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An Adult With Childhood Medical Trauma Treated With Psychoanalytic Psychotherapy and EMDR: A Case Study
An Adult With Childhood Medical Trauma Treated With Psychoanalytic Psychotherapy and EMDR: A Case Study
An Adult With Childhood Medical Trauma Treated With Psychoanalytic Psychotherapy and EMDR: A Case Study
2ORIGINAL
Blackwell
Malden,
Perspectives
PPC
©
0031-5990
42
An Blackwell
AdultUSA ARTICLE
Publishing
in
Publishing
with Psychiatric
Inc2006
Childhood Care
Medical Trauma Treated with Psychoanalytic Psychotherapy and EMDR
events. The younger the child, the more seriously ill EMDR
and invasive the procedures, the more likely the child
is to have ongoing adverse affects and posttraumatic Eye movement desensitization and reprocessing
stress disorder (Rennick, Johnston, Dougherty, Platt, (EMDR) has emerged as one of the most innovative
& Ritchie, 2002). One study of 43 children from ages approaches to treat the symptoms of posttraumatic
5–12 found that children undergoing cardiac surgery stress disorder. EMDR was developed by Francine
are at risk for developing PTSD, especially if the ICU Shapiro in the late 1980s and is based on an adaptive
stay is prolonged (Connolly, McClowry, Hayman, information-processing model. Two tenets of this model
Mahony, & Artman, 2004). Postoperatively, PTSD are: (1) present problems are based on earlier experiences
symptoms increased in 23% of the children, with 12% that have been stored in the brain (state dependent
meeting the criteria for a diagnosis of PTSD. No child learning) and these old feelings, thoughts and bodily
had PTSD preoperatively. Wintgrens, Boileau, and sensations need to be reprocessed, and (2) clinicians can
Robacy (1997) believe that emergency interventions facilitate profound therapeutic change much quicker
after accidents and painful, repeated medical proce- than was ever thought possible with EMDR (Shapiro,
dures are traumas that could lead to posttraumatic 2001).
stress reactions, but this has not been tested. Therapists trained in EMDR ask the client to focus
In addition to the effects of the trauma on the child, on a traumatic event, the negative cognition associated
the parents are also affected, which in turn affects the with it, and emotions and bodily sensations connected
child. Parental uncertainty related to survival of their with the incident. (See Table 1 for a summary of the
child has been found to have a profound impact upon structured protocol.) In EMDR, all dimensions of the
the child after a life-threatening childhood illness memory—the image, the thoughts, the emotion, and
(Santacroce, 2003). A parent, who has had to face the the body sensations—are accessed while the client
loss of a child, suffers from an emotional trauma that focuses on a dual attention bilateral stimulation; with
may interfere with the ability to connect and nurture either eye movements (client’s eyes following the thera-
and the parent may unknowingly distance, which affects pist’s moving finger back and forth across their field of
caretaking ability. This paper presents a case study of vision), auditory tones (listening to an audiotape with
a client who suffered a significant medical trauma when headphones to alternating sounds in each ear), or tapping
he was 8 years old and his treatment as an adult in (therapist alternating tapping usually on the client’s
psychoanalytic psychotherapy using eye movement hands which are placed on their knees), while at the
desensitization and reprocessing (EMDR) to target same time paying attention to the memory. The client
that trauma. then free associates according to structured protocols in
Utilizing an eight-phase structured protocol, the practitioner guides the client through a description of a disturbing event
related to his or her presenting problem(s). The practitioner asks the client to identify and focus on the image, cognitions,
emotions, and somatic distress associated with the traumatic memory.
While the client is engaged in eye movement or some other form of bilateral stimulation, he or she is experiencing various
aspects of the initial memory or other related memories.
The practitioner pauses with the eye movements or bilateral stimulation at regular intervals to ensure that the client is
processing adequately on his or her own.
and demanded perfection in others, especially women. running out. Mr. S. spent the day struggling to stay
His deepest relationship in college ended when his alive. He was eventually transferred by ambulance to
girlfriend wanted a greater commitment. Women dis- another hospital that specialized in the treatment of
cussed during treatment were described as cold and children and was reoperated on successfully. The
unreachable, and it puzzled Mr. S. that he continued following are verbatim excerpts from sessions that
to pursue people seemingly incapable of having a rela- illustrate Mr. S. remembering and reliving his experi-
tionship. ence in psychoanalytic psychotherapy.
