Phase 1: History Taking, Case Conceptualization & Treatment Planning

Trauma-informed Biopsychosocial History

Self-soothing skills and ability to state change / shift affective states
Strengths and developmental deficits
Identify potential processing targets from the client’s past, present and future:
• Including “T” and “t” experiences and pathogenic memories
Incorporate developmental, relational, cultural, gender, ethnic and spiritual elements
This information is used in general case conceptualization & specific treatment planning

Client Selection Criteria & Considerations

Client’s readiness for change
• Secondary gain issues
• Present-day stressors – personal, work-related, medical
• Timing issues – e.g., availability of client and clinician, client’s life circumstances
Available resources
• Internal – can ground and self-soothe (self-care) between sessions
• External – friends and family and physical safety (can call for help if needed)
• Client may perceive the therapeutic relationship as the only positive relationship
Affect tolerance
• Can experience emotion without disconnecting / dissociating
• Can ground and self-soothe (self-care) between sessions
Emotional stability
• Suicide attempts?
• Self-mutilation?
• Life threatening substance abuse?
• Dissociative disorders?
- Attachment history
  • Resources (adaptive) and/or targets (maladaptive)?
  • Includes past therapeutic relationships
  • History has significant influence on the therapeutic relationship
  • Therapist attunement to client is paramount throughout all phases of EMDR, regardless of client’s attachment history
- Case complexity – direct or titrated?
- Current psychosocial details
  • Medical concerns
  • Physical – e.g., eye issues, seizure disorders, cardiac issues, high-risk pregnancy
  • Chemical – medications
  • Legal issues – imminent testimony
  • Images fade
  • Emotionality decreases
- Dissociative tendencies / strategies
- Can maintain dual attention / dual awareness / dual focus

Case Conceptualization & Treatment Planning

Case Conceptualization

A clinician without a Case Conceptualization Model is like a captain of a ship without a rudder, aimlessly floating about with little or no direction – Meichenbaum
Conceptualizing a case is how we understand the client’s life based on our theoretical orientation, in this case, the AIP model
- Case conceptualization considers internal and external forces including precipitating causes and touchstone events. How did the problem develop?
- It represents the map of the client’s life
- It considers the 5 Ps:
  - Presenting problem
  - Predisposing factors that made the individual vulnerable to the problem
  - Precipitating factors that triggered the problem
  - Perpetuating factors that keep a problem going or unintended consequences of trying to cope with the problem
  - Protective factors
- Maladaptively stored, unprocessed information that is unable to link with adaptive information networks is the cause of nonorganic clinical complaints based on the pathogenic memories such as:
  - Anxiety and stress
  - Depression
  - PTSD
- The same information may result in damaged
  - Sense of self-worth
  - Sense of safety
  - Sense of appropriate responsibility
  - Sense of control or choices
- Perceptions of present experiences activate / trigger memory networks and the client experiences aspects of the unprocessed memories, e.g., emotions, physical sensations, and beliefs / thoughts
  - “The past is present”
- Apply the AIP model to the information gathered
  - During Phase 1 History-taking
  - Throughout the course of treatment, e.g. during processing phases 4-6 or Phase 8 Reevaluation
  - What the clinician understands about the client
    - Attachment history and style
    - Emotional strength and resilience
      - Client’s ability to access sufficient internal and external resources
      - Necessity of developing additional internal and external resources
    - Complexity and impact of trauma
  - Identifying informational gaps
- Patterns of thinking, actions and feelings that need to be addressed
- Identifying specific themes and targets for processing
- Goals of therapy
  - Behavioral
  - Cognitive
  - Affective
  - Somatic
  - State change to trait change

AIP-Informed Treatment Planning

As the clinician conceptualizes the case, s/he begins to develop a specific plan to address each of the client concerns and goals. Some call this a “target sequence plan”.

Primary focus of treatment is the AIP system and associated stored memories
Focus of procedures is to access and process dysfunctional, pathogenic memories to adaptive resolution
• This list includes related past memories, triggering present experiences and adaptive future actions
Client’s memory networks and innate healing ability in the form of AIP system is the most efficient and effective means to optimal clinical outcomes
Accessing the targeted memories as currently stored allows the appropriate associations to be made throughout the associated networks
Unrestricted processing facilitates thorough processing of the target memory and associated networks
In the event that processing becomes blocked or stuck, any intervention should imitate the client’s natural, spontaneous processing
• Any intervention may alter the course of processing, resulting in closing otherwise
available pathways to associated networks
• Target must be re-accessed and processed in unadulterated form
Processing causes all elements of a memory to shift to adaptive resolution

Possible Organizational Approaches for Treatment Plan

Dysfunctional / irrational beliefs (the most common approach for many clinicians)
• These beliefs may be conceptualized as the cognitive “themes” in a person’s life
• Beliefs – I’m worthless, I’m unlovable, I can’t trust
• There should be only one NC/PC pair per target sequence plan
Shapiro – Informational Plateaus form developmental foundation of beliefs
• Responsibility
• Safety
• Power and Control
Symptoms / complaints
• Recent traumatic experience – car wreck, robbery
• Anxiety / panic
• Depression
• Severe personality issues
• Dissociation
• Titrated history-taking
• Resource development and stabilization
Target mapping
• Graphic representation of issues / concerns / problems
• Demonstrates relationship between / among problems
Genogram
• Targeting plan derived from traditional genogram
Chronological
• May be inverted for more poorly resourced clients
Somatic experience / symptom
• Targets organized around “felt sense” or physical sensation
• Heart racing, butterflies, nausea, perspiration, tears, jaw clenched
Sensory elements – images, sounds, smells, tastes, tactile / touch
“Parts” – e.g., responsible, protector, scared little kid
Emotions – anger
Behaviors – avoiding social situations, lashing out at family, friends, co-workers
People or animals, locations, dates
Other – felt sense, e.g., “heaviness”

