Diane Clayton

"Pain in this life is not avoidable, but the pain we create avoiding pain is avoidable."

VICTIMS OF SEXUAL ASSAULT

In a traumatic event, the body's natural reaction is the "fight, flight, freeze, or collapse" response. Memories of sexual molestation affect the victim's behavior, self-esteem, motivation, and general beliefs they have about themselves. It is not unusual for untreated sexual assault victims to use avoidant behaviors to inhibit these overwhelming and disturbing memories. They often engage in compulsive behaviors and may turn to substance abuse.1

In my thirty-two years of treating recovering female addicts, I have observed that 75% had a history of sexual abuse. These victims feel dirty, think of themselves as unlovable, and may experience some form of sexual dysfunction, ranging from lack of sexual desire to compulsive sexuality. The younger and more chronic the sexual abuse, the more fragmented and fragile is the victim's personality structure.

Using eye movement desensitization and reprocessing (EMDR), the therapist is able to guide the client through these painful memories. Thoughts and feelings of worthlessness and powerlessness are replaced by those of worth and dignity. The victim stance is replaced by healthy self-awareness and stability.

WHAT IS EYE MOVEMENT DESENSITIZATION AND REPROCESSING?

In this chapter we are going to explore the complex model of EMDR. It is a phase-oriented approach to therapy based on principles and protocols designed to move the recipient of treatment through a process that is extremely prescriptive, and empowering.

EMDR is a rapid, safe, and effective psychotherapeutic modality when used in the treatment of sexual assault and other trauma-induced pathologies. It was discovered in 1987 by Francine Shapiro, Ph.D., while she was researching ways to reduce stress. Dr. Shapiro noticed that after rapid eye movements a disturbing event in her own life was no longer as disturbing. She believed she had tapped into a natural healing process much like the body's attempt to heal a wound.2

It was initially named eye movement desensitization. After further research, Dr. Shapiro published the first study3 addressing symptoms of post-traumatic stress disorder found in combat veterans and rape victims. This study revealed that after only three to five sessions the symptoms of post-traumatic stress disorder (hypervigilance, flashbacks, and nightmares) were extinguished.

For these tortured souls, the war was finally over and the rape had finally ended. This was as important a discovery for mental health counseling as the laser had been for surgery. From these humble beginnings EMDR has evolved into a therapeutic modality that is effectively used in treating everything from anxiety to dissociation.

In 1990, Dr. Shapiro noticed more was happening than just desensitiza-tion. It was as if a digestion of the memory had taken place. The participants had stopped reacting to the event with overwhelming anxiety but had metabolized and integrated the experience. The name was changed to eye movement desensitization and reprocessing.2

EMDR has many components of other therapies: cognitive, behavioral, psychodynamic, family systems, and experiential, just to name a few. All of these components are found in the procedures and protocols in EMDR and work faster than any of the therapies do individually. EMDR is combined with other modalities in the treatment of complex post-traumatic stress disorder such as ego state therapy.4

It has become one of the most researched psychotherapies. Most research has been on simple trauma as opposed to complex trauma. Information regarding research can be found on the website of the EMDR International Association at http://emdria.org and the Francine Shapiro Library at http:// emdr.nku.edu. The Journal of EMDR Practice and Research is dedicated to publishing EMDR's newest findings.

HOW DOES EYE MOVEMENT DESENSITIZATION AND REPROCESSING WORK?

Despite its proven effectiveness, EMDR has been criticized by some, perhaps because it is not known exactly how it works. Several theories have been postulated. Dr. Shapiro uses the language of neuropsychology to explain her theory. Her explanation is called adaptive information processing (AIP) theory. The AIP model proposes that the unconscious is composed of stored memories that guide us automatically like a well-worn path. These unprocessed memories are networked with or linked to certain other memories, emotions, and distorted thoughts and beliefs, and they elicit physiologic sensations. These emotions, thoughts, and feelings then arise in the present and cause disturbances.

Processing these memories frees the individual to respond more appropriately in the present. How EMDR accomplishes this "processing" is still a matter of debate in the scientific community. However, this therapeutic model guides treatment planning and predicts clinical outcome consistently in EMDR. The client is able to connect to more positive information that was previously blocked from awareness by traumatic memories.

