emdrc

Eye Movement Desensitization and Reprocessing
Treatment of Rape Trauma: A Case Report
by Dan Opdyke, Ph.D.

Brian Hissom and Associates

Treating Abuse Today
Vol 7 No 2 March - April 1997
pp. 9-12

Eye Movement Desensitization & Reprocessing (EMDR)

Eye Movement Desensitization, a technique using repeated imaginal exposures while requiring the client to make rapid eye movements, was introduced by Shapiro (1989a), who reported its use with posttraumatic stress victims. Shapiro (1989a,b) claimed success treating traumatic memories in a single fifty-minute session. Participants in early studies appeared to show remarkable improvements in symptomatology as indicated by self-reports of decreases in anxiety (Marquis, 1991; Wolpe & Abrams, 1991). Several case studies have reported remarkable treatment effects in only one session (Kleinknecht & Morgan, 1992; Puk, 1991; Spector & Huthwaite, 1993).

Single-case experiments have been suggested by critics of EMDR research (Lohr, Kleinknecht, Conley, Dal Cerro, Schmidt, & Sonntag, 1992). Montgomery & Ayllon (1994) reported on a case where the EMD procedure was applied across images in a multiple baseline design. Two dissimilar traumatic memories were successfully treated in six sessions. Heart rate and systolic blood pressure ratings were taken as the subject recalled the trauma, and both were significantly reduced from baseline. Symptom resolution occurred, as the subject reported driving alone at night for the first time in two years (Montgomery & Ayllon, 1994).

Between-group treatment outcome experiments have attempted to rule out placebo effects by attempting to control for the eye movement component of EMDR. Other than Shapiro's initial study (1989a), there have been only a few published between-group design experiments that address these questions (Boudewyns, Stwertka, Hyer, Albrecht, & Sperr, 1993; Jensen, 1994; Renfrey & Spates, 1994; Wilson, Becker & Tinker, 1995). While the results of these studies are equivocal with respect to eye movements being the critical component, the treatment procedure appeared to have clinically significant effects. Much is yet unknown about EMDR. It is rapidly becoming one of the most studied treatments of PTSD (as well as other disorders), and results to date have been very promising.

Jane H. is a 39-year-old Caucasian female rape victim who was abducted from the parking lot at her workplace. She was taken in a car at gunpoint to a wooded area where she was repeatedly raped, severely beaten, and left for dead. Following emergency room treatment and police procedures, Jane sought relief from the trauma at a rape crisis center. She attended only once. A family physician prescribed a mild sedative (hydroxyzine 25 m.g. @ bedtime), but Jane refused to take it because it made her light-headed. In the ensuing three months Jane continued to suffer from nightmares, insomnia, panic attacks, intrusive memories, anxiety, depression, and suicidal ideation. She was fearful of being alone. After realizing that her husband and family did not want to hear about her problems anymore, Jane reluctantly telephoned the mental health center for an appointment.

Jane has no previous history of emotional problems. She, in fact, prides herself on being strong and in control of herself. She does not use drugs or alcohol. Prior to the attack, Jane worked as an assistant restaurant manager in a suburban community. She has been married 13 years, and has a twelve-year-old son. Her husband works as a machine tool operator. Her parents and two sisters live in a nearby community.

Over the next four months, Jane met with a female psychotherapist at a mental health center and worked on issues surrounding her marriage and her family's lack of support. Her husband refused to attend the sessions and would not speak with Jane about the incident. Indeed, Jane's entire family urged her to "forget it" and get on with her life. Jane continued to suffer sleep disruption from nightmares however, as well as daily intrusive images of the rape. Dysphoric moods continued.

Although she was feeling supported by her therapist, Jane wanted her emotional turmoil to end. At one point she loaded her husband's gun and deliberated taking her life. She woke her husband at the last minute and he offered her support. In the following weeks they began arguing, her husband again refused to talk about the rape, and her flashbacks and intrusive thoughts continued unabated. Jane's depression deepened. In the meantime, the perpetrator was picked up and jailed. At this point the therapist recommended the Eye Movement Desensitization and Reprocessing (EMDR) procedure. Jane agreed to two 90-minute sessions with a male psychologist to begin the following month. Pretests were sent two weeks before the procedure. The Impact of Event Scale (IES)(Horowitz, M. J., Wilner, N., & Alvarez, W., 1979), Modified Posttraumatic Stress Scale (MPSS)(Falsetti, S.A., Resnick, H.S., Resick, P.A., and Kilpatrick, D.G.,1993) and Dissociative Experiences Scale (DES) (Bernstein, E.M. and Putnam, F.W., 1986) were completed and returned by Jane to the author at the beginning of the first session.

