EMDR: The Progressive Approach for severe Trauma 2

It is not rare for DID or subforms to get diagnosed after an EMDR session went terribly, terribly wrong. Once we understand why the basic protocol for EMDR can stir up so much within a system that patients get overwhelmed, we will look at a different approach to EMDR that can make processing safer and more manageable for people with structural dissociation.

 

While it is not fully clear how EMDR influences the brain it is suggested that the bilateral stimulation helps to connect neuronetworks that are otherwise dissociated. That way, people with a single trauma might get access to details of their memory that have been dissociated from their awareness before. With access to these areas it becomes possible to integrate these memories and symptoms will be reduced. People with single trauma can follow their associations and tap into one fragment of the memory, process it and go on to the next.

 

 

As far as we currently know parts within a dissociative system are actually neuronetworks that are mostly separate from each other. They hold different degrees of memory, emotion, thought patterns etc. During TraumaTime it was important to separate all that because it would have been overwhelming. Systems react differently to bilateral stimulation but for some it creates connections between these neuronetworks. The result is that parts get flooded with all the difficult things other parts hold for the system as well as all the relational difficulties within the system and the fear of the inner experience. All at once. Calling up a fragment of a memory while bilateral stimulation is applied can activate a dozen parts at the same time, regulation becomes impossible.There is no way that this can lead to an integration of the memory! It is just overwhelming and possibly retraumatizing.

 

 

For other hosts nothing that dramatic happens. But they keep getting stuck during the processing, encounter a lot of dead ends or ‘looping’ when things stop changing before they are processed to their satisfaction. Only the fragments that are stored with the fronting part get processed and there are huge chunks of the experience missing or the next step that would be needed to go down a specific ‘tunnel’ is stored with a different part. Without inner cooperation they will just get stuck with the trauma work.

 

 

When you are extremely sensitive to bilateral stimulation, meaning all your dissociative barriers just drop, your T might decide not to work with EMDR at all or only use it after years of strengthening inner connection and cooperation. They will probably not use the progressive approach then and instead use the basic protocol once you are all so ready for it that it can work. (It would be smart to eliminate bilateral stimulation from your DBT Skills too. You will never calm down that way.)

 

Tip-of-the-finger Procedure

For those who are somewhere in between, the EMDR process is turned around. In the basic protocol we choose a target memory and then follow all the different associations away from the core trauma. Think of your hand. Your palm is the core of the trauma and you follow the associations out to your fingertips, then return to the palm and process the next ‘finger’.

With severe trauma and fragmentation your T would use the ‘tip-of-the-finger’ technique and only pay attention to the experiences that are at the outer edge of the trauma. They would pick fragments like an emotion or a thought that you share in therapy and apply bilateral stimulation while you only focus on that piece. It needs a skilled T to help you not to get sucked into too much of the big picture. There isn’t the strong focus on association like in the standard protocol. Instead, your T will use a lot more direct guidance to help you. With a lot of tiny times of processing you can slowly get closer to the core of the trauma and when you get there, a lot of the things around it are processed already so it doesn’t get so overwhelming anymore.

 

When we process things from the ‘tip of the finger’ towards the core we can already feel a relief in many areas of our life; feelings and thought get processed and change. That way we can gain more stability and security that will make it possible to process more things that are closer to the ‘palm’. It takes more time and patience than the ‘quick and clean’ EMDR processing that is often promised to patients with a single trauma, but since that is not within reach anyway, using fragmented processing is the safest and fastest way to go. Only working with one fragment at a time does not mean that these piece won’t get integrated into the whole picture. We just don’t do it all at once.

 

 

Adult Self

Usually your EMDR T will work with you on strengthening your ‘adult self’ first. That could mean the host or other adult parts who are fronting, it could also mean gathering every aspect that is adult, spread over the system and sometimes found in younger parts too. The T will always ask the ‘adult self’ to connect with certain parts of the personality to support processing. Then fragments of trauma get processed with an adult part fronting and the trauma part co-conscious. That way connection is strengthened while the trauma gets processed and we don’t repeat the pattern of abandoning trauma parts that is at the core of structural dissociation. If we just leave each other alone again we don’t win much, there is more in trauma integration than just processing a memory. In rare cases a T might agree to work with a trauma part alone if support from the system is absolutely impossible but the relief is absolutely needed. But that would be an exception. Thorough stabilisation cannot be skipped, cooperation is key. Overcoming the phobia of traumatic memory is part of the healing, and that includes being with traumatized parts of ourselves. Switches cannot always be prevented but the aim is to manage processing without.

 

Dual Focus

To prepare you for processing your T might have to practice dual attention with you first. Dual attention means that you can focus on the here and now (like the bilateral stimulation) and at the same time focus on the fragment you want to process. People with structural dissociation tend to either have both feet in the here and now (ANP) or both feet in the past (EP). You might need to learn how to balance the ‘one foot in – one foot out’ before any processing is started. Usually that means solid co-consciousness. Without it the treatment doesn’t really work.

 

While the basic protocol advises Ts to push the patient to hold on just a little longer when they signal that they need a break, the opposite is true for the progressive approach. Ts are supposed to stop at once and actually keep the intervals shorter than what they expect the patient to be able to tolerate. No squeezing out a few extra second of processing. We usually already struggle to know when to stop and our T might double and triple check what we say and sometimes stop for us when we don’t notice that we need a break. Slower is faster. Treatment is not about pushing us to survive yet another extreme situation.

 

Sometimes when we process things as a team we might notice that the stress levels for the fronting part go up and it seems like the bilateral stimulation is just making things worse. At the same time the suffering of the emotional part goes down, the fragment they are working on does get processed. The fronting part might just get closer to an experience they haven’t been aware of before. It doesn’t mean that EMDR is broken somehow.

 

 

Trauma processing in DID always needs team work. The system needs to agree that they have permission to work on a certain fragment of memory. Sometimes parts have their own reasons for wanting to hold on to something and you can’t process things against your will. It is very common for abuser-imitating or abuser-loyal parts to show up during processing if they were left out in the decision-making. It really helps to settle these things first.

Trust in the T is crucial. In EMDR things might come up that cause self-conscious feelings. Imagine that in the middle of processing an abuser-loyal or sexualized part starts an argument and the body reacts in weird and confusing ways. That is not a rare situation for your T to handle but you need to have enough trust to share this experience even if it is embarrassing. Otherwise the processing will get stuck and you will be left alone to deal with it.

 

The lines between the phases of stabilisation and trauma work will be a bit blurred when your T is working with the progressive approach. At first you will mostly work on stability and occasionally work on a tip-of-the-finger fragment of trauma that is in the way of more stability. Over time your T will increase the processing a bit while always returning to stability. The conditions for processing get a bit blurred too. Your T will focus on processing the things that are needed to make it possible to meet these criteria. So thoughts and emotions that keep you in contact with abusers would be high on the list to make your life safer. Whatever keeps you from being able to say ‘no’ or ‘stop’ would be an important target. Because everything is so interwoven it will be impossible to work on stability without processing tip-of-the-finger content. The 3-phase model for trauma treatment is not followed in the letter but the spirit of it is not abandoned.

 

 

Back to EMDR for stabilisation in severe trauma