The first 2 years of psychoanalytic psychotherapy In one session, Mr. S. said: “Whenever we get near
treatment focused on his history and his current tonsils, I see the light and I leave. I’m cognizant of
painful disenchantment with his career and the organ- what’s around me but not quite, no fear, very comfort-
ization he had devoted himself to for 20 years. His ing when I fixate on the light. It must have been a trau-
depression seemed to be triggered by a growing matic moment when I was fighting to survive, [I] can’t
awareness that he received little recognition for his recall because it’s not clear or I don’t want to, for an
efforts and that he felt betrayed by a supervisor. As he hour or so I’m in another world . . . the feelings coming
clarified these issues, questions were raised about his back right to my head. I’m choking so bad, I’ll be sick,
commitment to such an unrewarding career path a fear when that’s happening, I won’t get another breath.”
and he began to entertain thoughts of leaving his job, Therapist: Possibly a memory of a state you were in at
which he eventually did. the time?
Mr. S.’s job required that he fly a great deal and he “That makes sense. I can remember knowing what’s
began to develop sinus infections, which caused con- going on but the conscious part of my mind is some-
siderable pain during flights. After exhausting various where else, my chest hurts, my legs are heavy, I can’t
treatments, he opted for surgery. Returning home lift them. I feel heavy like someone was punching
following the surgery, he was conversing with someone down on me all over, that’s when I see the light and
on the phone when he developed a severe panic attack. get away from it. I feel chilled, cold, my head feels
During the exploration of his panic attack in our next fine, the body feels cold. Did you see me move? It was
session, he was asked if he was swallowing blood. Mr. like a jolt through my body, pressure on my chest up
S. confirmed this. Perhaps the swallowing of blood to my neck, it hurts.” This may have been a memory of
postoperatively after his sinus surgery had triggered Mr. S. being resuscitated. He distinguishes the light
unresolved feelings related to his earlier operation, a from the operating room light because it moves. “If
tonsillectomy, which involved excessive bleeding. you try and pull away, it’s there.” I wondered if this
Mr. S. thought that may be true and recounted that was the light ENT surgeons wear on a hat while per-
during the tonsillectomy his artery had been nicked. forming surgery. “I’m feeling now like I’m all alone,
He had awakened in his room vomiting blood. Clamps just me. Don’t feel the presence of the doctor. He’s not
were inserted in his throat in an effort to control the helping, not on my side, just me and I’ve got to do it.
bleeding. This however, elicited the gag reflex trigger- I’ve got to protect myself. They are hurting me. Tender
ing torrents of blood. He recalled great confusion in spot there, my eyes welled up with tears. I pulled
his room, doctors and nurses coming and going, another away from it. Now it’s gone. I’m looking around for
little boy in his room being abruptly removed, and my parents.”
blood-soaked sheets being repeatedly changed. These Therapist: What are you feeling as you’re looking around
efforts went on for an entire day. Mr. S. lost 8 pints for your parents?
of blood undergoing multiple transfusions and was “Where is everybody? I’m scared. I keep hearing,
resuscitated three times. Blood supply of his type was don’t cry, and be a big boy. I thought if I lie quiet, it
Therapist: See if you can slow it down as if you are Therapist: Where do you feel it in your body?
watching a movie with a remote control. “I feel myself on the stretcher all tightly bound.
“I hear my mum’s comment, shaking her head. I see I feel really hot physically. My shoulders and neck are
my parents and aunt. I should be happy to see them. hot. My mind is jumping back and forth evading the
I know they’re upset. Don’t worry. It’s all right, but I middle part. I can feel them moving me around. I hear
can’t tell them.” them talking. Mum and the doctor.”
Therapist: What’s the worst part? Therapist: Now bring up that picture and the words “I’m
“My mom saying: ‘You’re sending him there to helpless. I have no control” and notice where you feel it in
die.’ It’s the first time I understand there is something your body. Now follow my fingers with your eyes. (Eye
wrong.” Movement #1)— (the clinician holds two fingers upright,
Therapist: What words best go with the picture that about 12–14 inches from the client’s gaze and slowly
express your negative belief about yourself now? moves his fingers horizontally from the left to the
“Something’s wrong with me. I have no control.” right of the client’s visual field while the client fol-
Therapist: When you bring up that picture of you lying lows with his eyes for approximately 28 bidirectional
on the gurney, what would you like to believe about yourself movements.)
now? “I open my mouth and blood pours out. There is
“It’s over. I’m safe now.” commotion, doctors and nurse, putting tubes in, taking
Therapist: When you think of lying on the gurney, how true my blood pressure, forceps in my throat, packing ice
do those words “It’s over. I’m safe now” feel to you on a scale of around my neck, changing the sheets from the blood.”