Researchers have referred to EMDR as going beyond a talking cure and checking into emotions and bodily sensations while noticing mental con-tent.5 EMDR gets behind words and taps into the unconscious. PET scans after EMDR showed an increase in prefrontal lobe activity. Before EMDR, PET scans revealed more activity in the limbic system. These results indicate that the client is functioning in the present rather than reacting from emotionality and events from the past.

Laboratory studies of eye movements6 have revealed effects on memory components. These studies have revealed that the following changes take place after eye movements:

• Decreased vividness of memory images and related thoughts

• Decreased emotionality related to memory images

• Physical changes such a lowering of the heart rate, skin conductance, and increased heart rate variability

• Increased cognitive recall of words and early childhood memories

• Increased episodic memory

THE EIGHT PHASES OF EYE MOVEMENT DESENSITIZATION AND REPROCESSING

The "treatment goal for the individual is to get the most profound and comprehensive results in the shortest period while maintaining a stable client within a balanced family and social system."7

EMDR is a client-centered, complex, eight-phase approach to psychotherapy. The more extensive the abuses, the more extended are the different phases. The sessions are generally ninety minutes long. The following description characterizes the EMDR protocol, though the particulars are unique to each individual.

Phase I: History and Treatment Planning

During the first phase of treatment the therapist takes an extensive history, if this is not too overwhelming for the client. It is essential to establish rapport and build trust in this phase. When someone has had an extensive sexual abuse history, they may have difficulty talking about the event or in some cases remembering the event. The psyche protects itself by creating amnesia barriers when an event is too overwhelming.8

Many victims blame themselves instead of their abuser and feel shame and humiliation about what has happened to them.9 They may experience self-loathing and have difficulty talking to anyone about such a traumatic, life-changing event. The therapist may get only parts of the story at this time if the client is too overwhelmed.

The therapist then determines if the client is appropriate for EMDR and if the client is emotionally stable enough at this point for processing. Stable implies that the client is functioning and living in a stable environment. The client is screened for dissociation. According to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), "the essential feature of dissociative disorders is a disruption or alteration in the usually integrated functions of consciousness, memory, identity or perception of the environment. The disturbance or alteration may be sudden or gradual, and transient or chronic."10

Dissociation is a defensive pattern used by victims of complex trauma that enables the blocking of memories that are too overwhelming. While EMDR does not cause dissociation, it does bring it to the forefront if it exists in the individual. Using the standard protocol in EMDR with this population will destabilize and open up an overwhelming response. Screening is a safety precaution. The client may need more rapport building and be resistant to working on these memories immediately.

Phase II: Preparation

Trauma is stored in fragments in the memory and locked in with the feelings, sounds, smells, and body sensations, as if frozen in time. EMDR processing releases a lot of emotional tension, and the client may abreact during processing.

Phase II prepares the client for processing. A concise but thorough consent briefing is completed in which the client is carefully informed of what to expect in treatment and reassured that control over the process rests entirely with them. Self-control techniques are taught. When processing, the client will experience the trauma again, but in a very short period of time, while being oriented to safety in the present.

The method of bilateral stimulation (BLS) is chosen. BLS is one of the features that make EMDR a unique therapy. Bilateral eye movements, hand taps, or sounds are employed while the client assesses the disturbing memories. The client follows the therapist's fingers or a light bar designed to move the eyes rhythmically back and forth. Tapping or sounds may also be used to stimulate processing. The therapist chooses the type of BLS most fitting to the client's individual needs.

If the client has had extensive abuse, the preparation phase will be extended and ego-strengthening exercises will be used to prepare the client and help establish the courage to face their trauma.

Phase III: Assessment

The goal of this phase is choosing the target memory to be processed first. There may be several targets, but the first is chosen based on what the client feels ready to process. Generally the earliest memory that started the negative beliefs about the self, known as the touchstone event, is identified with the present triggers and symptoms. Beliefs often espoused by sexual assault victims are "I am not lovable" or "I am not good enough."

