The Development and Uses of the “Blind to Therapist” EMDR Protocol

Vignette 1: Reassertion of Control Among “Executive Decision Makers” (Blore & Holmshaw, 2009a)

In 2004, the 38-year-old train driver of a train travelling at 125 mph (200 kph) was involved in a fatal impact with a 60-year-old man who had jumped in front of the train. Subsequent internal and external investigations exonerated the train driver of any blame. A subsequent coroner’s hearing revealed that the deceased had been depressed for more than a year and, at the time of the fatality, had been attending a psychiatric outpatient clinic. The train driver who had been referred for EMDR was suffering from posttraumatic stress disorder (PTSD; American Psychiatric Association [APA], 2000) and was very reluctant to describe the “peri-impact” memories of the incident. The train driver described how—despite every reassurance from his employers, the British Transport Police, and the Coroner—he still felt entirely responsible for the fatality. It was established at the EMDR assessment that the level of perceived responsibility was closely associated with being trained to always be in control of the train being driven. In effect, the suicide “proved” (to the driver) that he was not in control. As stated previously, Thompson (1981) has shown that in these circumstances, clients will attempt to reassert control, and it is likely that it is precisely what happened during EMDR history taking.

EMDR was conducted using the B2T protocol. The undisclosed target was given the cue word “27.” The first few BLS sets were characterized by abreactions, but the client did not use the safe place previously installed. After several sets of eye movements, the train driver announced quite spontaneously he had applied the emergency brakes and the train had come to a halt almost half a mile down the track. He then described the various “safety-of-the-line” procedures he had enacted, finally declaring there was nothing else he could have done. On returning to 27, he described the details of what had happened and was able to provide normal feedback from that point including revealing the 27 related to a milepost he had seen immediately prior to the impact. EMDR subsequently proceeded along the standard protocol and was completed in five sessions. The train driver was asymptomatic on discharge. He was subsequently assessed independently for a return to safety critical work and returned to driving trains. Eight years after discharge, with no further treatment interventions in the interim, it was noted that he was still driving trains without any problems.

Vignette 2: Shame and Embarrassment (Blore & Holmshaw, 2009a)

A 54-year-old female survivor of childhood sexual abuse experienced between the age of 7 and 11 years had sought help for complex PTSD symptoms in the past with little success. She had been referred this time for EMDR, having her memories reignited by discovering that one of her nieces had been sexually abused. At assessment, the client revealed she was troubled by one specific memory. Apparently, the perpetrator, now deceased many years previously, had never been confronted by what had happened and, indeed, no one knew the precise details of what had occurred other than the client herself. At assessment, the client was found to be suffering from both PTSD and chronic depression and explained that she could not discuss the image because it was “too disgusting for anyone to hear.” Therefore, not only did the client not wish to discuss the particular image but also did not wish to traumatize others. EMDR was conducted using the B2T protocol. The undisclosed target was given the cue word “lamp post.” The first few sets of eye movements were characterized by little or no change followed by rapid change and abreactions. Eventually, “lamp post” became less upsetting and resulted in the feedback, “He’s left,” which was the only clue to the image content. The client identified a PC (albeit negatively worded): “I’m okay, I know it’s not my fault”; and later admitted to having believed that the abuse was her fault for several decades (in effect disclosing the NC after completion of Phase 4 and identifying the PC). Treatment of the current trigger (hearing about her niece’s abuse) then proceeded smoothly as per the standard protocol. The client was discharged describing herself as better than she had been in years. The client, who had not sought any further psychological treatment, was described 4 years after EMDR as “flourishing.”