EMDR treatment began with a discussion of the pretests and an orientation to the procedure by the author (D.O.), a psychologist and Level II EMDR practitioner. Jane was informed that during the course of the treatment, strong emotions may arise. It was explained that she should stay with these emotions and follow the therapist's instructions. A safety signal was agreed on so that treatment could terminate at a moment's notice if she felt too uncomfortable. The treatment rationale was then briefly explained. explained that the goal of the treatment, if successful, was to reduce the anxiety and negative emotions associated with the memories.

Jane was told that the technique to be employed was intended to help store traumatic memories as if they were normal memories and not emotionally charged ones. It was Jane was then asked to focus on the most disturbing aspect of the incident and to report the words that went with the picture("I'm going to die") as well as any sensations and emotions that arose. She rated her emotional intensity on the 11-point SUDs scale from 0 = very comfortable to 10 = most uncomfortable you can imagine (Wolpe, 1958). Next she was asked for a preferred cognition ("I'm safe") and rated the veracity of that statement on a subjective 7 point scale (completely false to completely true) as she was recalling the incident. She rated "I'm safe" as a zero, i.e. completely untrue. Her initial SUDs level was 10. The ratings were taken before and at the conclusion of each session.

The author then asked Jane to visualize the scene (gun at her forehead), mentally repeat the negative cognition ("I'm going to die"), focus on her bodily sensations (heaviness in chest and arms), and to track a small moving light stimulus at the end of a 20-inch pointer as it traced a horizontal path across the line of vision and back in rapid sweeps approximately 14 inches in front of her eyes. The speed of these passes (or "sweeps") varied somewhat throughout the procedure. Sweeps were presented as fast as the client could track them. The width of the sweeps depended on her ability to track, but was generally from the extreme right to the extreme left of the visual field (approximately 18 inches). A number of sets of 24 sweeps were performed, as Jane was encouraged to follow visually while simultaneously attending to internal stimuli. Twenty-four sweeps was the default number, though the actual number varied depending on her reactions. When she was having a pronounced emotional reaction, the eye movements were continued until she appeared in good control. Short (30- second) breaks were taken between sets, during which she was encouraged to "let it go" and to report on her internal state.

Jane was asked "What do you get now?" following each set of eye movements. If she reported a changed image, she was instructed to "go with that." New imagery brought up was treated before returning to the original scene (Shapiro, 1993). Far from simple hand waving, the treatment requires keeping the client's attention and encouraging them to continue processing difficult emotional material.

Jane reported that the original memory arose and unfolded as if on film, and that it at times felt as if it were being erased by the sweeps. Details of the original event arose, and Jane learned that there were 5 attackers where she had previously remembered only one. Other graphic details arose which were not verbally shared with the author. Jane had been beaten severely with the handle of the gun and other blunt objects. Apparently she escaped only because she was left for dead. Jane appeared to be reporting the event as a spectator in this first session, an indication of mild dissociation. We ended with a relaxation exercise involving paced deep breathing. A final SUDs rating was taken once again at session end. Her SUDs were 7, though her prevailing feeling changed from fear to anger.

In the week interim between sessions, the therapist was available via pager and telephone. Jane paged once and the author called her each evening for a brief "feeling check" and to offer encouragement. Jane was flooded with memories and nightmares of the event, along with somatic sensations and dysphoria. She also had bursts of manic energy similar to those she recalled having after the actual event. Jane was encouraged to write her feelings in journal form and to use deep breathing to cope with internal stimulation. It is common in the EMDR procedure for a rebound of the initial symptoms to occur between sessions. These feelings were normalized and reframed as the "healing process." Jane received little encouragement from her family during this period. In fact, they continued to decry the idea of bringing it all up again.

Jane came in for the second session with much trepidation. She was not at all sure she was ready to go through with it. We rehearsed the STOP signal that she was told to use if she wanted to discontinue the treatment. Session 2 was tumultuous. Jane abreacted the entire incident from start to finish. She recalled previously unavailable details, including the identity of another assailant that she now remembered seeing in the police photographs. Her emotions ranged from terror and anger to an alert calm by session's end. Her final SUDs were zero and she rated her positive cognition ("I'm safe") as mostly true (6).

Results:

With the SUDs at zero, Jane saw no reason for further treatment. She was called a week later and stated "It's amazing...No, it hasn't come back at all. I've been sleeping hard..the best sleep I've had since before it happened. Flashbacks are gone. It used to be fragments popping up all the time. Now it's the whole memory. I don't think about it much, though. I think about the treatment instead." Two weeks later Jane was asked to mail in posttest data rating her level of disturbance (IES, MPSS, DES). These are compared to pretest results in Table 1.

Table 1

�

MPSS

IES

DES

�

Pretest

102

13.9

�

Posttest

12.9

�

Follow-up 1yr.

N/A

Jane appeared in court several months after treatment and was able to testify against the one attacker who was apprehended. He received a 25-year prison term. Jane stated during her one year follow-up that she felt that EMDR truly worked for her. Her MPSS and IES scores one year later attest to this (Table 1).