The client identifies a memory and brings forth the image that represents the worst part of the memory. The negative belief about the self is contrasted with what the client would like to think about the self and compared to how true the positive statement is in the present.

The client is asked to identify the emotions associated with the memory and how disturbing these emotions are in the present. This is rated on a scale of 0 to 10, referred to as the subjective units of disturbance scale.11

The client then focuses on the body sensation associated with the memory. After this baseline information is gathered the client is ready to move to the fourth phase, desensitization.

Phase IV: Desensitization

This is the phase where processing begins. The client holds the disturbing memory, the negative cognition, and body sensations in mind while the therapist starts the bilateral stimulation (BLS).

The client allows whatever internal experience is happening for them to emerge as they hold the memory. Through observing the client's face while processing, the therapist determines when is a good time to give the client a break from processing by saying, "Take a deep breath and blank out the memory." The therapist requests that the client share their experience. There are no right or wrong answers. The client shares what they have experienced internally and then returns to the last part of the memory, processing more with BLS.

When the client starts processing the event or events, the individual focuses on what happened but does not remain fixated on the event while processing. Information may emerge that the client had forgotten. Positive connections start to occur. The client moves through the different memory channels related to the event. Processing may plateau at different points, and the client is taken back to the target memory.

The therapist acts as a facilitator and stays out of the way of the processing. Only if the client gets stuck or derailed does the therapist intervene. The goal is to move the processing along until the memory channels are cleared and the disturbance is brought down to 0 or 1.

The client is taught to just observe and let whatever happens happen, like watching the scenery from a train. The processing follows, using targets from the past, present and future. Anticipatory anxiety about the event in the future is processed along with the past and present targets. Much of what happens for the client is free association. This is where tapping into unconscious material allows the client to get beyond words and make a connection, giving insight not readily achieved through talk therapy.

Phase V: Installation

Installation involves taking the positive belief identified in the assessment phase and pairing it with the identified trauma memory. Bilateral stimulation is added to reinforce the positive belief changed from the negative cognition.

The client holds the original image and the positive belief about the self before starting the eye movement sets. The installation continues until the client feels that the positive cognition is true. The client is asked to rate their belief on a scale of 1 (false) to 7 (totally true). This is referred to as the validity of cognition scale.

Phase VI: Body Scan

After the desensitization of the negative cognition and the installation of the positive belief, a body scan is taken. It consists of having the client scan down their body mentally, noticing any residual tension while thinking about the original target and the positive belief about the self. If tension exists, it is processed with bilateral stimulation.

Phase VII: Closure

This is the last phase completed before the client leaves the session. The client is instructed to keep a log of memories along with the cognitions, emotions, body sensations, and level of disturbance. This teaches the client that they are larger than the events in their lives and to observe themselves without acting. The log is used to determine the direction of the next session.

If the client is continuing to experience some disturbance at the end of the session, then a full debriefing is completed. The client uses self-control techniques and is grounded to the present. The goal is always to have the client leave in better shape than when they came into the session.

Phase VIII: Reevaluation

When the client returns for the next session, the processing that was completed in the previous session is evaluated. If the positive cognition has continued to be valid and the memory is no longer disturbing, then the log may be used to determine a new target for processing.

Research has shown that fidelity to the protocol is necessary to get the desired results in treatment. One should seek a therapist trained in programs approved by EMDR International Association. This serves as the governing body overseeing the training and education in EMDR. New and innovative strategies are researched as part of their mission.

ONGOING IMPACT OF SEXUAL ASSAULT

Sexual assault victims may experience anxiety, phobias, panic, and/or depression. The longer an individual goes without treatment, the more impact the trauma and avoidance behavior will have on the victim's life and affect the decisions they make in the present.

The victim engages in self-defeating behavior with unintended negative consequences. Processing allows new connections to be made so decisions in the present are clear and not colored by the past trauma and avoidance. Failing to attend treatment creates a domino effect, creating more pain and low self-esteem.

Sexual assault is so much more than the event itself. The person is left with feelings of helplessness, powerlessness, self-blame, and shame. Bad choices after the event create more feelings of self-loathing.

Post-traumatic stress untreated can last for a lifetime, leaving the victims with chronic symptoms and loss of potential for a happy life. The following case is an example of the effects of delayed treatment.

