Phase 4: Desensitization

  • This phase incorporates BLS (long, fast sets) to reprocess the accessed target memory to an adaptive resolution
  • Associated memory networks/channels of association may be activated during processing
  • Links to material, both adaptive and maladaptive, is spontaneous
  • Clears “the mud off of the windshield” so the client has the ability to access the inaccessible positive memory networks
  • The body’s innate healing ability (AIP) reprocesses the memory to an adaptive resolution
    • Useful material is integrated in the form of adaptive learning while non-adaptive dysfunctional material is processed and discarded
  • Majority of processing time is spent in Phase Four
    • Processing may access memory channels of association
    • Elements of the memory (sensory, emotions, body sensations, beliefs)
    • People, places, situations, anniversaries, etc.
    • Memories and associations may bounce among past, present and future
  • The protocol shouldn’t override therapeutic empathic connectedness with client
    • Calm, non-intrusive, energetically supportive presence
    • Provides sense of safety and security for client to allow them to go where they otherwise might not

Initiate Phase 4 Processing

  • Bring up the picture (or worst part) and the words [repeat the NC], notice what you’re feeling in your body and follow the back-and-forth.

Bilateral Stimulation (BLS)

  • Speed and length of reprocessing set
    • Begin with 15-30 seconds sets that are as fast as the client can track / follow / tolerate
    • Faster speeds seem to activate the memory networks more efficiently, taking the client
    “deeper” into the memory network
    • For more poorly resourced clients, shorter, slower sets are suggested to avoid over-accessing
    • For clients who seem to be less activated, longer, faster sets are suggested

Changes Indicating Reprocessing

  • Target specific
    • Sensory elements (image, sound, smell, taste, touch)
    • Beliefs – insights that are incremental or rapid flip
    • Emotions – seem appropriate for the experience being processed at the time
    • Physical sensations
      • Somatic release of physiological manifestations stored at the time of the incident
        • The Body Keeps the Score – Bessel van der Kolk
      • Physical “activity” you witness while the client is processing
        • Breathing
        • Eye flutters and movements
        • Skin coloration
        • Body shifts and non-verbal cues
    • Memory Network – Channels of Association
      • Based on sensory elements of the memory, thoughts, emotions, and body sensations
        • People
        • Places
        • Things and situations
        • Physical feelings
        • Anniversaries, etc.
    • The brain and body know best, whatever comes up, is what needs to come up
      • Don’t judge, be curious
      • Trust the process

Range of Processing Interventions to Maintain Affective Window of Tolerance

Normal Range

  • The client is able to maintain focus / dual attention
    • “One foot in the past and one foot in the present”
    • Client demonstrates normal range of emotion congruent with the target
      • Client is able to tolerate the intensity of the emotion that is surfacing
      • Intense emotion is acceptable, appropriate, and encouraged
        • You may use short, previously agreed upon affirming words or phrases to support and ground the client during the processing; only when necessary
          • Make sure it’s about the client’s needs and not the needs of the clinician
          • Be aware that certain phrases or words may be triggering / activating for some clients and not for others – e.g., That’s it or Good or Good job
  • At the end of the set: What do you get? or What do you notice? or What comes up?
    • Non-directive question allows the client to report whatever is being processed, in whatever manner it is being processed, without interfering with the client’s natural processing (whole brain access / processing)
    • This is a brief pause in processing to assess where the client is in the moment
    • It is not necessary to repeat the client’s report
  • Initiate the next set with phrase such as Go with that, or Start with that, or Notice that.
    • Continue the speed and length of the sets (long and fast based on client’s definition) as long as processing is proceeding

