EMDR: Drawing Procedure Using Pictures with Children
Phase One: Client History
Utilize Standard history taking: Ask about background, look for events that have contributed to current symptoms/presenting problem, explore current triggers, and future needs. Identify if EMDR interventions are a good fit for treatment. Identify possible targets from negative events that were identified through history taking. With children, parents may need to write a time line identifying negative events, especially during pregnancy or pre-verbal time in the child’s life.
Ask the child his/her perception of what it was like at the time of the event, both when they can remember the event and when they have no recall of the event. The perception of the event can be used as a target as well. Work with the client to identify the Belief Schema (Roy Kiessling's framework–Shapiro's Negative Cognition) that goes with the negative events/trauma . Use clinical judgment and client’s preference to decide which target to reprocess first, as well as which protocol will be used.
With Roy Kiessling's Processing Continuum, decide on which procedure to start with:
EMD-restricted without accessing body sensations for desensitization only focusing on one target,
EMDr-contained with access of body sensations and free association within one target,
EMDR-no restriction-access of body sensations and allowing the mind to jump anywhere it needs to go when therapist has identified the client is ready to go there/can handle whatever memories, emotions, etc. that may come up.
Phase Two: Preparation
Stabilize and increase access to positive affect. This can be done through any of the following:
calm place, container (you can have the child draw their safe place or container and then follow protocol to strengthen it through slow, shorter sets of Bilateral Stimulation (BLS).
Calm place: Activate all 5 senses with the calm state: ask what the child is seeing, feeling, smelling, tasking, or hearing there. Ask the child to notice what it feels like to be in a calm/relaxed/neutral state and enhance/strengthen with slow short sets of BLS.
Container: Ask the child if it feels better to know they can put any memories, worries, etc. into the container to keep them there until the child is ready to work on them. Most often positive feelings are reported; strengthen those with slow short sets of BLS.
Strengths/mastery: strengthen positive characteristics of the child such as the child's strengths–smart, kind, good at trying new things, did something good. You can have the child draw a time they felt they demonstrated each characteristic, connect that time with the location in the body; ask the child to think about that time and where they feel positive feelings in their body and strengthen the characteristic with slow, shorter sets of BLS (about 8-12 sets).
Strengthen positive relationship or positive parts of a relationship, such as a time the child felt loved or cared for by someone, etc. (teacher, sibling, parent, aunt, uncle, friend’s parent, etc.) Have the child draw a time they felt cared for/loved by someone. Connect that time with the location in the body; ask the child to think about that time they felt loved/cared for and where they feel positive feelings in their body. Strengthen the time with slow, shorter sets of BLS.
TIP: some children like to be in control of how many sets of BLS you as the therapist apply. Sometimes I ask children to tell me to stop the BLS when the characteristic/time we are strengthening feels “strong enough” to help them the next time they need to remember they are “strong” or “smart” or “loveable”, etc.
Have a STOP sign to use with kids. They can also draw their own so they have control over how big the stop sign needs to be. While the child draws the sign (or you can have a printable stop sign off the internet for children who get frustrated with drawing) or decorate one you print. The child can work on identifying times s/he may want to stop, how to recognize feeling overwhelmed or flooded so they can stop. Check with the parent or carefgiver and child for signs that the child may be dissociating (sleepy, bored, spacey, blank look) so that protocol can be put into place to ground the child if dissociation starts to happen.
Phase Three: Access and Activate
Confirm with the client their agreement to reprocess the target you both have selected for reprocessing.
If a client is not ready to reprocess an entire target, it can be titrated or broken down into more manageable parts to be reprocessed.
FOR EXAMPLE: have the child DRAW part of the incident that s/he feels s/he can handle to reprocess and work on just that small part of the incident. After the SUD reaches ZERO or is ECOLOGICALLY SOUND, you can move on to reprocess another part of the target by having the child draw that part to reprocess it.
Follow phase three desensitistion to help the client agree on the Negative Cognition (NC) and Positive Cognition (PC). Depending on the age, the child may not be able to give a very descriptive NC or PC. It may be something like the following examples:
NC “I feel bad” PC “I can feel better”
NC “I am bad” PC “I am ok” or “I am good”
Phase Four: Desensitization (reprocessing)
Process the selected target to work toward an adaptive state. Goal is to get SUD to ZERO, or to an ecologically sound state (some SUDS cannot go to ZERO due to them being an ongoing stressor or due to some other maladaptive brain network needing to be reprocessed before the SUD can go to ZERO. Use Faster, Longer sets of BLS. Since children have smaller neuro networks, usually not as many sets of fast BLS are needed compared to adults. In my experience, about 15-20 sets have been the norm depending on the age and needs of the child.
