Client D approaches a counselor for services after reading about her work with trauma and addiction. He is 57 years of age and has nine years of sobriety from alcohol at the time he seeks help. A successful businessman during his drinking days, he changed professions in recovery and pursued an advanced degree to work as a treatment clinician. At the time he presents for counseling, he is working in a prominent leadership position in a treatment setting. Although Client D has been an active member of a 12-step fellowship for many years, he finds himself struggling with the rigidity on certain issues as interpreted by many groups. He is actively exploring ways to expand his recovery wellness. In the history taking, Client D reveals that his biological mother relinquished him at the time of his birth. After spending seven days in a home for unwed mothers, a couple unable to conceive adopted him. Five years later, they were able to naturally conceive Client D's younger sister, and then years later they adopted another son from an unwed mother. Client D describes that, overall, he was well cared for by his adopted parents and he describes his childhood as relatively carefree. However, there are still some issues from that period that continue to play out in his life.

When Client D presents for services, he is unsure if he can even name the relinquishment and experiences connected to being adopted as trauma. However, he has keen awareness that even though he is sober and successful in his work, he is struggling in many other life domains, namely connecting with others. He has also identified problems with compulsive overeating throughout the years, even following his sobriety from alcohol. In the initial history-taking session, the counselor explains to Client D that trauma does not have to meet PTSD criteria to name it as trauma, explaining the concept of adverse life experiences as they are described in the AIP model. She also uses the wound metaphor as a teaching device.

Client D is traveling a great distance to see the counselor for services. During the initial history-taking session, the counselor assesses him to be sufficiently stable and capable of handling an extended history. She asks him to write out as much of a narrative as he is comfortable writing about his history. Upon reading his presentation, the following statements are identified as trauma-fueled statements influencing his presenting maladaptive symptoms and become candidates for EMDR targeting sequences:

In this initial session, the counselor begins gathering information about Client D's existing coping skills, most of which were gained from 12-step exposure. He mentions that he has begun exercising again, and she encourages him to continue. The two begin discussing a plan for how Client D could build more body-based coping skills (e.g., breathing) into his daily regimen. The counselor provides him with online resources that teach breathing and related skills, and he is willing to try these before the second session.

When Client D presents for his second session, he and the counselor review which breathing strategies worked best for him and discuss other visualizations that might work for distress tolerance. The counselor picks up on his statement in the history that some of his fondest childhood memories came from spending time at the lake, and they transition this into a safe place exercise with bilateral stimulation. Client D chooses to alter the place for the purpose of the exercise and use the serenity of a Caribbean beach and also chooses tactile bilateral stimulation (using a machine to create the tapping). They also "tap in" a positive experience the client had at a 12-step meeting the night before the session. Anything positive and adaptive can be frontloaded, pre-installed, or "tapped in" as an act of preparation.

Client D responds well to these preparation exercises, and by the third session he expresses readiness to commence processing. The counselor reads the negative self beliefs that were identified in his narrative and asks him to notice which one(s) seemed to most resonate in his body as distressing. For him, it is clearly the statement, "Something is wrong with me." The counselor sets up the targeting sequence using a combination of the traditional 11-step setup and the Parnell modified protocol. (Note: This counselor generally does not rely on numbers unless she feels it is useful for the process to ask.) Client D is able to give the following information at the start of the first reprocessing session:

Client D is instructed to hold all of these things together and to "just notice" his experience as the counselor turns on the machine to begin the bilateral stimulation. As a technical note, when bilateral stimulation is used to install positive material in phase two preparation, the speed is on the slower side. However, when a client is processing, the speed of the bilateral stimulation is generally faster, analogous to pressing down on the gas pedal to move the client through distress. The technical choices associated with speed are generally covered in standard EMDR trainings.

Within the first two to three sets of bilateral stimulation, Client D is able to very deeply connect with what is going on his body. For the client, a self-confessed intellectual who has the tendency to overanalyze, being able to just sit with body level experience and notice is huge. The bilateral stimulation is applied at one-minute intervals, and at the end of each set, the counselor checks in to see what Client D is noticing. Whatever he reports, the counselor advises him to "go with that" or "just notice that." The free association components of EMDR are a major part of the reprocessing experience, because clinicians do not ask the clients "What are you thinking?" or "What are you feeling?" The goal is not to analyze and interpret in a verbal sense. Rather, when something comes up, the client is encouraged to just notice, be curious, and explore, as the stimulation is applied. For Client D, many of his check-ins reveal experiences like, "There is a heaviness in my chest when I think about [the sound of his peers' laughter]." He just notices this feeling as the stimulation is applied, and after several sets, he begins spontaneously manifesting his own insights. Toward the end of the first reprocessing hour, he is able to make a connection with the positive cognition, "I'm okay. I'm content." At the end of the session, when the counselor checks in with him about the initial issue/belief, he reports a clear body scan. His initial goal statement/positive cognition of "I can work through it" is completely true, and he is able to name two other positive cognitions to claim as completely true: "I am a human being" and "I can trust myself." The session ends with installing both of these completely true positive cognitions together with the clear body scan.

