Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based trauma-focused psychotherapeutic intervention for trauma-related disorders. It has especially gained acceptance as the most efficacious treatment for Post-Traumatic Stress Disorder (PTSD). But, in the majority of cases, it is used as a singular module, and there has been no report on the integration of any other psychotherapeutic approach with EMDR in the treatment of PTSD. In this article, two case studies of individuals were described in which EMDR Treatment was conducted according to the standard protocol presented by Shapiro (1995) in combination with a few psychodynamic principles in one or two sessions to resolve trauma effects. It was a supportive therapeutic relationship along with a deeper understanding of the clients' and therapists’ unconscious processes. It was called and discussed as “Analytic Intervene’’ in EMDR.
Keywords. Eye movement desensitization and reprocessing (EMDR), Post-traumatic stress disorder, trauma, analytic intervention, depression.
Introduction
Traumatic experiences lead to a variety of psychological problems, and PTSD is the most common among them, which also has high comorbidity with other psychiatric conditions (American Psychological Association, APA, 1994; Kessler et al., 1995). EMDR is widely recognized as the first line of treatment for such trauma-related conditions (Hase & Brisch, 2022; Shapiro & Laliotis, 2011). It consists of eight phases such as history taking and preparation of the client, identifying the target traumatic memories, dual-attention stimulation in the form of repeated sets of eye movement, installation, resolving any residual somatic sensations, closure, and reevaluation that address past traumatic events and present triggers of the symptoms (Davidson, 2001; Marcus, 1997; Shapiro, 2001).
Clinical applications of this therapy are primarily explained by the Adaptive Information Processing model (AIP; Hase, 2021), which posits that the direct reprocessing of the stored memories of etiological events and other experiential contributors can have a positive effect on the treatment of most clinical complaints. This prediction has received support in several research studies, including clinical trials and case studies (Hase, 2021; Shapiro & Laliotis, 2011; Shapiro, 2002; Valiente-Gómez et al., 2017). Very limited studies have been conducted to see its effectiveness in Pakistani culture. One such study was carried out by Mustafa (2015) in which the application of EMDR treatment of PTSD along with depressive symptoms in the Pakistani scenario was established (Mustafa, 2015).
In recent years, additional applications have been developed by expanding the standard protocols by experts and consultants in several sub-specialty areas, such as clients with acute trauma, a wide variety of PTSD, and even trauma-related personality issues (Brown & Shapiro, 2006). Moreover, components of other psychotherapies have been incorporated into the standard EMDR (Capps, 2006). Similarly, in the present study, two clinical case studies were conducted where psychodynamic psychotherapy was integrated into EMDR as an analytic intervention. We have used it as a strategy to deal with the blocked processing.
Method
The research design of the present research study was a descriptive case series design in which two patients having psychological trauma were enrolled for the administration of EMDR by a therapist through convenient purposive sampling.
After the initial session, their suitability for the EMDR was established through protocol suggested by EMDR, which includes a patient history of psychological trauma, his/her willingness to get EMDR, and his/her positive response during safe place building. They were briefed about it, and their consent was obtained before the start of treatment. The detail of these two cases is narrated below:
Case Study 1
The patient was a senior Government officer in his late forties and presented with seven monthly histories of low mood and flashbacks of traumatic memories. There were multiple traumatic memories, and the main scene was where he witnessed a massive firing by terrorists.
At the same time, he lost an important promotion, and he had a sense of losing his carrier due to the same experience, which was traumatic and now professionally embarrassing as well. He started to feel persistently low and has had frequent reminders of this traumatic event. After seven months of personal struggle, he decided to consult. The patient was fortunate that he had a large support system, including a family who cared for him and an active professional life. He has easy access to psychiatric help. On the first assessment, the Individual simultaneously fulfills DSM IV diagnostic criteria for Post-Traumatic Stress Disorder and Major Depression. After detailed history taking, EMDR was decided as the first line of treatment for him. Six EMDR sessions were done in a total period of about two months.
In the first EMDR session, the Subjective Unit of Disturbance (SUD) was checked with its range of 0 to 10, where 0 means no disturbance and 10 donates maximum disturbance; it was 8 for the major traumatic memories. The Validity of Positive Cognition (VOC) was determined, which has a range of 1 to 7, where 1 has weak positive cognition, and 7 is strong positive cognition, and it was found to be 1 for this patient. Negative cognition was that “I am a failure,” and preferred cognition was that “I am competent and successful.” This session was done as incomplete at the end; SUD was 6 in the next session again, SUD didn't drop below 6, and again it was declared as an incomplete session and ended in a safe place.
