A Case Study: The Integration of Intensive EMDR and Ego State Therapy to Treat Comorbid Posttraumatic Stress Disorder, Depression, and Anxiety

Intensive Eye Movement Desensitization and Reprocessing

The typical format for EMDR treatment has been consistent with the traditionally accepted procedure of a weekly psychotherapy session. Recent research, however, suggests that using EMDR in a more intensive or concentrated format can be highly effective in symptom reduction (Abel, 2011; Grey, 2011; Wesson & Gould, 2009). Intensive EMDR, for example, may involve seeing the client 3–5 days a week for 60-, 90-, or 120-min sessions or for two separate 60-min sessions each day (E. C. Hurley, personal communication, July 1, 2011). Such treatment has also been described as consecutive day EMDR treatment (Grey, 2011) or concentrated EMDR treatment (Abel, 2011). The research on this model, albeit limited, supports its efficacy in reducing trauma symptoms. Grey (2011) successfully treated a woman with comorbid MDD with psychotic features and panic disorder with agoraphobia with three 90-min sessions per week for 4 weeks. After 3 months, she maintained subclinical scores on the Beck Depression Inventory (BDI)-II and the Beck Anxiety Inventory (BAI). Wesson and Gould (2009) treated a British medic in Iraq for an acute stress reaction to a land mine explosion. He was seen 2 weeks after the explosion and treated with the EMDR Recent Events Protocol on 4 consecutive days and was then immediately able to return to frontline duties. Treatment effects were maintained at 18-month follow-up. The promising results of these studies support the need for further research on an intensive model of EMDR.

Using EMDR to Treat Posttraumatic Stress Disorder

Several randomized clinical trials and meta-analyses support the efficacy of EMDR in reducing PTSD symptoms (Bisson & Andrew, 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005; Davidson & Parker, 2001; Hogberg, 2008; Marcus, Marquis, & Sakai, 2004; Maxfield & Hyer, 2002; Seidler & Wagner, 2006; Van der Kolk et al., 2007). Neuroscience research also supports the efficacy of EMDR. In one study, the brains of 10 people with PTSD were assessed before and after EMDR treatment. Following EMDR therapy, there was a reduced arousal level, a reduced orienting to new stimuli, and a significant improvement in PTSD symptoms (Lamprecht, Kohnke, Martin, Matzke, & Munte, 2004). Most recently, the National Registry of Evidenced-Based Programs and Practices of the U.S. Department of Health and Human Services Substance Abuse and Mental Health Administration (EMDR International Association, 2011) listed EMDR as a treatment for PTSD, anxiety, and depressive symptoms along with general global mental health function.

Using EMDR to Treat Depression and Anxiety

MDD is diagnosed in 6.1% of the American adult population annually, whereas GAD is diagnosed in approximately 3.1% of the American adult population annually (National Institute of Mental Health, 2011). Given the prevalence of trauma within the mental health population, EMDR would appear to be an appropriate method of addressing the life experiences that could contribute to the comorbidity of MDD, GAD, and PTSD (e.g., early trauma, attachment disruptions, and grief). Some preliminary research supports this assertion and shows that after treatment with EMDR, there may be a reduction of fear and other anxiety symptoms (Gauvreau & Bouchard, 2008) and a reduction of depressive symptoms both related to grief (Sprang, 2001) and to non–grief-specific depression (Bae, Kim, & Park, 2008).

Ego State Therapeutic Techniques

Paulsen’s (2009) extensive work with ego states includes a technique where the client creates an image of a meeting place in the client’s mind where the ego state work will be done. The part that wishes to speak, or with whom the therapist would like to speak, is asked to look through the eyes of the client. The part that is looking through the eyes has ego cathexis. The other parts have object cathexis and may be referred to in the third person (Paulsen, 2009).

A more common way of working with ego states, and the one that was used in this treatment, is the Dissociative Table Technique developed by Fraser (1991, 2003). For a more detailed description of this technique, see Martin (2012). Forgash calls this a workplace (Forgash, 2004, 2005; Forgash & Knipe, 2008), whereas others call it a meeting place procedure (Gonzalez & Mosquera, 2012). It is also commonly called the conference room technique in which the therapist uses guided imagery to bring the client to a room with a conference table (Paulsen, 2009). The client’s ego states (or those parts relevant to a particular issue) are then invited in the client’s mind to come into the room and join the client at the table. A conversation ensues, which may involve mapping the internal system, negotiations with parts that are currently impinging on the client’s well-being, meeting the needs of younger parts of self, and other work specific to a given client.