In the second reprocessing session, Client D and the counselor check back in with the initial memory that was taken through the targeting sequence in the session prior to determine if anything else may have come up. Client D reports, "I now have the power to observe it—I was just a kid. I should forgive myself for putting myself through all of that." He says that in the session prior, he felt as though he was reliving it. This shift in perspective about the memory is a common experience after memories are processed with EMDR. In the spirit of the three-pronged protocol, the counselor and Client D commence the second reprocessing session by having him just notice how he presently views the memory. By going with the free association together with the application of bilateral stimulation, Client D spontaneously begins articulating new positive beliefs about himself that he is able to work with and come to as completely true statements: "I have the power," "I've got this," "I am safe," and "I don't have to protect myself anymore." Additionally, the two positive beliefs that he reported in the previous session held as completely true statements. In the final check-in during that second reprocessing session, the client reports a clear body scan and articulates two new positive beliefs: "I am whole" and "I don't feel judged anymore." He states, "I'm anchored, attached to the present."

In the next session, after checking in with the positive beliefs to make sure that they hold as true statements, the counselor transitions into future template work. There is an option to take the other negative statements identified in the client's history and set those up as separate targeting sequences. However, when the counselor checks in with Client D about these statements, they no longer seem valid. In EMDR, it is common to have a generalization phenomenon, defined as the automatic resolution of other memories and issues of concern that occurs after reprocessing the memory that seems the most charged to the client. Thus, the two move into working on the future element of the three-pronged protocol after having successfully worked through the past and present.

For his future template, Client D states that he wants to work on issues of connectedness and problems connecting with others. Following some organic dialogue about the issue, he identifies the belief that he is somewhat confident that he can connect with others. The counselor asks him what is keeping him from complete confidence that he could connect, and he immediately identifies a message that he received in 12-step recovery: "Ego is bad." The counselor asks him to consider that notion and any body experiences as he holds it. After applying a few sets of bilateral stimulation, Client D recognizes that he is kinder and gentler—and that he could extend that to himself and others. He then makes a connection to a famous story in 12-step recovery about the "bright-light experience," and he relates feeling that he finally has something to give to others. Previously, his feeling like a fraud, both personally and professionally, stood in the way. In the next few sets of bilateral stimulation, he makes connections to his family and work life. He ends the session expressing: "I am more than a victim, a survivor, or a 'rescue.' I am whole." The client and counselor install this realization as a completely true positive belief.

The final two in-person sessions with Client D can be described as EMDR re-evaluation. The positive beliefs achieved in previous sessions hold as completely true statements with clear body scans. Natural conversation progresses into discussing what potential pitfalls that he might see in moving forward. Client D identifies, "I can find fault like there's a reward for it, at least that's been my pattern." He states that this tendency began around the time of the target memory, at 6 years of age. The counselor asks him to hold the present experience of that memory together with his insight about finding fault. After a couple sets of bilateral stimulation, he expresses: "That's my head talking, not my heart or my soul." In the next set: "That's a useless energy drain." The counselor decides, in testing the potency of the generalization effect, to inquire about one of the client's other negative beliefs identified at the time of history taking: "I am disconnected." She asks him how valid that belief seems in the moment, and he responds, "It was a delusion—I'm finding the connection within." The counselor instructs him to "go with that" for a few sets for bilateral stimulation, and he ultimately expresses, "I am home." When asked what, to him, the opposite of "I am disconnected" would be (i.e., his positive cognition), he states, "I have the capacity to be connected." He reports this is a completely true statement, and it is installed with bilateral stimulation and a clear body scan. Client D then holds this positive belief as he pictures future life scenarios, and no distress or concern registers.

Client D and the counselor follow up via phone call three weeks after the last session (as part of the re-evaluation process), and the client notes overall positive progress and maintenance of goals in the weeks since the final in-person session. He states he is no longer "obsessing" over how he feels and is "over" his fraud complex. He reports 20 pounds of weight loss in the weeks since his EMDR work and an increase in faith that everything in his life is going to be fine. A final phone call one month later confirms the maintenance of these gains.