In the third session, Light Stream Technique was also done to soften the image in addition to cognitive
Discussion about the acceptance of himself in the present rank and blocking belief of losing his career after that traumatic experience was challenged in cognitive intervention, but at the end of the third session, SUD was still not less than 5. It was the time that therapist tried to understand the client at an analytic level. The patient talked, and the therapist made interpretations of the patient's words and behaviours. In this broad therapeutic orientation, it was realized that there is a conflict between the desire to get promoted and the social need to adjust to the present rank. Predominant defence mechanisms were intellectualization and denial. He has underlined perfectionist personality traits. After the trauma, this person regressed in the latency phase of his psychosexual development. In the fourth session, the individual was offered support, and his defence mechanism of intellectualization was utilized. During this session, while the patient was doing eye movements, he was suggested to feel comfortable/safe and to encourage himself to participate in this important operation in his country. After that SUD dropped to 2, and the session again ended in a safe place.
In the fifth session, the therapist observed that his mental state had changed. His mood was euthymic. There were no flashbacks or intrusive thoughts. He said, “At first, after the first and second sessions, I was very tired. But then, I was amazed as things lightened up. Now, when I think of the accident, it doesn’t affect me as it used to. It's an amazing phenomenon, and I’m working a few more hours. I feel much chirpier about it and look forward to working more. I want to do things at home. It's lifted a weight - pressure that was overbearing for a very long time. I'm conscious of it not being there. My wife has noticed a difference in me. I think that I might be able to write on "war and peace" based on my views, my own experiences, and knowledge.” The fifth session was a complete session, and major trauma was successfully processed; in the sixth session, minor scenes of traumatic memories were processed completely with standard EMDR protocol. A graphical description of the technique used with Case 1 is given in Figure 1.
Graphical Description of Techniques Used with Case 1
Case Study 2
In the present study, the second patient was 21 years old young adult, an only son of a senior Government officer. He lived in Rawalpindi and was a student for a master's degree. He came with four monthly histories of difficulty interacting with him and in his day-to-day social life. This interaction was unavoidable, and he used to feel sadness and guilt every time after the interaction. He started feeling difficulty concentrating on his studies. These academic difficulties ultimately brought the problem to the surface. Moreover, there were repeated reminders of the traumatic events related to the college. History revealed that the boy had a history of being bullied by seniors; for two days, he decided to quit the academy, and at night he flew away. Soon after that, he realized that he had missed an important opportunity in his life, and now he could never join back.
He spent most of his childhood away from both his parents with his grandparents and uncles. As a child, he had never been able to get attention and respect from his parents. Therefore, as a young adult, he has never been able to make a cohesive sense of self and has a strong unconscious desire to identify with his father to get that attention and respect. His rigid superego does not accept his identity as a civilian and gives him constant remorse and guilt. Moreover, the individual was also facing constant rejection by his father ever since he left the academy.
In the first EMDR session, the major traumatic memories were realized to be the scene of leaving the Air Force Academy at night. The subjective unit of distress (SUD) about this event was 9. His negative cognition was That “I am unacceptable,” and his positive was, "I can learn to become accepted.” The validity of cognition (VOC) was 2. The first two sessions were done as incomplete sessions. His SUDs after the first session were 7, and 5 after the second incomplete session. The individual was grounded with the safe place technique in both of these sessions.
In the third session, the light stream technique was tried. In the beginning, it was followed by an EMDR session, in which SUD dropped to 4. This session again ended as incomplete in a safe place. On the psychodynamic understanding of this student, it was identified that the conflict between the unconscious desire to identify with the military father and the social need to continue life as a university student. His behavior was explained in terms of past experiences and motivational forces. His actions were viewed as stemming from his unconscious desire.
In the fifth session, the client was offered support and acceptance by the therapist in a transference and defence mechanism of repression, and denial was registered for the Analytic Intervene. Transference was encouraged. The defence mechanisms of denial and regressions were supported. The therapist and the co-therapist accepted the individual as a young, educated civilian; the client was encouraged to develop himself in civilian life. He was encouraged to explore himself as a successful civilian. In the sixth session, the SUD dropped to zero. VOC was raised to 7. At this point, he was given insight into his behavior, and defence mechanisms were also brought into his consciousness. A graphical description of case 2 is given in Figure 2.
