STAYING IN THE WINDOW OF TOLERANCE: OVER ACCESSING
As EMDR clinicians it is important to know how to keep our clients in their window of tolerance. This post focuses on those clients who are hyperaroused, overaccessing the material we are trying to activate in Phase three of our work for processing through the distress. One of the challenges with the history taking or most often, the reprocessing phase of EMDR, is to assist clients who over access or flood when addressing targets.I heard Dr. Joany Spierings, a Trainer/Consultant/Therapist from the Netherlands, at a recemt EMDRIA Conference in Anaheim. She presented on Cognitive and Non Cognitive Interweaves, having developed her techniques by working with the most severely traumatized clients that her colleagues could not help.
I would love to give a website for Dr. Spierings as she was a delightfully entertaining as well as informative presenter. When I inquired about other sources for her materials, she stated the primary way to learn more from her is when she is back at an EMDRIA conference. Hopefully she will be back soon to the States so we may learn more from her! She is also the author of EMDR and Mourning, available at HAP trainings, an excellent protocol for EMDR grief work that I have used and found beneficial.
There is much more from Dr. Spierings’ day long training, but I want to share highlights, as I understood them, of course, as well as recommendations from the manual. In this post, we will focus on over accessing clients, and I will do another on options for under accessing clients.
Where to Start
Francine Shapiro reminds us the very first thing to consider, when the client is 'over accessing' is that the client is simply processing the material; that is, having opportunity to have, in the present, a normal response to an abnormal event. It's not the affect, it is the movement, the clearing out of material, that indicates progress. “Clients and clinicians need to develop affect tolerance to allow clients to experience their feelings without fear.”
This is perhaps one of the most challenging aspects for newly trained EMDR clinicians to manage and, I suspect, keeps many from using their EMDR training beyond resourcing or, sometimes, at all. It takes a significant shift as a therapist to be responsible for leading someone into a distressing process rather than alleviating their distress in our traditional therapies. I call this “pain with a purpose,” and I keep that in mind when some of my most traumatized clients are experiencing such deep pain in reprocessing past trauma. All of their responses that had to be frozen, blocked, distorted or denied at the time, in order to survive and cope, are being released for healing within the presence and guidance of the EMDR therapist. We are giving them this gift that no one else, typically, was able or willing to give them at the time.
Spierings reminds us of the window of tolerance for each client, where that client is able to process without hyper arousal or hypo arousal, varying from person to person and within the same processing session.. She describes the purpose of interweaves to “help the client get in touch with necessary information for the continuation of the process or that the client cannot activate themselves.” When a client is over accessing, we need to bring the arousal down with whatever tools we have.
Use of Interweaves
At the same time, interweaves may distort or mask channels. We want the processing to proceed without alternation, eventually. These techniques or interweaves are ‘nudges’ or ‘assists’ to help them do so. They need a ‘foot’ in past dysfunctional neuronetworks and the present adaptive self, what Spierings calls “the there and then and the here and now.”
Spierings uses the computer metaphor to explain that intrusion happens because the brain’s job is to sort out and combine (assimilate) information. The brain is just doing its job and processing will occur when the ‘file’ was created, just like the computer programs save a document until it is activated. The brain cannot delete so it keeps trying to resolve it. There are, initially, inaccessible and missing ‘files’ as well, that may need the ‘nudge’ of an interweave, psychosocial education, or, in dissociative identity disorder, coconsciousness or integration of parts.
She educates clients with a visual of the past and present, using the metaphor of watching a movie while processing past traumatic material. If there is NO safe “here and now”, they are not ready for EMDR processing. As we have learned in our EMDR practices, some clients take many months to develop some type of present safety or peace as a balance for the past that needs processing.
Specific Techniques and Interweaves:
Some of the cognitive and non cognitive interweaves, following, may be very familiar, others may be new to you. We most often use interweaves to maintain present awareness and unblock stuck processing. We may need to orient them to present time, place, person, location by saying: “you’re in this chair now… in my office… with me now… it’s (year and day)… you were just a child…it’s old stuff [my favorite]”. Spierings adds that you can use the client’s name, eye contact, touch if allowed, throw and catch objects, have them repeat present roles (“I am mother of…wife of… etc” or ask “how old are you now?”. Others that are useful include nurturing them through with affective use of the therapeutic self “I know it hurts…”; encouragement “you are doing fine…it’s working…you are brave…you already survived.” (Spierings) The manual suggests using cadence sounds “good… good… good…good…”; having the client talk or open their eyes, if closed, while continuing BLS; or, changing BLS movements if possible.
Distancing techniques can also be used, such as changing to a still photo; changing to a black and white picture; placing a glass wall; seeing in a VCR/TV, stopping the ‘video’ or using the ‘remote ‘to pause , or watching from a train. All of these strategies create distance between the client present self and the past traumatic incident. You can also suggest holding the hand of their adult self or a spiritual figure or putting material two streets away instead of right in their face. With children “imagine someone protecting you now” or provide information they did not (developmentally) have. Children very commonly need new information for developmental gaps. (Spierings)
Cognitive interweaves, drawn from one of the three clusters of NC’s–responsibility, safety, choices—that most fits the client’s specific experience, are also effective, such as “You are safe now; you had no choice; it wasn’t your fault, you were just a child; you did the best you could.”
Non Cognitive Interweaves:
You can elicit a present day adult perspective by using a tape measure to show the2 yr old vs. adult height. (Spierings) Another technique I’ve used is looking at their adult hands an
Another technique I’ve used is looking at their adult hands and another suggestion (source unknown) is to use a pair of children’s shoes to compare foot size to the adult. For both children and adults, you can have them bring or create a resource object to hold, or a trusted person, into the session.
When the Client Continues to Over Access
When you have to stop processing due to a failure of the window of tolerance, you can mediate the client’s (and your own) thoughts that it’s a failure by asking, “What is the most valuable experience of today? What does that say about you?” (Spierings) I use “what do you know about yourself that you did not know before?” for this purpose, as well as to close incomplete sessions (frequent in my 50 minute per hour practice).
Spierings states if a person cries at length, flooding with tears with no healing, it is probably not the deepest emotion. It may be anger, so explore what’s underneath the tears. I had a client who sobbed uncontrollably in processing severe physical and emotional abuse, starting at age 2, by his father. It was completely unsafe and useless to cry then, so he had a lot of “old tears” to shed. It became stuck, however, at the flood of tears for most of several sessions. Considering that his limbic system was overactive (per Dr. Earl Grey’s question of which part of the brain seems over active), I worked to strengthen the prefrontal cortex as an anchor for his emotions. He benefitted from developmental and psychosocial knowledge, eagerly learning from recommended books about parenting, anger, and other areas he’d missed growing up. But what really moved him further is when he began to express the anger he felt, frozen not only in time, but out of fear of being like his abusive father. Here we have an over accessing of sadness and an under accessing of anger, not an uncommon result of childhood trauma.
Bonnie the Blogger