Although it is understandable to want to work with, protect, and try to rescue an abused child part, it is essential in ego state therapy to first honor and work with powerful protective ego states (Paulsen, 2009). These powerful parts originally served a protective purpose in childhood or adolescence, but in adulthood often lead the client to behave in self-destructive behaviors or in ways that prevent optimal growth. These protector parts are often introjects of abusive parents, other role models, or perpetrators. Paulsen (2009) calls them “honchos.” In Internal Family Systems language, they may be “managers” or “firefighters” (Schwartz, 1995). The therapist acknowledges their many years of hard work that was initially helpful in some ways in childhood. Parts of self “typically seek to protect their existence and roles, even if those are counterproductive,” so change involves strategic negotiations (Forgash, 2005, p. 6). Ego state therapy, like all therapy, is rooted in the belief that change is possible. And as parts of self change, accept new roles, and/or are brought into present awareness, the client’s progress is often dramatically enhanced.

The therapist carefully explains to the client that parts cannot be extinguished, even ones that the client may hate. Then the therapist helps educate a protective part about how it is now unintentionally sabotaging the adult client’s ability to grow and thrive in the present (Forgash, 2005; Forgash & Knipe, 2008; Paulsen, 2009). Negotiating with the protective part to step back and allow the client, who is no longer a child, to make decisions by himself or herself, even if he or she may make a mistake, is often a first step. A way for the protective part to express concerns, rather than take over, is agreed upon. Sometimes, protective parts are willing to take on a very different or even opposite role in the present.

In the treatment described in this case study, a negotiation with the client’s powerful protector—what she termed the perfectionist part of self—was the essential first step to making change possible. The perfectionist part of self was intolerant of the client’s emotional life and of her romantic relationships. (In structural language, it was phobic of some of the client’s other EPs.) This had to be addressed for the client to accept all of herself and to be less internally embroiled.

Some writers emphasize the idea that underneath the costume of the often fearsome honcho is a frightened young child ego state that was forced to take on that protective role (Paulsen, 2009; Schmidt, 2006). Thus, after the honcho’s power is acknowledged, that protective part is sometimes willing to take off the costume or mask and access the child ego state to meet early needs. That step was not used in this treatment.

Ego states may be defined by a particular age or by a function or trait. In this treatment, there were five parts of self: a 7-year-old, an adolescent, a perfectionist, an academic, and a nurturing mother, all of which were known by and readily accessible to the client. This previous accessibility made the work more efficient. Often in ego state therapy, protective parts are difficult to access, whereas child and adolescent parts come forward readily because they are eager to be heard and have their needs met. Protective parts may remain obscure and inaccessible because the client’s ANP cannot tolerate acknowledging these protective EPs (Gonzalez & Mosquera, 2012). The practitioner has witnessed this in sessions with other nondissociatively disordered clients.

Design

This study used a quantitative single-case study design to examine the efficacy of the integration of intensive EMDR treatment and ego state therapy with a client who met the criteria in the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) for the following diagnoses: PTSD, MDD, and GAD (American Psychiatric Association, 2000).

Participant

Throughout this study, the client’s confidentiality was maintained and ethical procedures were followed for her protection. The client was a single, 21-year-old, White college student attending a major university in the Northeast. The first author (FL), herein referred to as “the practitioner,” had treated her for a year during high school and now agreed to treat her intensively with EMDR and ego state therapy for symptoms of PTSD, depression, and anxiety as an alternative to a recommended hospitalization.

Treatment

This intensive treatment followed Shapiro’s eight-phase EMDR standard protocol, with ego state work integrated throughout. The 25.5 hr of integrated EMDR and ego state therapy treatment were provided over 3 weeks. In Phase 1 (history taking and treatment planning), an updated history was taken, with attention given to how dysfunctional ego states were currently affecting her. In Phase 2 (preparation), grounding techniques were reviewed to prepare the client for EMDR treatment. Phase 2 also involved meeting ego state parts to establish communication and negotiate new roles for them that would allow the client to heal, also assuring that each part had a safe place or grounding technique to access. In Phase 3 (assessment), the client’s negative cognitions were assessed and connections were made to her different ego states. During Phase 4 (desensitization), crucial interweaves and interventions in relation to her parts were employed. The integration of intensive EMDR and ego state therapy continued to be used during all EMDR phases, as will be shown in the following texts.