Figure 2
Graphical description of techniques used in Case 2
Discussion
The current case reports illustrate the importance of EMDR in the treatment of PTSD along with depression in two patients suffering from PTSD/depression in the Pakistani scenario. Patients’ traumatic memories were reprocessed into adaptive ones using standard protocol EMDR and additional uniqueness (McNally, 1999). So, these case studies not only measure EMDR effectiveness in complicated trauma clients but also provide a proposal of an explanatory model. It looks at a relatively ignored or unidentified component of the EMDR treatment: the therapeutic relationship and analytic intervention. The unique aspect of these case reports is the integration of EMDR with psychodynamic psychotherapy. The author prefers to call it Analytic Intervene. We suggest that by incorporating key concepts of psychodynamic theory in the EMDR session as an analytic intervention, we can help the client. These basic concepts are early childhood experiences, psychosexual development, the existence of unconscious motivation or conflicts, the existence of ego, the superego, and the existence of defence mechanisms, transference, and countertransference. In analytic intervention like psychodynamic therapy, the patient talks, and the therapist interprets the patient's words and behaviours. Dream interpretation can also be a part of the analytic intervention. It is not recommended that an analytic intervene therapist has to do everything in every session or with every patient. Rather any one or two components from the above-mentioned concepts may qualify it to be called analytic intervention.
It is suggested that this analytic intervention can be used just like a cognitive intervention. Theoretically, it can also include a supportive therapeutic relationship that encourages transference and provides more opportunities to share feelings. The therapist identifies defense mechanisms and notices any arrests in psychosexual development. During the intervention, the therapist supports the healthy defense mechanism. It is proposed that after the analytic intervention, it becomes easier to deal with and reduce subjective distress (SUD) in a few cases. The researcher wanted to introduce it as a remedy for blocked processing and not as a component of standard EMDR therapy. It can also include analysis of transference, interpretation of dreams, and slips of the tongue. Practically at the time of blocked processing, the therapist may choose any of these psychodynamic mechanisms depending upon the individual case or his training and perform an analytic intervention to get the therapy going.
Although cognitive intervention is useful in many cases, it may not be acceptable by a few clients or therapists as it may affect the nonjudgmental stance of the therapist, especially with emotionally charged clients. Analytic intervention, on the contrary, is a supportive technique for a client who is in depression and dealing with traumatic memories. It places emphasis on the influence of experience on the development of current behavior. It emphasizes that previous relationships leave lasting traces which affect self-esteem and may result in maladaptive patterns of behavior, as we have noticed in our second client. An important innovation in our first patient was an auto suggestion. In our first case, during the last three sessions, the patient learned that if
during the session, he felt better with the suggestive statements by the therapist, for example ‘‘I am safe now” he can say this to himself whenever he gets a flashback or gets some disturbance due to the traumatic event. Simply by doing this, he noticed that the symptoms started to improve. This is different from the suggestion of hypnosis, where the patient is in an altered state of consciousness. In the suggestion part of analytic intervention of EMDR therapy, the patient is fully alert and can learn to do this on his own. We like to call it autosuggestion.
Shapiro (2001) views the dynamic of EMDR as one of accelerated information processing or dual attention stimulation; Dyck (1993) suggests a conditioning model, and Armstrong and Vaughan (1996) offer it as an orienting response model (Armstrong & Vaughan, 1996; Dyck, 1993; Shapiro, 2001). None of these models adequately address every aspect of the therapy. While in the present study, the psychodynamic basis of the therapeutic relationship and possible analytic intervention was suggested for future research. There is substantial reason to conclude that a carefully aimed analytic intervention, like cognitive intervention, may have a significant impact. The psychodynamic basis of EMDR is not a new subject. Felicity de Zulueta (2006) wrote, “For Freud, as for Shapiro, psychopathology (and dreams) is constructed out of networks of memories; the original troubling memories of childhood experience being subject to strategies of avoidance, yet ever ready to be triggered, with accompanying physiology, when an associative cue is encountered” (Felicity de Zulueta,2006).