1–7 scale, where 1 feels completely false and 7 feels totally true? He recalls noticing that his aunt is upset. Noting a flower
“2.” (Validity of cognition scale (VOC)—the VOC nearby in his room, he tells her: “Don’t worry, the
will be the basis for inserting the client’s positive cog- flower made me sick.” Mr. S. describes these recollec-
nition “It’s over. I’m safe now” once the dysfunctional tions as not being upsetting but like well-sequenced
material is processed. This allows for the positive cog- pictures with some gaps. “I have a burning in my
nition to associate with previous traumatic memories.) neck, stiff, something is there, I don’t know what it is,
Therapist: When you bring up that image of you lying on couldn’t sense it, like if you’re angry and tense up.”
the gurney and those words “I’m helpless. I have no control,” Therapist: Go with that. (Eye Movement #2)
what emotion do you feel now? “For a few seconds, I felt relaxed and then my
“Scared.” muscles tighten up in my neck right through my head.”
Therapist: On a scale of 0 to 10, where 0 is no disturbance Therapist: Go with that. (Eye Movement #3)
and 10 is the highest disturbance you can imagine, how dis- “Got more tense, the left side of my neck, not as much
turbing does it feel now? as before . . . feels like my brain is tingling, like shivers
“10.” (Subjective units of disturbance scale (SUDS)— through my body. If there was more of that, it would
the SUDS will also be checked later in the session in be better, get rid of something.”
order to determine the effectiveness and thoroughness Therapist: Go with that. (Eye Movement #4)
of the processing.) It didn’t scare me before. This “Felt better, better able to concentrate . . . like when I
changes that, seeing them upset, something is wrong, look back a few minutes ago, it was irritating, not
the minister is there. There is a bible on the bed. now. Tension is always in the back of my neck that
I’m trying to figure out what’s going on. Nothing fits just came to me.”
into what I understand. I hear my aunt . . . “Is there Therapist: (Eye Movement #5)
nothing you can do? When I hear that, I’m off in the “My head feels cloudy, confusion. Got more tense,
distance.” tightening top of shoulders, for a second my mind
Mr. S. knew, however, that his father was enraged Therapist: We touched on your father’s anger and your
with the doctor. This doctor had functioned as the anger, what about your mother’s anger?
family’s general practitioner. The father never returned “It’s funny when you say that … like I was an adult
to this doctor for his care, referring to him as the around my parents. There was no spanking, telling me
“butcher.” Mr. S.’s mother, in contrast, continued to to do things. Like I was grown up and didn’t need
bring her son to this doctor and received her own advice.”
medical care from him. At the most basic level of ana- Therapist: You were special. They didn’t cross you.
lysis, this behavior suggests a massive denial of what “They never said I should or shouldn’t, whatever
happened. Denial served the function of shoring up her you want.”
identity following a confrontation with the ultimate Therapist: Your boyhood had ended. Perhaps you didn’t
horror for a parent, the loss of a child. Unfortunately, feel loved in the same way again.
this protective state impedes the processing of the “I jumped from being a baby to an adult. I guess a
traumatic event, blocked communication regarding situation like that could make that happen. I felt like
those events, invoking what some have referred to as an adult my whole life, always cognizant of what’s
a covert conspiracy of silence, thus irrevocably altering going on around me.”
the positive, loving, affective coloring of their bond. Subsequently after the processing of this traumatic
The depth of her emotional investment in him is pro- incident, Mr. S. recognized that he lost trust in the peo-
tectively regulated because it is entwined with the ple who were supposed to love and protect him. Lack
unbearable. On his side of the equation, Mr. S. had lost of trust perpetuated experiences that made the world
his mother. They both emerged from the hospital seem unsafe through a wary, avoidant façade that kept
transformed. As Mr. S. said, “I was all grown up.” Mr. S. in a state of isolation. He was able to mourn the
Unfortunately, what is also transformed in trau- loss of his mother and expressed anger towards the
matic contexts is the self-representation and associated doctors and his family. Overall, he experienced a greater
beliefs about the self. An answer must be found, an sense of compassion for himself and an increased sense
explanation must be forged that accounts for frighten- of self-respect as a survivor. Prior to his psychotherapy
ing changes in the personality or behavior of the care- and EMDR processing, Mr. S. did not realize the
taker. Due, in part, to basic cognitive immaturity, the impact and extent of this event on his functioning. In
child draws the conclusion that something is wrong addition, the disruptive effects of trauma affected his
with him or her. This preserves the image of the care- ability to concentrate.