In Week 1, there were six sessions for 60, 90, or 120 min in length that totaled 9.0 hr. In Week 2, there were five sessions, four of which were 120 min and one was 60 min, totaling 9.0 hr. In Week 3, there were five sessions of 60, 90, or 120 min totaling 7.5 hr. Lateral eye movements were the primary form of bilateral stimulation during EMDR Phases 4 and 5 (processing and installation), although tactile stimulation was sometimes used instead.

Pretreatment Assessment

An interview grounded in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic assessment procedures revealed that the client met the diagnostic criteria for PTSD, MDD, and GAD. The practitioner administered five quantitative assessment instruments: the BDI (Beck, Ward, & Mendelson, 1961), the BAI (Steer & Beck, 1997), the Impact of Events Scale (Weiss & Marmar, 1997) as a measure of PTSD symptoms, the Schwartz Outcome Scale (Blais et al., 1999) as a measure of self-satisfaction and confidence, and the Dissociative Experiences Scale (DES; Carlson & Putnam, 1993) as a measure of dissociation. The client’s negative cognitions were also assessed (Shapiro, 2001). The practitioner relied on the clinical interview as well as the definitions provided by the aforementioned scales for the diagnoses.

At baseline, the client’s BDI (Beck et al., 1961) score was 46, which is considered “severe.” Her BAI (Steer & Beck, 1997) was 37, which falls in the “severe range.” The Impact of Events Scale (Weiss & Marmar, 1997) indicated “severe PTSD,” with a score of 50: 12 on the avoidance scale, 20 on the intrusion scale, and 18 on the hyperarousal scale. The Schwartz Outcome Scale is an assessment of perceived satisfaction with life (Blais et al., 1999); the client had a total score of only 8 out of a possible 60. Finally, her score of 15 on the DES (Carlson & Putnam, 1993) did not indicate a dissociative disorder.

On the EMDR Negative Cognition Checklist (Shapiro, 2001), which lists 37 of the most commonly held negative cognitions such as “I am not safe” or “It is my fault,” the client checked a remarkably high 27 of 37 statements as true for her. Negative self-beliefs may be strongly connected to particular parts of self. The depth of what she described as her “self-hatred,” evidenced by the very large number of negative beliefs about herself, contributed to the practitioner’s conceptualization of the case, and determination that ego state therapy would be helpful, despite the absence of a dissociative disorder.

Ego State Assessment

The client was fully aware of several ego states, and she understood during this treatment that these had caused her hospitalization and/or prevented healing. It became evident almost immediately to the practitioner that intensive EMDR would yield only small gains if treatment did not address these parts of self and their related needs and concerns. The most powerful of these ego states was the perfectionist, which had an unremitting focus on superior achievement both in academics and in outside activities to the exclusion of all emotions. Other ego states, as mentioned, included a 7-year-old state, which was focused on a core traumatic memory. Guided imagery work, as will be shown later, in which the 7-year-old ego state was healed by a nurturing mother ego state part in a sacred space, produced a fundamental resolution of the client’s self-hatred. Treatment also included negotiations with the perfectionist ego state and the academic ego state about completing the semester’s work over the summer.

Client History and Presenting Problems

The client was the youngest of three daughters, born to middle class White parents. The first was 5 years older than the client and was born with severe neurological impairments, requiring intensive care. When the client was 8 years old, her eldest sister died. The client explained that she had been very close to this sister and the sudden loss was devastating for her. She also experienced more criticism from, and more conflict with, her mother. The client stated that this heightened conflict prematurely interrupted her grieving, as she withdrew to defend herself.

As a young child, the client experienced being left alone much of the time, with few memories of spending time with her parents. She reported feeling “unseen, unheard, and blamed.” During this course of treatment, the client had supportive conversations with her father who corroborated much of her childhood and adolescent experiences.

