How much does the client have to talk, or feel, to heal?

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October 05, 2013 at 7:39 PM

Since developing Progressive Counting (PC) in 2007, I’ve been teaching it quite a bit, often to therapists who are already trained in other trauma resolution methods. I enjoy the reactions: typically surprise and excitement for how well PC seems to work, how quickly, and how smoothly, relative to other trauma treatments. I’ve also heard two typical objections that I find curious:

  • Some EMDR-trained therapists say, “This can’t work – it wasn’t emotionally intense enough for real healing to occur.”
  • Some TIR-trained therapists say, “This can’t work – the client has to be able to tell the therapist what happened for real healing to occur.”

Oddly enough, the CBT people have no trouble with PC – it makes sense to them, perhaps because PC looks a lot like other types of exposure. I say “oddly” because I am used to CBT people having irrational objections to innovative treatments. At least, some years ago it was rather common for CBT therapists to react to EMDR by saying, “It can’t work [better than exposure] – that eye movement thing has no effect; it’s stupid and specious.” By now EMDR has been found to be the most effective and efficient of the well-established trauma treatments (Ho & Lee, 2012; Greenwald, McClintock, Siebel et al, 2013), and it is evident that the eye movements do indeed contribute to treatment effect (Lee & Cuijpers, 2012).

But now it’s the people with the formerly innovative treatments such as EMDR and TIR, who are (sometimes) behaving like the rigid establishment types. What gives?

Actually I think it’s as simple as that: they – I should say we, since I have been a leader in the EMDR community for two decades – have become the establishment.

Especially when we have a treatment that works really well, we may develop a belief that some element of the procedure must be essential to the outcomes. Thus a therapist who has had much experience and success with EMDR might come to assume that emotional intensity is an essential element of trauma treatment. And a therapist who has had much experience and success with TIR might come to assume that talking about the memory with the therapist is an essential element of trauma treatment.

But is it true? Not necessarily.

These assumptions can be refuted via the memory reconsolidation research (see Ecker, Ticic, & Hulley, 2012), which does not indicate any requirement for either emotional intensity or specific types of disclosures from client to therapist. And memory reconsolidation is recognized as the core neuropsychological process underlying any therapeutic trauma resolution procedure.

These assumptions can also be refuted by looking at the outcomes of trauma resolution therapy sessions in which the memory was resolved (or processed, or healed, whatever terminology you may prefer) without the client necessarily saying much about the memory to the therapist, and/or without the client experiencing much or any emotional intensity. Even within EMDR such events are not unusual. Likewise with PC, as per the “complaints” noted above. Yet, as with EMDR, benefits of PC have been found to persist for at least one to three months post-treatment (Greenwald, McClintock & Bailey, in press; Greenwald, McClintock, Jarecki, & Monaco, 2013; Greenwald & Schmitt, 2010).

This is not to say that the client will never need to say something to the therapist during trauma work, or that the client does not ever need to experience emotion to heal. My own extensive clinical experience, particularly with EMDR and PC, leads me to the following conclusions:

  • Clients do sometimes need to say something out loud to the therapist about the memory. However, clients seem to know when they need that, and if therapists are adequately preparing their clients, clients can generally be trusted to say what they need to say – whether that amounts to numerous disclosures, none, or something in between. Indeed, in exit interviews following some of the early PC sessions, some clients who had only made a passing comment or two regarding memory details later said, “You know, being able to tell you about what happened was really important.”
  • Some clients have told me that being allowed to maintain privacy regarding memory details was essential to being able to do the work. So we would not want to go overboard in directing clients to disclose, because that could be counterproductive for those who value privacy.
  • In an EMDR session, sometimes the emotion can be pretty intense, but not always. I have had clients who got their EMDR work done with so little emotion that they would interrupt to ask, “Am I doing it wrong?” Even in PC, which is generally less emotionally intense than EMDR, clients may experience emotional intensity. Sometimes it is quite challenging for them; more often it’s not so difficult. Again this is not a therapist strategy or decision, within work on a given memory; it’s just something the client experiences in whatever way it may play out.

As therapists, our goal should be to help our clients to heal (in the service of achieving their goals) as efficiently and painlessly as possible. We don’t expect to eliminate time, effort, or pain in this process, but the more these can be minimized, the greater number of clients will be able to tolerate the trauma resolution procedure and get that much closer to achieving their goals.

Indeed, the initial excitement about EMDR was precisely because, compared to the extant trauma resolution methods, EMDR appeared to reduce treatment time and difficulty (Greenwald, 1996). So if PC, or the next trauma resolution procedure to come along, should happen to represent a further improvement, shouldn’t that be OK with us? Yes, it should be – as long as we are able to look, beyond our own assumptions, at the actual data.

References

Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. NY: Routledge.

Greenwald, R. (1996). The information gap in the EMDR controversy. Professional Psychology: Research and Practice, 27, 67-72.

Greenwald, R., McClintock, S. D., & Bailey, T. D. (in press). A controlled comparison of progressive counting and eye movement desensitization & reprocessing. Journal of Aggression, Maltreatment, & Trauma.

Greenwald, R. & McClintock, S. D., Jarecki, K., & Monaco, A. (2013). A comparison of eye movement desensitization & reprocessing and progressive counting among therapists in training. Manuscript submitted for publication.

Greenwald, R., & Schmitt, T. A. (2010). Progressive Counting: Multi-site group and individual treatment open trials. Psychological Trauma: Theory, Research, Practice, and Policy, 2, 239-242.

Ho, M. S. K., & Lee, C. W. (2012). Cognitive behaviour therapy versus eye movement desensitization and reprocessing for post-traumatic disorder: Is it all in the homework then? Revue Européenne De Psychologie Appliquée/European Review of Applied Psychology, 62, 253-260.

Lee, C. W., & Cuijpers, P. (2012). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44, 231-239.



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Posted by Robin Shapiro on
Hi Ricky,
I nearly never get single incident trauma clients, and mostly get sent the complex, highly dissociated types. How does PC work with those folks?
Posted by Ricky Greenwald on
Robin, PC has less free association than EMDR (still some though) and some therapists who work a lot with the dissociated types have told me that they prefer PC because it is better contained. You don't have to worry so much about what will come up or where it will go. It's also a little easier for clients, and a little faster.
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