Vignette 3: Minimizing Potential for Vicarious Traumatization

A 36-year-old male involved in a serious and disfiguring injury at work was referred for EMDR. The injuries were mostly concealed from view and had healed well over a period of 2 years. The EMDR therapist who, coincidentally, had a close relative who had sustained an identical injury at work 10 years previously and had trained originally as a nurse, revealed in supervision that she had been very upset by the client’s history. She reported in supervision that she had been having intrusive images of both her relative’s injuries and one particular lecture slide of a similar severe injury that had been projected onto a large lecture theater screen during her nurse training. It was agreed during supervision to use the B2T protocol, with the intention of minimizing the potential for further distressing imagery. In addition, the therapist was advised to seek EMDR for her own memories (cf. F. Shapiro, 2001, p. 132, relating to the suggestion that the clinician self-administers EMDR after sessions).

Having coached the client into the nature of change as per normal use of the B2T protocol and identifying two targets, one allocated the cue word “paper” and a second given the cue word “instructions,” treatment proceeded relatively smoothly until a point of recurrent “no change” occurred during feedback. Given that basic strategies for unblocking processing did not appear to work, and that it was not possible to use a cognitive interweave, a visual interweave was used in which the client was asked to provide a second image and place it alongside the target memory. The second image was to represent a “resolution” of the target image—in other words, an adaptive outcome. With the two images in place, BLS was restarted. The feedback thereafter was “. . . ‘paper’ has receded into the background, but the new image has come forward . . .”—in other words, change had now occurred. Further processing revealed subjective units of disturbance (SUDs) ratings of 0 and a return to the standard protocol ensued by inquiring about a PC.

Circumstances prevented the therapist from obtaining treatment herself until after the discharge of the client she was treating. In subsequent supervision, the therapist reported she had still been “manufacturing” her own imagery during sessions, but that using the B2T protocol had helped enormously by “not having to listen to detailed descriptions of the client’s imagery.” At the time of writing, 18 months after treatment conclusion, both client and EMDR therapist reported no problems.

Vignette 4: Cultural Issues—Avoiding Distress Being Witnessed by a Fellow Countryman

A 32-year-old male Iranian, who spoke only Farsi, was a single man who had been imprisoned without trial, tortured, and publicly flogged in Iran. The client was treated in the United Kingdom with EMDR in the presence of a translator. The client reported having been in constant fear of execution and was taken in front of a firing squad on more than one occasion. He was able to speak about all of these incidents but identified an early childhood trauma that he chose not to describe. It transpired that he was reluctant to disclose the target because of the depth of emotion that describing the target generated. Crucially, the client was unwilling for the interpreter to witness his distress.

After discussion in supervision, it was agreed to use the B2T protocol and the overall situation was managed as follows: The interpreter remained in the room during history taking, preparation, and assessment phases. As per the B2T protocol, the client had examples of change post-BLS sets explained, along with the usual addressing of fears and setting expectations. During preparation, an arrangement was made to refer to targets by simple cue words and to use basic sign language to indicate change or no change following BLS. Once it was clear that preparatory phases were completed, including the assessment of the relevant target, the interpreter was asked to leave the room with instructions that he would be called back periodically.

During initial BLS sets, the client was clearly in touch with the target memory, with tears pouring down his face. Between sets, the therapist would signal an inquiry by raising her eyebrows, and initially, the client would shrug his shoulders. As the processing continued, the client’s body language quickly began to signal a change and the distress on the client’s face turned to one of interest until he nodded and said, “Okay.” EMDR continued for another set, and then the interpreter was asked to return to the room. A short break in processing ensued in which the client was able to have his feedback interpreted into English. A new target was then chosen, and the whole process with the translator leaving the room was repeated. The client was later able to complete the standard protocol with the translator present during processing.

A year following discharge, it was reported that the client had enlisted for college to learn English. At the time of writing, he is well and adjusting to life in England.