At the time of this clinical treatment, the client presented with profound depression because of relational, academic, and familial pressures and her ego states’ responses to those pressures. The intensity of the depression confined her to her dorm room for 10 days. Her therapist recommended voluntary hospitalization to treat her “vegetative depression,” so she took a medical leave from the university. Once at the hospital, the client’s perfectionist ego state pushed the client hard “to get out of here.” The client found this internal pressure empowering at a time when she had been quite helpless. The client was able to reconnect with the practitioner who proposed an intensive level of work that might enable her to complete her semester. The client’s short-term goals for treatment were to significantly decrease her symptoms to be able to complete her semester’s coursework. The client’s long-term goals were to feel proud of herself, to put less pressure on herself about her studies and her relationships, and to no longer feel burdened by an unrelenting sense of responsibility for others.

Case Conceptualization

The practitioner viewed the client’s symptoms as related to traumatic familial experiences. He thought that her difficulty in forming attachments and her struggles to acknowledge her needs in intimate relationships, which she reported in Phase 1, and the development of her self-critical personality stemmed from her complex family history. The practitioner used the theoretical underpinnings of the AIP model to conceptualize the case and understand the client’s presenting symptoms. The client’s symptoms manifested in cognitive themes about a sense of worthlessness and a sense of responsibility. The negative cognitions that this treatment focused on were “I must be perfect” in relation to her sister, “I am a failure” in relation to academic work, and “I am a bad person” in relation to her mother.

When working with long-standing relational trauma, it is often necessary to expand Phase 2 (preparation) to develop stronger internal resources. The client was easily able to access her calm place as well as her container in which to put away disturbing images and memories, which she had established during her initial work with the practitioner 3 years earlier, and further resourcing appeared unnecessary.

As was explained earlier, it is often very useful to use ego state therapy within the EMDR protocol to meet the competing needs of a client’s ego states, parts, or alters that are preventing change or causing self-harming behaviors (Forgash, 2005; Forgash & Knipe, 2008; Gonzalez & Mosquera, 2012; Knipe, 2008, 2009; Paulsen, 2009; Twombly, 2005; Twombly & Schwartz, 2008). The practitioner hypothesized that as the client reprocessed her traumatic experiences, integration of these experiences and of her parts would occur and her symptoms would reduce, allowing for better functioning and improved well-being.

Course of Treatment

Summary of the Work

The previous description of the intensive therapeutic work illustrates how the phases of EMDR were used, and how ego state therapy was integrated throughout these various phases. This successful integration of EMDR and ego state therapy resulted in the full reprocessing of each of the targeted memories, with the level of disturbance reduced to 0 and the VOC rising to 7. The practitioner’s negotiations in the conference room with the client’s perfectionist and academic ego states successfully modified their self-critical influence so that continued academic, social, and emotional well-being was much more likely. The ego state therapy with the 7-year-old and lonely part of self led to profound shifts in the client’s self-acceptance.

Psychometric Measures

In the first week of treatment, after 9 hr of EMDR, the client’s score on the Impact of Events Scale had dropped from 50 to 27 (Figure 1). This indicated that her PTSD symptoms were now in the moderate range, whereas her score on the Schwartz Outcome Scale had doubled from 8 to 15, indicating greater self-satisfaction and confidence (Figure 2). Midway through the second week, after 14 hr of EMDR treatment, the client’s score on the BDI dropped from 46 to 24, indicating a moderate level of depression (Figure 3). Early in the third week, after 22 hr of EMDR treatment, the client’s score on the Impact of Events Scale had further dropped to 12 (see Figure 1). Each of these measureable changes indicates that the client had a major reduction in symptoms. At that point, the client also endorsed only 8 out of the 37 negative cognitions, significantly reduced from her initial endorsement of 27. Furthermore, all 8 negative cognitions that the client held to be true related only to being behind in schoolwork, further evidence of her profound shift.

FIGURE 1

Scores on the Impact of Events Scale-Revised.

FIGURE 2

Scores on the Schwartz Outcome Scale.

FIGURE 3

Scores on the Beck Depression Inventory.

In the fourth week, the client’s Schwartz Outcome Scale rose to 25 (see Figure 2), triple the original score. Because the BAI addresses “the past month,” 33 days after the client had begun the intensive treatment, it was readministered. Her score had dropped from 37 (described as “severely, it bothered me a lot”) to 25 (described as “moderately, it wasn’t pleasant at times”; Figure 4). Similarly, her score on the BDI had dropped to 15, indicating only a mild mood disorder (Figure 3). Ultimately, at the Week 4 reassessment, following the intensive 3-week treatment, the psychometric instruments indicated that the client no longer had any significant symptoms of PTSD, no longer met the criteria for MDD, and her GAD had decreased from severe to a moderate level. She also reported many fewer negative beliefs about herself and expressed greater self-satisfaction and confidence (see Figures 1–4). There were no further changes in her psychometric scores during the 6 weeks of follow-up therapy.