Methods to Identify Appropriate Targets for Treatment Plan

Direct questions
Float back (Browning & Zangwill, 2005)
• Activates elements of current experience: sensory, negative belief, emotions, and body sensations and invites the brain and body to access implicitly stored memories (channels of association) that are being activated in the present
Affect Scan (Shapiro, 1995)
• Activates elements of current experience: sensory, emotions, and body sensations
• Useful when other elements of experience are present, but there is no easily identifiable belief
Notice the sensory elements (sights, sounds, smells, tastes, touch sensations), the negative beliefs, emotions, and body sensations that you’re experiencing as you focus on that memory.
As you focus on all of this, ask your body and brain to take you back to earlier times when you had similar experiences – when you felt like this – to the time before, and the time before, to your earliest awareness

Treatment Plan

Introduce client to bilateral stimulation (BLS) with resources such as Container and Happy Place
• Educate the client about EMDR and the protocol sequence, explaining the effects of BLS and memory processing
• Explain how creating adaptive resources will strengthen / reinforce the client’s ability to ground her/himself and tolerate intense emotion
• Clients are able to have a positive experience of BLS as they experience activation of elements of adaptive networks (sensory, cognitive, emotional, somatic)
• By association, help them extrapolate how the same activation will likely be present during processing of disturbing material
• Educate client on potential of high levels of emotion occurring
• Emphasize the importance of establishing their ability to state-change after activation
Prepares client stabilization resources in the event history-taking is activating and dysregulating
Collaboratively agree on the theme / focus of treatment
• If we could take one thing off your plate to give you some relief, what would it be?

Temporal Organization – Three-Pronged Protocol – preferred order

Using the Three-Pronged Protocol, identify the memory elements / target components (sensory input, thoughts, emotions and body sensations) associated with the theme
- Target – a specific memory or dream; person; actual, imagined, or anticipated event; or some aspect / element of an experience, such as thought, emotion, or body sensation
- Node – biologically stored experience where elements of the memory network (target elements) meet
  - All targets are nodes: not all nodes are targets
Consider the behaviors and skills needed as stabilizing resources for the client
General rule – process all negative associated material for a specific target before moving to the next target
- Past – What past experiences set this in motion?
  - Touchstone memory – the earliest recalled experience that becomes a primary self-defining
    event
    - Early memories form the foundation of the dysfunctional memory networks
      - Usually, these memories are between ages 4 and 12
      - We become highly verbal and cognitive around age 4
      - Forms basis of judgments about the quality or experience of other things
      - Non-declarative memories that contribute to current dysfunction (feeder memories) are likely to occur when the target memory is from adolescence
        on
  - Worst – may be any time, though they tend to be in the past
  - Other past experiences related to the organizational theme’s memory network
  - Clusters of similar targets may be grouped as one montage target for more efficient use of processing time
  - Progressions – additional fleeting memories may surface during processing– make note and revisit at a later time
  - Based on AIP, adaptive processing of past experiences will likely generalize to other experiences in the three prongs
- Present – What current experiences are activating / triggering the memory networks?
  - Can be activating adaptive / resource networks as a resource
  - Can be activating maladaptive networks of unprocessed memories
  - Some may remain because of second-order conditioning and require targeting
  - Others may be based on recent experiences not associated with the memory networks identified for processing
- Future
  - Explore and identify client’s visions and goals
    - How client would like to see her/himself engaging in life in the future in an adaptive way
- Identify client’s ability to incorporate more adaptive perspective, behaviors and outlooks
- Explore, identify and target potential challenges
- Prepare for potential disruptive life experiences
Exceptions
- When the client is poorly resourced, it is more clinically appropriate to invert the protocol, allowing the “easier” processing to build the resource network
- In relationships that are time-limited, there may not be time to do comprehensive processing
  - In relationships that are time-limited, there may not be time to do comprehensive processing

Characteristics of Cognition / Belief

Verbalization of the affective “felt sense” from the time of an experience, + or –
Conclusion(s) the client draws about the self, based on an experience, or group of similar experiences

Negative Belief / Cognition (NC)

Characteristics
• Self-referencing – “I statement” in present tense
• Generalizable
• Irrational
• Presently held
• Childlike perspective – can produce more therapeutic “bang for the buck”
• Likely external locus of control – developmental perspective
• Congruent with the client’s presenting concern
• Resonates with the client’s affect
• Not a description of the client’s experience or personal characteristics
• I can’t do it vs I’m worthless
• She’s mean vs I’m bad
Identifying appropriate belief for the issue
• When you think of ____________, what negative belief do you have about yourself?
• At 3:00 in the morning when you can’t sleep, what do the rats whisper in your ear?
• What might people say about someone in that situation?

Positive Belief / Cognition (PC)

Self-referencing – “I statement”
Generalizable
Rational
• Not magical thinking
• No absolutes
• Avoid always or never
Adaptive re: target memory and what actually happened
Adult perspective
Internal locus of control
Along a polar continuum with the NC – same theme
• I’m not good enough –> I can one day begin to learn that I might be okay as I am
• May have to work backwards from the PC to get to best NC/PC pair for the issue
Resonates with the client’s adaptive goal
Will feel relatively untrue prior to successful processing, but is somewhat believable
Provides a “light at the end of the tunnel”
Is not a negative of the NC – I’m not a bad person

Examples of Negative and Positive Cognitions

Negative Cognitions from Early Childhood Developmental Stages

Attachment-Informed Negative Cognitions

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