Identifying & Sequencing Treatment Targets
EMDR for Complex TraumaIn working with complex trauma clients we are talking about a significant trauma history with many many events, many moments that are still stuck in the client's nervous system bearing down on present experience. It is critical that we have some degree of organization around how we're gonna proceed in terms of targeting these various events, these various experiences. We're going to be using direct questions to establish the memories that are haunting our clients most vividly, most intensely. So that's the very first thing I'm paying attention to. As I'm taking this trauma history, I'm making notes in the margin as I go.
You know, capital t, big t trauma, little t trauma, developmental trauma, omission, commission. I'm noting all of this because this is going to get transcribed onto my treatment plan. I particularly pay attention to any intrusive symptoms that a client is reporting. Nightmares, flashbacks, intrusive images. These are the low hanging fruit for our clients.
These are the obvious targets that are causing distress that the client can easily identify that we are going to tag to particular events in the client's life and we're going to go after those events. This is an effective way to reduce PTSD symptomatology right upfront. When there are not obvious intrusive symptoms that are going to lead us to old memories, we're going to be using a float back technique to try to explore for those early targets. I use float back more than any other technique as I'm trying to establish a range of targets for my work with a client.
With float back technique, we are starting with the current distress, we're starting with current triggers, current symptoms and we're going to invite the client to float back internally exploring for times where they have felt or experienced something similar. If a client is presenting with very heightened affect, with an intrusive belief, negative belief, with certain sensations that are extreme, we may just do an affect or a somatic or a cognitive bridge back to earlier times in the client's life. Taking that presenting component of experience, the feeling, the sensation, the thought, and floating it back. For some clients, it's helpful to create a timeline to actually have them map out on paper to organize the experiences of their lives and noticing visually the connections between present symptoms, present patterns, and early big T traumas or developmental traumas.
There's times where I've also created genograms where we map out the family, the extended family, the generations. And I ask the client to tell me stories about different family members, about the dynamics between different family members, about the patterns that have been carried from one generation to the next. I ask the client to bring in photos of different family members and we use the photos, we use the genogram as a way to elicit memory and to begin to see where the distress emerges in the body and we use this as a way to identify targets. Sometimes for very dissociative clients, sometimes for children, teenagers, it's very helpful to work with collaterals, to work with other people in the person's life, be it friends, be it family members, to gather these stories, to gather perspectives about what has occurred historically over time within various environments.
In situations where there is extreme anticipatory anxiety about doing therapy, about doing trauma focused processing. We're not looking backward for targets but we are looking forward. I often use the flash forward technique to identify imagined feared scenes in the future. We identify a scenario that represents the worst case situation and that becomes our target.
So using the flash forward approach to identifying targets is sometimes what we need to do if we're dealing with that anticipatory anxiety early on in treatment.