Discussion

Client D's story is an example of EMDR therapy being used as a recovery enhancement measure. Although clinically not meeting the criteria for PTSD upon presentation, it is clear that trauma, especially attachment-related or developmental trauma, continued to cause symptoms of depression and overall disconnection with life, even after his substance use disorder was put into remission. Client D's journey may read like a textbook case of how EMDR can work very quickly, and in many ways, his case allows for that because he presented for treatment already reasonably stabilized; he had a job, nine years of sobriety, strong family support, and a willingness to work on himself. In essence, he was the model client for an EMDR clinician. The reality can be somewhat different, often treating clients who have not worked on themselves to the level Client D had. Additionally, clients generally described as survivors of complex trauma can also pose a challenge in conducting strict EMDR. Deborah Korn observed, "While EMDR and other trauma treatments have been proven efficacious in the treatment of simpler cases of PTSD, the effectiveness of treatments for more complex cases has been less widely studied" [35].

The more diverse the client's needs, the more contingencies should be planned for in the delivery of EMDR. Many Face 2 EMDR practitioners believe that enhanced flexibility allows counselors to be better able to work with clients with multiple inter-related diagnoses or symptoms. In addition, these clients generally require a longer period in phase two preparation, especially if they are coming to treatment with little to no skills for regulating distress.

Client J, a lower-income white woman who is 39 years of age, has been in and out of community mental health facilities for the better part of her adult life. She suffers from both bipolar disorder and PTSD, resulting from a series of abuses at the hands of her parents with alcohol use disorders and sexual assaults in late adolescence. Although Client J has never been diagnosed with a substance use disorder, she reports periods of substance abuse throughout her adult life to cope with stress, usually when she is not compliant with her medications for the bipolar disorder. She struggles significantly with medication compliance. Although her bipolar symptoms are regulated when she is medicated, she often complains about the side effects and the cost of the medications.

Her counselor does not initially consider EMDR, because Client J seems so unstable. The client is adamant that if she is just prescribed the right medication, all of her problems will go away. During the first two months of treatment, the counselor carefully meets her where she is and does not use overt confrontation, even about behaviors that are clearly detrimental to her mental health progress (e.g., choosing certain friends, attempting to reason with her equally troubled ex-husband). As a result, a solid alliance forms. Through some trial and error, Client J's psychiatrist is able to find a medication that works well in keeping the bipolar symptoms reasonably stabilized, and the level of the client's day-to-day lability significantly decreases.

During the first few months, the counselor works with Client J on coping skills, including guided imagery and deep breathing. She responds well to these two exercises, so the counselor suggests that they try adding some tactile bilateral stimulation, explaining that the tapping may help further enhance her relaxation. The two work on a light-stream guided imagery technique, together with some tactile stimulation, and Client J reports that she feels more relaxed than ever before. During the next session, the counselor teaches Client J a guided imagery safe place exercise using bilateral stimulation, and she reports that she likes this exercise as well. For the next one to two months, they focus on these trauma-informed coping exercises. Because Client J does not have much good going on in her life, aside from receiving subsidized housing and having a solid relationship with her case manager, building resources becomes incredibly important.

After observing how well Client J responds to the preparation exercises, the counselor explains that stimulation could be used in a different way to help process some of her traumatic memories, and the client is willing to try this approach. The first several sessions of trauma processing with EMDR are all over the place, and the counselor uses a significant amount of interweave, or open-ended questions/statements typically used to assist complex clients work through blocks within the EMDR processing. However, after these first several sessions, Client J is able to quickly process a series of traumatic memories that are both recent (e.g., an accident) and deep-seated (e.g., past abuse). EMDR is used off and on over a nine-month period. (Breaks in formal EMDR bilateral reprocessing occur because, during some sessions, Client J states a need to just talk, which could be viewed as part of re-evaluation.) Significant improvements in Client J's overall self-image and decision-making begin. In the counselor's last contact with Client J by phone, she reports that she is remaining on her bipolar medications and realizes that she will probably need to do so for the rest of her life. However, her mood swings are no longer as violent and her lifestyle choices have improved because much of the underlying traumatic material has been processed.

Discussion

If the counselor had rushed into reprocessing past traumas with EMDR, more harm would have resulted. It was important to introduce coping skills/preparation slowly and carefully, then add the bilateral stimulation, and then proceed with trauma processing. If one prepares for the journey, the journey will be smoother—a major lesson in helping people processing their traumatic memories with EMDR.