I can tell you about a trauma therapy practice that contributes to dropout, that I’ve never seen written about anywhere: treating the client’s disturbing memories in the wrong order. I learned about this in several ways.
1. I blew it with my own clients. Case example: Seventeen-year-old boy in a residential facility as an alternative to incarceration. He told me, “A couple of years ago I was walking down the street with my cousin when he got gunned down [and died]. I got really mad, kind of went crazy, that’s when I started getting into trouble.” So naturally I encouraged him to do EMDR on that memory. We set it up and it was going really well — for the first few minutes. Then he gave the Stop signal I had taught him. We stopped and I asked him what was up? He said, “It’s not working. It’s still a 10 (on the 0-10 scale for how bad it feels).” I told him that it was working well, but that it would take some time to get better. Nope. He was done. Not just with that session, but with me. Because I had made him hurt, and I had made him fail. And even though he was required to keep meeting with me, I was never able to salvage that relationship.
Lesson learned: Don’t start with The Big One; start with a test run, something small, for practice. Let the client build a track record. Case example: Fifteen-year-old boy in an aftercare program post-incarceration. When it was time for the trauma work, we started with a minor upsetting incident that had happened that day in school: a girl saying Hello to everyone at the lunch table, except for him. SUDS (0-10 rating) of 6, but he said that a month from now, it would only be a 1. So this was a good target for a test run. It took only five minutes of EMDR to get to a 0. He laughed and said he didn’t realize that “talking about it” (via EMDR) would make him feel better. In the next session, we worked on an age 6 death of a close family member. A few minutes in, he gave me the stop signal, and explained, “It’s not working. It’s still a 10.” Familiar, right? But I was able to reference the test run he had done the previous session. I said, “It is working, it’s going well. It’s just that this one will take longer than the other one, because this memory is more serious.” He thought that made sense and was able to hang in there to complete the session. And over time, he did more EMDR, and had an excellent outcome.
2. I heard about other therapy failures. For some years, I handled the intakes for our intensive therapy service. In the intake interview I routinely asked the prospective client about their prior therapy experience. Over and over, I heard, “I tried EMDR before, but it didn’t work for me.” Or alternately, “I tried EMDR but it just messed me up.” I needed to know if that meant that the client wasn’t capable of doing EMDR, or if something had gone askew in the treatment approach. So I tracked down what was done. Roughly, here’s what I heard:
- The therapist rushed into EMDR without giving the client enough chance to prepare for the (sometimes intense) experience (about 10% of responses).
- The therapist went for the big one (about 45% of responses).
- The therapist had the client choose which memory to work on (about 45% of responses).
I explained to these prospective clients that because unprocessed traumatic memories create a psychological wound or sore spot, later upsetting experiences hit that sore spot, and are magnified. So if you just go for some random big bad memory, and there are previous memories underneath, creating a sore spot reaction, that memory can feel so big and bad that EMDR just doesn’t work. (It does work sometimes! But I sure met a lot of people that it didn’t work for.) I explained that our therapists guide the client through the memories in chronological order, to clean up any sore spot reaction from earlier memories, before treating the later ones. And sure enough, those clients who had failed in their previous attempts succeeded with our therapists, nearly every time.
3. I keep guiding our trainees. In our EMDR and PC training programs, we encourage people to start with a test run, and then work through the list of worst memories in chronological order. And when they do this, it usually works out. But being new to EMDR or PC, they don’t always do exactly what I told them to do – go figure! And then they talk about what went wrong, on the discussion board or in our follow-up group consultation sessions. You’ll never guess what they tried in those gone-wrong sessions… Letting the client choose, going for the big one, or in some other way not going in chronological order. Yup. But with the practice and supervision, hopefully they sort it out by the time they get through the training.
In my opinion – based on all this experience and observation – target order is make-or-break. Yet it’s never been subject to research. Until now! We recently published what I believe is the first-ever research on target order strategies in trauma therapy. The paper reports on three studies.
Study 1: Survey of trauma therapists. First, we surveyed therapists to see what they’re doing, and why. We found that therapists have a variety of target order strategies, including letting the client choose, going for the big one, going in chronological order, and others. Therapists also reported that they might modify their strategy according to the client’s needs or capacities.
Study 2: Treating earlier vs. later memories. This study was conducted with participants in our EMDR and PC training programs, in two parts. First, we had several groups of participants a) identify a disturbing memory, and give it a 0-10 SUDS rating; b) float back (in their mind) to an earlier memory “where you first learned to feel that way”; c) treat that earlier memory; and d) give the initially identified (but not worked on) memory another SUDS rating. We found that treating the earlier memory led to a reduction in the distress rating on the untreated later memory. Just as I had been telling our prospective clients it would do.
Then we had different groups of participants do a floatback, give a SUDS rating on the earlier memory, treat the later memory, and then re-rate the earlier memory. We found that treating the later memory led to a reduction in the distress rating on the untreated earlier memory – basically the same result, but in reverse. But the effect was smaller going backwards; treating earlier memories had a bigger effect on the later ones.
Study 3: Treating therapy clients’ memories in chronological order. We had three therapy clients give SUDS ratings at the beginning of each session, for each memory on their worst things list. As their trauma memories were treated in chronological order, for two of the clients, nearly all of the later ratings went down, whereas for one of the clients, some of the later ratings went down, and some did not. We concluded that treating earlier memories reduces the distress level of related later memories; and that whether all or only certain memories are related can vary by individual.
These research findings support my team’s preferred strategy of test run and then chronological order. But the findings provide support for some other strategies as well. I am hopeful that other researchers will further pursue the target order question.
And meanwhile? If you’re routinely starting with the big one, or permitting your clients to choose, I’m sure it works much of the time. But I’ll just say: it’s risky.
