist was using before. This mixing of models can be useful if the therapist remains alert to the ways that the best elements of each model can be successfully integrated. But it can be problematic if the “hybrid” leaves out crucial elements of EMDR such as the targeting of specific key memories; the focused use of sets of bilateral stimulation; the identification of negative beliefs about self that are related to traumatic events; the identification of a positive, more realistic cognition about self that might replace the negative belief; and/or the emphasis on including physical sensations in the processing. Fidelity to the basic EMDR eight-phase model has been shown to be very important for the effectiveness of the method (Maxfield & Hyer, 2002), and so alterations and extensions of EMDR for therapy for more complex clients require the careful judgment of the therapist (as well as the informed consent of the client). As a general rule, we can say that, for experienced therapists, everything previously learned about how to do effective therapy prior to EMDR training—all understandings about people, all the ideas and interventions learned through reading and workshops and from previous clients—is still important, is necessary, and provides a context for doing effective EMDR therapy. The tools described in the chapters to come are meant to supplement, not replace, the skills and understandings of experienced psychotherapists.

The chapters of this book are divided into four parts. The first, comprising Chapters 1 and 2, is an overview of the application of the AIP model to Complex PTSD and other dissociative conditions. The second part, Chapters 3 to 6, presents ways of treating (i.e., resolving) psychological defenses that are often linked intrinsically to disturbing memories but can be conceptually defined as separate entities because defenses typically contain dysfunctional positive affect, as opposed to the disturbing affect within memories of traumatic events. The third part, Chapters 7 to 14, focuses on several issues important in the EMDR treatment of dissociative conditions. And Chapters 15 to 17 are detailed case reports illustrating how these AIP “tools” can be employed in actual treatment sessions.