Vignette 5: Need for the Presence of a Translator Versus Prevention of Information “Leakage”

A general medical practitioner referred a 37-year-old Libyan freedom fighter to an EMDR clinic for treatment of memories of repeated physical assaults. The referral letter included a photocopy of a second letter written in English by the client’s cousin explaining need for “. . . great caution . . .” as information would in all certainty “. . . find its way to government sources . . .” and the “. . . family would be in mortal danger.” The therapist, on seeing the client and explaining EMDR, offered—through the translator—to conduct treatment with the absolute minimum of information. This decision was made because it was assumed that identifying any memory content could have identified the client’s family back in Libya. However, because of the need for translation, it was not possible to ask the translator to leave the room (as in the previous scenario). A safe place resource was installed relatively easily, and explanations and examples of the types of changes that often occurred with EMDR was discussed—again without reference to memory content other than their associations with “strong emotions.” Particular emphasis was placed on the possibility of very small changes in memory post-BLS sets using a metaphor relating to the common competition scenario of two images, ostensibly the same, and with the caption “spot 10 differences.” Demonstrations of how EMDR would proceed then followed.

The first target was given the cue word “street,” and the client was reminded that when the eye movements stopped, he only needed to nod his head to indicate change in apparent experiences of the memory, shake his head to indicate no change, or shrug for “uncertain.” The early BLS sets tended to result in shakes of the head. However, the client was visibly relaxing, suggesting change was happening. This seeming contradiction resulted in breaking off processing and restating the nature of change. This revealed that the client had thought change only applied to the imagery. On restarting processing, feedback after BLS sets quickly turned to head nods.

The client had several problems with “stuck processing.” The therapist reported using a visual interweave strategy, which involve “stretching the images or otherwise intentionally manipulating them in some way.” We have called this strategy “morphing.” The effect was immediate, and the processing was restarted.

In due course, the translated feedback revealed that the client had spontaneously considered the thought, “We’re safe,” which he insisted was more important than “I’m safe.” After this, EMDR was then proceeded more or less as per the standard protocol from that point.

To assist with the confidentialization process, it was necessary to make changes to the log of events between sessions. Initially, it was understood that anything written would be in Arabic and need translating, so instead of writing words down, he drew what looked like cartoon images of a face with varying degrees of happiness or sadness, and thus not giving any information away that could potentially also be “leaked.”

The client describes himself as “happy” 1 year after treatment. The family finally left Libya 18 months after the client’s EMDR was completed.

Vignette 6: Reducing Potential Stalling in Processing: Client With Severe Stammer

This case is different to the other vignettes in that only a single component of the B2T protocol was used rather than the complete protocol. Treatment commenced with the use of the standard protocol and a fully identified image, NC and PC, but then changed to the B2T protocol when it became apparent that providing feedback was hampering processing.

A 31-year-old computer technician who suffered with a long-standing stammering problem sought help for his memories of an assault at work. Unfortunately, the contract to provide treatment excluded treating preexisting problems, so the cause of the stammering was not investigated. The first target image was duly identified, and despite the very obvious problem with stammering, Phase 4 commenced unremarkably. However, a few sets into processing the stammering deteriorated markedly to the point that feedback took so long that processing continually stalled. Even mentioning “the target” seemed to make the problem worse and eventually “(name of) location” was used as a cue word in its place. Various strategies thereafter were tried to encourage brief feedback without success. Treatment was therefore stopped, the safe place exercise was used, and a discussion ensued so as to establish what might facilitate feedback. It was agreed to use the feedback method adopted in the B2T protocol. Treatment was duly recommenced, but even stating that there was, or was not, change proved too difficult. In the end, the client was encouraged to nod or shake his head to indicate change post-BLS set. This immediately helped, and a sequence of BLS ensued followed by nods/headshakes. It was less obvious that a channel of association had been cleared by processing and, with hindsight, several erroneous “returns to target” followed. Eventually, desensitization was complete, and a PC was obtained. After a return to Phase 4, because of a second target emerging, the process of choosing a cue word and adopting nods and headshakes was repeated—this time much more smoothly.

On completion of treatment, the computer technician was relaxed and able to speak more freely with only a minimal stammer. It is likely that some of the treatment effects were down to the subsequently disclosed information that “previous therapists have given up on me,” thus underlining that taking a client-centered approach—as EMDR encourages us—can reap huge dividends in terms of relief of suffering. The client returned to work promptly. That was 2 years ago.