Over-accessing / Hyperarousal

  • Client demonstrates difficulty maintaining dual focus / dual attention during processing
    • Client demonstrates intense emotion that causes disconnection from reality of the present moment
      • Will likely appear as uncontrollably emotional or “hysterical”
      • Client is not able to tolerate the intensity of the emotion that is surfacing
      • During the current set, decrease speed of BLS and shorten the length of the set
    • Using EMD (Eye Movement Desensitization) is appropriate in these situations
  • At the end of the set: Take a deep breath (maybe even have them repeat the breath if necessary) [pause] What are you thinking? or When you think about [the target] now, what are you noticing? [pause for response] 0-10, how big is your upset now?
  • Deep breath helps shift from sympathetic to parasympathetic nervous system
  • Directive question, emphasizing focus on the target and present orientation, “requires” client to access left brain (cognitive)
    • Limits amount of emotional and physical information being processed to “slow down” the processing
    • Reassessing or re-accessing the target memory after each set minimizes associations and limits access to “data” stored in additional memory networks
  • As a last resort, ask a question that limits focus to a single element of memory
    • Of the five senses: What are you seeing (hearing, smelling, or tasting)? or What physical sensations are you noticing?
    • Focusing the attention on the body is grounding — What do you notice in your body?
    • If the image is color, make it black and white
    • If there is movement, freeze it or if frozen, add movement
    • If the client sees the image as if up close or happening around them, have them view it from a distance
  • Decrease the amount of emotional and physical information being accessed by
    • Shortening the set
    • Slowing the speed of BLS
    • Changing direction or modality of BLS
  • Take more time between sets than you would for someone who is processing within the normal limits of the Window of Tolerance
  • You may try using short, previously agreed upon, affirming words or phrases to support and ground the client during the processing
    • Make sure it’s about the client’s needs and not the needs of the clinician
    • Examples – You can do this. You’re here with me. You’re safe now. It’s old stuff. That was then, this is now. The only place this is happening is your brain.
  • Honor the stop signal should the client use it
  • It is important for the clinician to note any personal activation (transference) s/he may be experiencing due to the client’s distress

Under-accessing / Hypoarousal

  • Client demonstrates difficulty accessing maladaptively stored material during processing
    • Client experiences minimal or absence of emotion and is overly focused in present
      • Will likely appear as having flat affect
      • Likelihood is that client is not able to tolerate emotional intensity of any sort
    • Note any sensation in jaw or throat and have client to give it words / voice
      • Notice your jaw (throat) and give yourself permission to say, silently or aloud, anything you want – anything you’ve been holding back
  • If there have been minimal signs of processing, at the end of the set ask, What are you feeling? or What are you noticing in your body?
    • Having client focus on emotion and/or body sensations “requires” client to access right brain
    • If the client reports nothing or numbness direct focus to location of the experience in the body
  • Check the possibility of client being “frozen”
    • Give yourself permission to do whatever you’d like, inside or outside – punch, kick, scream, stomp your feet…
  • Increase the amount of emotional and physical information being accessed by
    • Lengthening the set allows more time to access implicitly stored memories
    • Changing the speed
      • Slower may be more activating for someone who grew up in chaotic environment
      • Faster may increase activation
    • Changing direction or modality of BLS
    • Check in on target and scan for new data or additional disturbing associations
    • Emphasize multiple elements of the memory
      • Ask questions that break down the five senses: Notice what you are seeing, hearing, smelling, and tasting? or Notice what physical sensations you’re experiencing in your body.
      • If the image is black and white, make it color
      • If the client sees the image as if from a distance, bring it closer
      • Once the client has attended to the experience, suggest: Notice what you are experiencing and ask your brain and body to take you back to the time before and the time before, back to your earliest experience of [restate client’s experience]
    • Emphasize the negative belief to intensify emotion
    • Change the action of the experience: if frozen, add movement; if moving, freeze it
    • Move as quickly as possible between sets to prevent the client from down-regulating
    • There are no supposed tos, just let whatever happens, happen. Be curious.

Processing Considerations

  • Whenever possible, the clinician should allow the client to process spontaneously, without unnecessary intrusion or intervention
    Stay out of the way and let whatever happens, happen
    It is the client’s AIP doing the work that needs to be done to adaptively process the memory / experience
    • Any therapist intervention / intrusion / comment changes the memory and necessitates re-accessing the target in undistorted form
  • New memories may spontaneously occur during processing
    • Specific memory elements often process spontaneously, without additional attention
    • Feeder memories that contribute to current disturbance / dysfunction
    • These are untapped, implicitly stored earlier memories that “feed” or block the processing
    • Others may require additional targeting or an additional target treatment plan
    • Processing will not access all channels that are connected each time
  • Dormant networks may be activated by new experiences
    • There may be gaps based on developmental issues
    • They require new information so AIP system can bridge the gap in order to process
    • Once the linkage occurs, adaptive changes may be successfully integrated

Timing of Re-accessing / Reassessing the Target

  • Checking in on the initial target accesses the memory in its undistorted, currently stored form
  • The goal is to access any as yet unprocessed information or remaining channels of association
    • Necessary step following therapist intervention
  • When processing changes become minimal, vague, or client gives neutral feedback or no changes
    • Vague or lack of new material is indicative of reaching the end of a channel of association
    • If the client repeatedly reports positives
    • If a client is poorly resourced, as long as the positives are strengthening, the clinician may choose, time permitting, to continue sets of DAS/BLS to enhance the positive memory networks
  • When you check in on the target now, what do you get / notice (or what comes up)? [pause for response]
  • If client reports “nothing,” ask, 0-10, how disturbing is it now? and then go with that.
  • If the SUD is 1 or 2,
    • Have the client focus on the body sensation, Notice where you feel that 1 (or 2) in your body and go with that.
    • You may also ask process questions, e.g., What makes it a 1? What keeps it up at a 1? What’s the danger if it stays a 1? What purpose does the 1 serve? What would it take to be a 0? What would it mean if it were a 0? What’s the danger of it being 0?