taker as omnipotent, which is crucial for the child to In the case of an adverse medical experience, there
believe so he can continue to exist. may be a conscious awareness of the traumatic nature
In the session following the EMDR, Mr. S. was asked of the event, or as in Mr. S.’s case, there may only be
to return to the troublesome scene. He reported that he other presenting issues related to trust and relation-
no longer felt “in it.” He could picture it but did not ship development with symptoms of depression and
feel the experience as he did previously. Mr. S. com- attention deficit disorder. His panic attack after his
mented: “If I think how we pieced it together, now it’s nasal surgery served as a trigger for the unprocessed
like looking at photographs, matter-of-fact, no sense frozen traumatic memory of his botched tonsillectomy.
of anxiety . . . I can think of her being upset but that It may only be in the course of treatment that the client
upset is not now . . . I never remember seeing her becomes aware of the significance of the event particu-
upset to the same degree again. She’d feel bad if some- larly if it occurred in childhood.
one died, but she was really upset when I was on the In the context of psychotherapy Mr. S.’s readiness
stretcher.” for identifying the appropriate EMDR targets for
Intellectual: Spiritual:
Able to concentrate better A renewed sense of hope & confidence
Procrastinates less
More productive Vocational:
No longer on Ritalin Changed from old job which he considered “abusive” to
one that is more challenging and gives more recognition
Physical:
Less hypevigilant Environmental:
Able to relax More adventuresome
Increase in energy Seeks out new experiences & activities
2002), and as illustrated here, is an important adjunct of the (Israeli) National Council for Mental Health: Guidelines for
the assessment and professional intervention with terror victims in the
for effective treatment. EMDR can also be used in the hospital and in the community. Jerusalem, Israel: National Council
context of many other treatment approaches including for Mental Health.
cognitive behavioral, family systems, experiential, and Bowlby, J. (1988). A secure base: Parent-child attachment and healthy
human development. New York: Basic Books.
transpersonal (Shapiro, 2002). Recent research suggests Carlson, J., Chemtob, C.M., Rusnak, K., Hedlund, N.L., & Muraoka, M.Y.
that trauma is a right brain phenomenon and most (1998). Eye movement desensitization and reprocessing (EMDR):
psychotherapy is largely a left brain endeavor; thus, Treatment for combat-related posttraumatic stress disorder. Journal
of Traumatic Stress, 11, 3–24.
there may be significant areas that are not accessible Chambliss, D.L., Baker, M.J., Baucom, D.H., & Beutler, K.S. (1998).
with talking therapy only. The bilateral stimulation Update of empirically validated therapies, II. The Clinical Psychologist,
inherent in EMDR may assist in reconnecting these 51, 3–16.
Christman, S.D., Garvey, K.J., Propper, R.E., & Phaneuf, K.A. (2003).
neural pathways that have been dissociated from each Bilateral eye movements enhance the retrieval of episodic mem-
other. ories. Neuropsychology, 17, 221–229.
Connolly, D., McClowry, S., Hayman, L., Mahony, L., & Artman, M.
Acknowledgment. The authors wish to acknowledge (2004). Posttraumatic stress disorder in children after cardiac
surgery, Journal of Pediatrics, April, 480–484.
the consultation and discussion with Peter Purpura, Clinical Resource Efficiency Support Team (CREST). (2003). The
PhD, during the treatment of this case. management of posttraumatic stress disorder in adults. Belfast,
Northern Ireland: Department of Health, Social Services and
Author contact: kwheeler@mail.fairfield.edu with a copy to Public Safety.
Department of Veterans Affairs & Department of Defense. (2004).
the Editor: mary@artwindows.com
VA/DoD clinical practice guideline for the management of post-
traumatic stress. Washington, DC: Author. Retrieved from http://
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