THE CASE OF EMILY

In 2006, Emily was drugged and kidnapped by a sexual predator and raped repeatedly for two days. The drug left her paralyzed for a period of time. After escaping from the predator she felt dirty and blamed herself. Emily is a white, middle-class, female, thirty-six years old, and divorced; her life changed overnight from this event.

She had met the man in a restaurant on a date, and while she was in the bathroom, he put something in her drink that caused her to feel disoriented. He then offered to give her a ride home. Unable to drive, she accepted his offer. While unable to move from the effects of the drink, she was trapped in her house with this man.

After the terror and repeated rape, she blamed herself and started acting out her feelings of self-blame and -loathing. For two years after the event Emily used alcohol and drugs to numb her pain. She was arrested numerous times over a two-year period. On the last occasion of her arrest, she was kept in jail for a month. After this happened she sought treatment.

The psychiatrist recognized that Emily was not alcohol dependent but suffering from post-traumatic stress disorder. After six sessions of EMDR, Emily processed through the rape, her feelings of being dirty, and the humiliations of being arrested. She stopped drinking and using drugs and returned to her former functioning self. She had been competent and successful before the rape. The two-year delay in treatment had been costly both emotionally and financially to Emily. From a recent contact she reports her life is going well. The treatment effects have held over time.

EARLY-LIFE IMPACT OF SEXUAL ABUSE

Ongoing sexual abuse before the age of six, mixed with other life instabilities, may lead to complex post-traumatic stress disorder.4 The personality fragments into different ego states to accommodate the needed duality of existence. This may happen when sexual abuse is perpetrated by unstable parenting figures.

A distant mother and raging alcoholic father that sexually abuses create overwhelming fear, insecurity, and confusion in a child, creating inadequate attachment.

Children often identify with their parents, and if one is an abuser, the child's survival is dependent upon the abuser. The child labels itself as bad, rather than the parent, to ensure its own survival. The child will punish itself. Ironically, in order to feel safe from harm, the child may abuse herself. The child often experiences emotional deregulation and may engage in self-harm such as cutting.

Dissociation runs on a spectrum. Splitting of the personality may result. To protect itself, the psyche may develop alternative ego states. The following case is an example of ego splitting.

THE CASE OF MARIA

Maria is a forty-two-year-old divorced female of first-generation Spanish/ Italian descent with a sixteen-year-old son. She is an educated businesswoman, beautiful and bright. She began experiencing flashbacks and terrible nightmares six years ago. When the flashbacks occurred, she thought she was losing her mind. She started seeking treatment, and over the course of four years, she received many different diagnoses, depending on how she presented at the time of her appointments. One diagnosis was attention deficit disorder, and she was placed on medication. Several more diagnoses followed. None of the treatments she received improved her hopeless mood or improved her ability to function. She had shut down and isolated herself.

Due to nightmares and flashbacks, Maria became fearful of staying in her home. She spent a good deal of her resources staying in hotels to feel safe. After four years of missed diagnoses and failed treatment, she entered EMDR treatment.

In the flashbacks were childhood memories of being sexually fondled by her father for as long as she could remember. He had been a "gypsy" and was raised in a culture where he had learned to steal and had been sexually molested himself. Maria's abuse was ritualistic in nature. Objects had been inserted into her vagina. She remembered the pain being so unbearable that she would escape into a fantasy in her mind. It was like she would leave her body and look down upon the event. Her parents had told her she was special and that she would be ahead of the other girls her age. Her father was an erratic alcoholic, and her mother was rejecting and emotionally distant.

The memories of the molestations had been buried. Maria had difficulty sleeping for most of her life. She did not understand why she had such difficulty. When the memories started surfacing, she asked her parents, who denied any such thing ever happened. This further reinforced her fear that she was losing her mind. Her parents cut off their relationship with her after the confrontation. She felt abandoned and had little reason to live. After doing some research, she found her suspicions were well founded. Her father had been arrested for fondling another child. Other buried memories returned.