Feeder Memories & Blocking Beliefs

  • These often surface during Phase 4 Reprocessing when the SUD is stuck at 1-2 or during Phase 5 Installation when VoC is 5-6
  • A feeder memory is an unidentified earlier memory related to the target memory that contributes to the client’s current dysfunction
    • May prevent 0 SUD until identified and processed
    • Access feeder memories
    • Focus on the negative cognition and scan childhood memories
    • Focus on dominant emotion and physical sensations, “name it to tame it” and float back or scan for earlier memory
  • A blocking belief is a negative belief that is blocking successful processing
    • Often linked to another negative belief associated with a feeder memory
    • Processing the initial target will stall until the blocking belief is reprocessed
    • Ask the client to close eyes, think of the situation and verbalize any thoughts that come up
    It’s not okay or safe to get over this
    It’s not okay to feel – I won’t be able to handle it
    I don’t deserve to get over it
    If I feel better, it means that what happened didn’t matter
    I’m betraying (being disloyal to) my friend(s) or family if I get over this
  • If the SUD doesn’t change / is stuck, the process questions above help identify possible feeder memories or blocking beliefs
    • Once identified, feeder memories and blocking beliefs may process through without further intervention
    • Occasionally, they will require individual targeting
    • In some cases, creation of an entire treatment / target sequence plan is needed
  • Have the client scan back on the disturbance – Notice where you feel that disturbance in your body and ask your brain and body to scan back to an earlier time…
  • To identify any fears or secondary gain issues, you may also suggest or ask
    See if there’s a part of you that is concerned about getting over this
    What would happen if you were to get over this problem
  • The memory / memory network may be too large to process in the remaining session time
    • It may be useful to “tag it” and put it away in the container for processing as a separate target at a later date
  • Once identified or activated, add a set(s) of BLS to facilitate processing

Fears & Avoidance

  • Secondary gain – what will the client have to confront or do if therapy works?
  • Fears
    • Process itself – suggest that the client chooses the first target for processing
    • Eye movements
    • Fear of feeling the emotions
    • Losing the respect of the therapist if the client experiences intense emotion
    • Discovering the cause of emotional disturbance
    • Normalize it. It’s already happened. The only place it’s still happening is in your brain. Why not clean it out so there’s room for positive experiences?
    • Going crazy / losing control – emotions are part of past experiences and will be processed adaptively
    • Losing good memories – quite the contrary, getting the “mud off the windshield” allows clients to access more positive adaptive memories
    • Change – address it with future template
    • Secondary gain
    What will become of me?
    I won’t know who I am. I’ve been like this all my life.
    • Losing relationship with the therapist
    • Disloyalty to family relationships / roles by changing roles
    • Make sure the client isn’t blocking emotional / cognitive processing effects
    • Worse case scenarios
    • Negative beliefs (demand characteristics) work overtime: I have to be perfect and do it right

Advanced Procedures

  • Make modifications to the basic protocol only when needed
    • Begin identification of potential needs during case conceptualization and treatment planning
    • May be incorporated during reprocessing phases
  • Once the client resumes spontaneous processing, return to “undistorted” processing
    • Client’s sense of self-efficacy and self-esteem may strengthen as a result