DRAWINGS: have the child draw the target if s/he has not done so already.
If possible, take a picture to print of the drawing in case the child needs it for later during the re-evaluation phase or if further reprocessing is needed. The reason is the child may choose to scribble Left and Right across the picture as a form of BLS. You can have the child do the any of following for BLS:
Scribble Left and Right over the page
Use tappers/headphones the provide BLS
Use EYE MOVEMENTS (although most kids have not preferred this in my experience)
Tap on the child’s shoulders, knees, hands, or other appropriate area the child is comfortable
Use a play “magic wand” to help “get out the yucky feelings” and later in phase 5 install “positive feelings”
Have the child jump left and right into two hula hoops side by side while looking at the picture
Follow phase 4 protocol to complete reprocessing the target. Process past, present and future times related to the target selected.
Be sure to bring up the worst part, negative belief currently held, desired positive belief, current emotion, and physical sensation (only bring up physical sensation if you are NOT doing restricted reprocessing). You can use cognitive interweaves (clinical interventoins to increase insight) to help unblock stuck processing. You can also have the child draw what it would be like if their situation was the way they had hoped.
Phase Five: Installation
This phase increases connections to positive cognitive networks and increases generalization effects within associated memories. Verify if the selected PC still fits or if it needs to be changed slightly.
Check to see where VOC level is now on scale of 1-7. Work to increase the validity (how true the PC feels) until the VOC is 7 or is ecologically sound (it makes sense to you as the clinician that at that time the VOC cannot go higher).
DRAWING: You can have the child draw what it looks like at the start of this phase, and draw the changes as s/he works through the target. You can have the child draw what it looks like/feels like to have the VOC be a 7 and strengthen this with BLS. You can also have the child draw what it would be like if their situation was the way they had hoped.
NOTE: BLS sets are still fast since we are working to process the target from a negative toward an adaptive resolution. (we are not resourcing at this time-resourcing has slow BLS)
Phase Six: Body Scan
This phase is where we clear out any place the body is holding on to disturbance related to the target.
NOTE: this phase will only be completed when the therapist is including body sensations into EMDR therapy; therapist has identified that the client can handle more than very restricted reprocessing.
DRAWING: Give the child a ginger bread man black and white color page. Ask the child to draw on the ginger bread man any place there is tension, pain, or sensations/yucky feelings, tingling, or sensations of any kind. You can get out a magnifying glass for the child to use on the ginger bread man (or the child’s body) to “find” the body sensations.
You can have the child scribble left and right on the drawing to “scribble the sensations out” until they are all gone.
Other option: have the child draw changes on the ginger bread man (e.g. by erasing them or coloring over them with a “healing color”) until the gingerbread man is all healed/does not feel disturbance any longer.
Phase Seven: Closure
This phase ensures client stability at the end of the EMDR session and until the next session.
It is my suggestion to end with a resourcing/stabilization technique by either teaching one, or reviewing one that you have already created with the child.
For example: get out the drawing of the container/calm place and have the child practice it before leaving.
Teach the child the “butterfly technique”. This is a technique that can be used anywhere, especially if the child needs to SEE their calm place to really access it. We want to make sure we equip the child to stabilize themselves when they are outside of our care by teaching adequate stabilization techniques.
I usually teach parents the techniques so that they can coach their children to utilize them when parents notice their children are starting to feel dysregulated. Direct the child to practice the technique(s) daily so that they can be easily applied when emotions need to be regulated.
Phase Eight: Reevaluation
This phase assist therapist with exploration of treatment effects.
The therapist should explore any changes such as insights, behavioral changes, new ways of responding or relating to the target/triggers.
This also helps to re-access the memory from the last session to measure the SUD and/or continue reprocessing the target if it was not completed from the last session.
DRAWING: You could have the child draw the target and explore if any subjective level of disturbance (SUD) still exists. If there is disturbance reported, you can work through all of the EMDR phases to reprocess anything left causing emotional charge. The image for this post is a drawing of processing a spide phobia with a young child.
I recommend taking any EMDR specialty trainings from Roy Kiessling, LISW for enhancement of clinical skills related to EMDR, the EMDR continuum, and learning how to apply EMD, EMDr, and EMDR to treatment with clients.
Shanon Claussen, LISW, Consultant in Training
Thank you Shanon for another inspiring and educational post on EMDR with children. You can contact Shanon at firstname.lastname@example.org for more information or consultation.
I would add Roy's EMDR Basic Training model that I offer in Iowa teaches this protocol as part of the Part 1 procedures and adults can benefit from this processing option as well.
Bonnie the Blogger