When she was a child, because of her father's erratic behavior, the family was ostracized by the community where they lived. Other children were not allowed by their parents to play with Maria. She had attended many schools, never able to maintain friendships. She felt alienated and rejected. Her friendships would abruptly end as people in the neighborhood witnessed her father's behavior. As a small child, she recalled being taken to many different hospitals on numerous occasions for urinary infections. Most of the abuse occurred before the first grade.

After some time in treatment Maria started to trust her judgment that her flashback memories were real. Because of her dissociation, she had memory lapses and would often awaken in a childlike state. This was terrifying. Sometimes she would find work she had done that she did not remember doing. She felt very young and small and did not remember how to use phones or computers or respond to e-mails. Awakening from the nightmares was difficult. She knew she was not herself and struggled to get back to her normal functioning. Aware of her condition, she understood when she switched from an adult to a childlike state.

After Maria was stabilized and was taught grounding techniques, she started EMDR processing. For the first time in her life she started sleeping through the night. She processed old memories, and the pieces of her life started to make sense, like pieces in a puzzle. She started to feel more control over her life. She became more hopeful.

Prior to treatment she had planned to commit suicide when her son completed high school. After two years of treatment she had worked thought much of the painful memories.

Because of the insecurity she felt in the attachment and bonding experience with her parents, she has not yet overcome her fear of connecting to people. She has difficulty in relationships. Either she tends to cling or run away from them. Her attachment is a disorganized one. She is now working on this problem and is more hopeful about her future.

Utilizing grounding techniques and orienting herself to be present most of the time, she has realized her potential to be a high-functioning adult.

COMPLICATION IN PROCESSING

Victims while in processing often get stuck around beliefs regarding responsibility, safety, and choices.2 A cognitive interweave is brought into EMDR processing when the client has difficulty in these areas. A cognitive interweave created by Dr. Shapiro may be a statement or giving of information to the client needed to move the processing.

The therapist integrates the new information with BLS. Clients have difficulty feeling safe in the present, particularly sexual abuse victims. Many were threatened at the time of the assault and may feel that if they disclose what happened, they will be harmed. Victims, particularly children, have fear of disclosure. Although the person may be an adult now, the fear of disclosure is still locked in the body and psyche.

Victims of pedophiles experience confusion in processing regarding responsibility because pedophiles groom their victims before abuse. The pedophile may be generous financially, provide nurturing, and make the child feel special. A loyalty and bond develops between the victim and predator.

The experience of an assault combined with having their abuser provide positive things for them creates a trauma bond.9 The victim may willingly participate, feeling they owe the perpetrator. Reenactment is a common behavior for the victim. The female victim may compulsively go from one abusive relationship to another if treatment does not occur.

Because of the developed loyalty to the perpetrator, the child fails to disclose, feels confused about their participation, and blames herself. This creates a "double bind" for the victim. Processing is more difficult because of these confused feelings. Psychoeducation for the victim regarding grooming behavior relieves some of the confusion. The following case is an example.

THE CASE OF SARA

Sarah is now in her twenties, a white, single, poor female from a southern state. She is experiencing anxiety and depression. She grew up in a single-parent family where her mother was weary with two jobs and had little time to spend with her. She had experienced emotional deprivation and loneliness as a child and teenager. When she was in high school, her gym teacher had taken some interest in her. The teacher would invite her to her home and showed special interest in her.

After a while the teacher started soliciting sexual favors from Sara. It left her with feelings of self-loathing and self-hatred. She started cutting herself. Later, when in EMDR therapy, she was stuck feeling that the gym teacher was the only one who had cared about her. To give up the belief meant that she was unlovable and unworthy. Sara could not win with either cognition. It took months for the client to work through her stuck processing.

EMDR WITH COMPLEX TRAUMA

EMDR can be very powerful in moving the victim to trauma resolution. It can also be destabilizing if processing ensues too quickly and the standard protocol not modified. Complex trauma with EMDR has not been researched as completely as single events. The current research indicates that using Resource Development installation, titrating the trauma in processing, and extending the preparation phase produces the best results.12 Hypnosis, ego state therapy, and cognitive therapy combined with EMDR strategically helps the client to develop a higher level of affect tolerance. This is needed for the client to tolerate the abreactive responses commonly experienced in EMDR processing.