Cognitive Interweaves

  • Ways to activate stalled, ineffective or blocked processing
  • Mimics spontaneous processing
    • Fit the intervention to the client
    • The client emotionally / developmentally arrests at the time of the trauma
    • “Lay down new track” to link to the next informational “stop”
  • Clinician offers statements, observations, suggestions that interweave appropriate networks and associations
    • Instructions or questions that stimulate thoughts, actions and/or imagery
    • Looping
      • Repetitive negative thoughts, affect and imagery associated with high SUD after several sets
      • Offer an associated “track” of adaptive information that is developmentally appropriate for the “stuckness”
    • Insufficient information
      • Educational or developmental deficits result in lack of appropriate data to progress behaviorally or cognitively
      • Offer information
    • Lack of generalization
      • Processing hasn’t generalized to associated targets
      • Strengthen positive connections to the issue
    • Time pressures
      • Client fails to process intense emotional experience in last third of the session that may be due to multiple associated NCs or other channels of association
  • Tend to organize around themes / developmental plateaus – Responsibility, Safety, Power/Control/Choices
    • Shift the client from child to adult perspective
      • From external to internal locus of control
    • Differentiate the present from the past
  • Strategies – statement or question relative to the stuck point
    • New information
      • May require basic psychoeducation
      • Whose responsibility is it?
      • Who taught you that…?
    • “Columbo” – I’m confused….
  • Socratic method – series of questions to help client discover realistic belief about an experience
    • Revealing the issue
      • What evidence supports (the idea)? What evidence is against its being true?
    • Conceiving reasonable alternatives
      • Might there be another explanation or viewpoint? Why else did it happen?
    • Examining potential consequences
      • What are the worst…best…bearable…most realistic outcomes?
    • Evaluate the consequences
      • What happens if you keep thinking or believing this? What could happen if you started thinking differently nor not holding onto (the belief)?
    • Distancing
      • Imagine a specific friend / family member in the same situation. What would you tell them?
      • What if it were your (sister, brother, child, parent, friend)? What would you say?
  • Metaphor / Analogy – tell a brief applicable story or give an analogy
  • “Let’s Pretend” – give the client permission to visualize / enact internally (or externally) adaptive alternatives
    • If you could have said or done anything, no consequences, what would it have been?
      Do it – in your head or here in the room.
  • Somatic interventions
    • Give the client permission to do whatever s/he would like to do
    • Allows the client to “complete” the action that s/he didn’t think possible

Ego State / Parts Work as Cognitive Interweaves

  • Ego State Theory (P. Janet, 1907) says personality is composed of separate parts or ego states
  • Ego states form our “internal family” (Richard Schwartz –
  • An ego state has a specific role, mood, and mental function
    • When the ego state is active / conscious, it is “large and in charge”
    • Often clients are not aware of these ego states
      • Looking Through the Eyes of Trauma and Dissociation (Paulsen, 2009)
  • Identify parts of self-involved in internal dynamics such as
    • Keeping the client “stuck”
    • Self-sabotage
    • Self-criticalness
    • Avoidance
    • Child-like behaviors
  • May integrate child ego states
    • Identify youngest “stuck” age
    • Have the client’s adult, competent, caring, loving self to invite the child part to meet in a comfortable, neutral gathering place, e.g., a park, fairy castle, playground
    • Resourcing speed (slow) BLS is optional for the remainder of the process – e.g., bilaterally recorded music
    • From this point on, the adult client should interact with the child part
      • Have your adult, competent, caring, loving self ask the child if s/he would be willing to look at pictures (or a movie) that will prove you are s/he all grown up?
        • These pictures can be portraits, candids, school photos, it doesn’t matter. Much like the time lapse aging videos on the web. This should be done rather quickly to minimize potential of activation
        • Begin the pictures from one year older than the child’s identified age, proceeding annually until 20, then by decades until the present
      • Now ask the child if s/he believes you are s/he all grown up
        • If no, direct client to ask what the child needs and address it – e.g., to ask questions, see the pictures again
        • If yes, proceed
      • Ask the child if s/he would be willing to come sit by you or sit in your lap?
        • If no, address concerns
        • If yes, proceed
    • Have the adult client provide loving touch and words of affirmation
      • I want you to hug that child and hold her/him, telling her/him all the things s/he needed to hear – e.g., how safe, smart, sweet, kind, loving, precious, good, beautiful/ handsome, s/he didn’t deserve the yucky things that happened or were said
      • You’ve held onto all that icky, yucky stuff for so long. You don’t have to do that anymore. You can come stay with me now and give it to me. I’ll take care of it.
    • The child needs a new job now that s/he no longer has to hold onto all the trauma.
      • You are very important to me and have done everything you knew to do to help for so long. Now that I’m going to take that responsibility on, what do you say we come up with a job for you to do that’s more age appropriate? How do you feel about being in charge of playing and reminding me how important it is to play? Would you be willing to do that?

Overview of Early Trauma Approach – Katie O’Shea & Sandra Paulsen &

  • Four step process
    • Well-developed ability to contain all but the specific target experience
    • Felt sense of safety
    • Recalibrating / resetting emotions
      • Based on Jaak Panksepp’s research on mammalian emotions
      • Early memories are implicitly stored resulting in a felt sense as an adult
      • Minimizes potential over-accessing
    • Clear (process) early trauma
      • Begin with time before conception to address potential transgenerational transmission of trauma and cellular memory
      • Process through the early years of life to address developmental deficits