There is no single psychodynamic perspective that has general acceptance. But one should also accept that this does not set principles of psychodynamics apart from other specialist fields of psychotherapy. In fact, over the past three decades, there has been a convergence of assumptions across different psychotherapeutic specializations, cognitive–behavioral, humanistic–experiential, and psychoanalytic–psychodynamic. Psychodynamic principles have been recognized as the most comprehensive body of knowledge for understanding the complexity of human subjectivity (Shapiro & Laliotis, 2011). There are a few limitations of this study as well, such as these case reports cannot provide information regarding a control group of individuals who did not receive any EMDR. The ostensible improvement resulting from EMDR in these reports may be due to numerous variables other than EMDR itself, such as placebo effects (Gastright, 1995). It should also be noted that these case studies do not challenge the existing explanatory model of EMDR. It looks at one component of the EMDR treatment. Interestingly, it has also been realized that psychoanalytic experiences in psychotherapies are more like feelings and not thoughts; therefore, become indescribable in thoughts for the therapist himself.
Conclusion
In treating stress-related disorders, EMDR may be seen as having the primary goal of helping clients reprocess information that is held dysfunctional to enhance adaptive functioning. In certain cases, EMDR therapy may get blocked, so it is proposed that therapists may use analytic intervention when working with clients to achieve these goals.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th Ed.). American Psychiatric Association.
Armstrong, M., & Vaughan, K. (1996). An orienting response model of eye movement desensitization. Journal of Behavior Therapy & Experimental Psychiatry, 27(1), 21-32. https://doi.org/10.1016/0005-7916(95)00056-9
Brown, S., & Shapiro, F. (2006). EMDR in the treatment of borderline personality disorder. Clinical Case Studies, 5(5), 403–420. https://doi.org/10.1177/1534650104271773
Capps, F. (2006). Combining eye movement desensitization and reprocessing with gestalt techniques in couples counseling. Family Journal, 14(1), https://doi.org/10.1177/1066480705282055
Davidson, P. (2001). EMDR: A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-16.
Dyck, M. (1993). A proposal for a conditioning model of eye movement desensitization treatment of posttraumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 24(3), 201-10. https://doi.org/10.1016/0005-7916(93)90022-0
Felicity de Zulueta, C. (2006). EMDR and the energy therapies: Psychoanalytic perspectives. The British Journal of Psychiatry, 189,193-194. https://doi.org/10.1192/bjp
Gastright, J. (1995). EMDR works! Is that enough? Cincinnati Skeptic, 4(3), 1-3.
Hase, M. (2021). The structure of EMDR therapy: A guide for the therapist. Frontier Psychology, 12. https://doi.org/10.3389/fpsyg.2021.660753
Hase, M., & Brisch, K. H. (2022). The therapeutic relationship in EMDR therapy. Frontier Psychology, 13. https://doi.org/10.3389/fpsyg.2022.835470
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52(12), 1048-60.
Marcus, P. (1997). Controlled study of treatment of PTSD using EMDR in an HMO setting. Psychotherapy, 34, 307-315.
Mustafa, N. (2015). Eye movement desensitization and reprocessing (EMDR): A case study of a man with multiple traumas. Pakistan Armed Forces Medical Journal, 5(0), S262-S263.
Richard, M. (1999). Research on Eye Movement Desensitization and Reprocessing (EMDR) as a treatment for PTSD. 10(1),
Shapiro, F. (1995). Eye Movement Desensitization and Reprocessing: Basic principles, protocols, and procedures. Guilford Press
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. Guilford Press
Shapiro, F. (2022). Paradigms, processing, and personality development in EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism. American Psychiatric Association.
Shapiro, F., & Laliotis, D. (2011). EMDR and the adaptive information processing model: Integrative treatment and case conceptualization. Clinical & Social Work Journal, 39, 191–200. https://doi.org/10.1007/s10615-010-0300-7
Shapiro, F., & Laliotis, D. (2017). Weekend 1 Training of the Two-Part EMDR Therapy basic training. E. I. Inc.
Valiente-Gómez, A., Moreno-Alcázar, A., Treen, D., Cedrón, C., Colom, F., & Perez, V. (2017). EMDR beyond PTSD: A systematic literature review. Frontier Psychology, 8, https://doi.org/10.3389/fpsyg.2017.01668