More research is needed on complex trauma and EMDR. Many pioneer therapists are forging ahead and developing techniques in stabilization and processing with EMDR, keeping the client oriented to the present. Dr. Shapiro initially recognized the EMDR Dissociative Disorder Task Force13 to make recommendations and guidelines outlined in her second-edition text.2

THEORY OF STRUCTURAL DISSOCIATION OF THE PERSONALITY

Theory of structural dissociation of the personality (TSDP) postulates that the personality of traumatized individuals is unduly divided in two basic types of dissociative subsystems or parts. One type involves dissociative parts primarily mediated by daily life action systems or motivational systems. The other type involves dissociative parts, fixated in traumatic memories, primarily mediated by the defense action system. The more severe and chronic the trauma, the more dissociative parts can be expected to exist.8 This theory helps to guide the use of EMDR with complex trauma and dissociative disorders.

In sexual assault the victim attempts to integrate the experience. The ability to integrate preserves their mental health and guides them in an action plan. When integration is unsuccessful, the survivor may split off the emotional part of the self from what presents as the apparent normal part. The greater the trauma, the more fragmented are the parts of the self.8 This means in treatment that longer preparation is required to not overwhelm an already-stressed system that could totally decompensate without creating a structure for treatment.

Structural dissociation is found to exist in different categories: primary, secondary, and tertiary. Primary dissociation involves all forms of trauma and includes post-traumatic stress disorder. There is some splitting of the apparent normal self and emotional parts. In secondary dissociation there are more emotional parts and one apparent normal self. In tertiary disassociation there are many parts of self as a result of more traumas.8 An incorrect diagnosis and premature processing can be a disaster for the client. While EMDR is very effective, a healthy respect for its impact is important for the therapist and the client. Treatment must be phase oriented with much preparation and stabilization. The standard protocol described above must be altered to accommodate the complexity of the individual.

In summary EMDR is a powerful, effective psychotherapeutic modality that is still evolving with new research for treating all traumatic disorders. There is hope for those that prior to EMDR had poor prognosis for recovery. With EMDR used by a well-trained therapist there is a light at the end of the tunnel. The client can hope to have a full recovery and have the quality of life possible before trauma. Fidelity to certain phases of the protocol is important. The client must be ready to face their trauma and prepare to be empowered by the process.

REFERENCES

1. Abel, N.J., & O'Brian, J.M. (2010). EMDR treatment of comorbid PTSD and alcohol dependence. Journal of EMDR Practice and Research, 4(2), 50-59.

2. Shapiro, F., (2001) Eye movement desensitization and reprocessing, basic principles, protocols, and procedures (2nd ed.). New York: Guilford Press.

3. Shapiro, F. (1989b). Eye movement desensitization: A new treatment for posttraumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211-217.

4. Forgash, C. (2008). Healing the heart of trauma and dissociation with EMDR and ego state therapy. New York: Springer Publishing Company.

5. van der Kolk, B., McFarlane, A., & Weisaeth, L. (1996). The effects of overwhelming experience on mind, body, and society. New York: Guilford Press.

6. Propper, R., & Christman, S. (2008). Interhemispheric interaction and saccadic horizontal eye movements. Journal of EMDR Practice and Research, 2(4), 269-281.

7. EMDRIA.org, Definition of EMDR, Revised 10/25/09.

8. van der Hart, O., Nijenhuis, E., & Solomon, R. (2010). Dissociation of the personality in complex trauma-related disorders and EMDR: Theoretical considerations. Journal of EMDR Practice and Research, 4(2), 76-92.

9. Carnes, P. (1997). The betrayal bond. FL: Health Communications, Inc.

10. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: Author.

11. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.

12. Korn, D. (2009). EMDR and the treatment of complex PTSD: A review. Journal of EMDR Practice and Research, 3(4), 1465-1487. 13. Fine, C., Luber, M., Paulsen, S. Puk, G., Rouanzoin, C., & Young, W. (1995). A general guide to the use of EMDR in the dissociative disorders: A task force report. In Shapiro, Eye movement desensitization and reprocessing: Basic principles, practices and procedures. New York: Guilford Press.

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