FIGURE 4

Scores on the Beck Anxiety Inventory.

While home for a visit 6 months after her intensive treatment, the client met with the practitioner for a follow-up. During this meeting, the client’s score on the BDI score was 4 (0–10 is considered “normal ups and downs”) and her score on the BAI was 1 (1–21 indicates “very low anxiety”). The client’s score on the Impact of Events Scale score was 10, indicating the continued absence of any significant PTSD symptoms. The client’s Schwartz Outcome Scale score had dramatically improved to 53 out of a possible 60 (see Figures 1–FIGURE 2FIGURE 34). Finally, regarding negative cognitions, she ascribed to 6, but reported that none of them had a powerful influence on her daily life. These scores indicate sustained success from treatment after 6 months.

The practitioner spoke by phone to the client 18 months following the intensive treatment. The client was now studying abroad for the year, successfully handling a course load of engineering classes in Germany and adjusting well to living there. She had several German and American friends at the university where she was studying. Her mood was bright during the conversation.

Behavioral Changes

As mentioned earlier, after 3 weeks of intensive EMDR therapy, 25.5 hr, the client returned to live on campus and resumed classes full time. She commuted home for long weekends and the practitioner saw her for 2 hr a week for 6 more weeks until she left for a summer job out of the area. Psychometric scores did not shift further during this second stage of work. This may have been caused by the high level of stability she had reached. However, there were major functional shifts. She was able to face her challenges in an increasingly coherent way. The client’s own evaluation at the end of the 9 weeks of treatment showed major insights about herself and her family. She had consolidated a new narrative about herself, evidence that the 3 weeks of intensive EMDR and ego state therapy had allowed for further integration of her painful experiences, resulting in both less chaos and less rigidity (Siegel, 2011).

Near the end of the work with this practitioner, the client said, “This has been one of the calmer periods of my life. I’m terribly behind in my schoolwork and I’m not crying every day.” In her last session, the client reflected at length on what she had learned in these 9 weeks,

She continued,

At the 6-month follow-up, the client reported that she had completed her semester’s assignments by the agreed date and had received excellent grades. The client excitedly described all she was learning at an internship in a Midwest aeronautical company. The client stated that she is increasingly excited about a career in “the real world” rather her original goal of academia.

Intensive Treatment

Future research is recommended to further evaluate the use and effectiveness of intensive treatment. If the results support the use of intensive treatment, it is hoped that programs will reevaluate policies and structure of treatment, and insurers will agree to pay for this apparently cost-effective treatment.

Recommendations for Future Research

This case study and the previously mentioned cases (Abel, 2011; Grey, 2011; E. C. Hurley, personal communication, 2011; Wesson & Gould, 2009) all indicate that rapid change occurred when intensive EMDR was used with several different diagnoses. This is an important clinical consideration for practitioners. Furthermore, for those involved in research, expanding this line of inquiry will help determine when, if, and with whom intensive therapy is most helpful. Future research questions should focus on (a) comparing the outcomes of intensive EMDR and weekly sessions of EMDR in a randomized controlled trial and (b) comparing the outcomes of standard EMDR to that of EMDR plus ego state therapy in a randomized clinical trial. Research could also evaluate the mechanisms involved in rapid change.

The client felt that she accomplished much more during 3 weeks of intensive work than she had in the year of weekly therapy with this same practitioner when she was a mistrustful teen and more than she had done in her often-interrupted therapy with an EMDR-trained therapist while at the university. Therefore, qualitative studies exploring clients’ subjective experience of intensive EMDR versus weekly sessions would also be beneficial.

Limitations

A major limitation of this study is the case study design, which allows for limited generalizability because it only focuses on one individual. Another limitation of this study is that the primary researcher also functioned as the practitioner. Although this could be a threat to validity, the researcher used peer conferencing, following of EMDR fidelity protocols and objective psychometric measures to assure ethical procedures and to decrease this threat to validity. A complicating factor in this study was the inability to conduct an extensive follow-up with the participant because of her summer internship in the Midwest, transfer to a university across the country, and then her study abroad.