The drops from pretest to posttest on the two primary instruments are significant clinically. The DES was employed primarily as a screening instrument and was not included at follow-up. The IES results indicated the virtual elimination of flashbacks and the associated anxiety and numbness. Avoidance items were still endorsed at posttest. At one year follow-up these avoidance items were not endorsed at all. The MPSS indicated that Jane?s flashbacks disappeared and sleep returned to normal. She continued to feel somewhat cut off from others, but this may have represented the reality of her family environment. Her hypervigilance continued at posttest two weeks after treatment. At one year follow-up Jane was still somewhat hypervigilant according to her MPSS report, though she saw this as only a little bit distressing. EMDR seems to have an initial circumscribed impact on anxiety and intrusion symptoms, with avoidance and arousal symptoms diminishing more slowly over time.

Discussion:

EMDR appears to be an expedient method for eliciting and treating traumatic memories in as few as one or two sessions. It has been used successfully with rape trauma survivors (Rothbaum, in press, 1997), virtually eliminating the symptoms of posttraumatic stress. The technique should be used only by those trained in its practice however, as it is more complex than it appears on the surface and can bring up a flood of memories which do not abate between sessions. Potential clients should be carefully assessed for their readiness in dealing with uncomfortable abreactions. The quality of the relationship, however brief, should be one that instills confidence and safety. Social supports outside of the clinic should be encouraged. Rape trauma survivor groups and psychoeducational work with spouses/significant others are recommended adjunctive therapies. Finally, clinicians using EMDR must manage their own anxiety as they witness the reliving of horrible events. Given the above caveats, the EMDR method can be used successfully even by male therapists with rape victims in cases where the rapist(s) was male.

Case reports are limited in their validity and generality. Even the significant pre-post changes in symptoms reported here can be attributed in part to nonspecific factors (e.g. placebo). Studies involving groups of participants have documented that EMDR works as well as other exposure therapies, and in a fraction of the time (Boudewyns, P.A., Stwertka, S.A., Hyer, L.A., Albrecht, J.W., & Sperr, E.V. ,1993; Opdyke and Ayllon (unpublished manuscript); Renfrey and Spates, 1994; Wilson, S.A., Becker, L.A., & Tinker, R.H., 1995). Yet other studies refute these findings (Jensen, 1994). While the scientific community continues to determine the efficacy of EMDR, trained clinicians can offer help to trauma victims on a case by case basis.

Acknowledgment

The author wishes to thank Karen Steanson, Ph.D. for reviewing a previous draft of this article.

References

Bernstein, E.M. & Putnam, F.W. (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, 174, 727-735.

Boudewyns, P.A., Stwertka, S.A., Hyer, L.A., Albrecht, J.W., & Sperr, E.V. (1993). Eye movement desensitization for PTSD of combat: A treatment outcome pilot study. the Behavior Therapist, 16, 29-33.

Falsetti, S.A., Resnick, H.S., Resick, P.A., & Kilpatrick, D.G. (1993). The Modified PTSD Symptom Scale: A brief self-report measure of Posttraumatic Stress Disorder. The Behavior Therapist, 7, 161-162.

Horowitz, M. J., Wilner, N., & Alvarez, W. (1979). Impact of events scale: A measure of subjective distress. Psychosomatic Medicine, 41, 207-218.

Jensen, J.A. (1994). An investigation of eye movement desensitization and reprocessing (EMD/R) as a treatment for posttraumatic stress disorder (PTSD) symptoms of Vietnam combat veterans. Behavior Therapy, 25, 311-326.

Kleinknecht, R. A. & Morgan, M.P. (1992). Treatment of posttraumatic stress disorder with eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 23, 43-49.

Lohr, J.M., Kleinknecht, R.A., Conley, A.T., Dal-Cerro, S., Schmidt, J., & Sonntag, M.E. (1992). A methodological critique of the current status of eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 23 (3), 159-167.

Marquis, J.N. (1991). A report on seventy-eight cases treated by eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 22, 187-192.

Montgomery, R. W. & Ayllon, T. (1994). Eye movement desensitization across images: A single case design. Journal of Behavior Therapy and Experimental Psychiatry, 25, 23-28.

Puk, G. (1991). Treating traumatic memories: A case report on the eye movement desensitization procedure. Journal of Behavior Therapy and Experimental Psychiatry, 22, 149-151.

Renfrey, G. & Spates, C.R. (1994). Eye movement desensitization and reprocessing: A partial dismantling procedure. Journal of Behavior Therapy and Experimental Psychiatry, 25, 231-239.

Rothbaum, B.O. (In press). A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims. Bulletin of the Menninger Clinic 61, 1-18.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress, 2, 199-223.

Shapiro, F. (1989b). Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211-217.

Wilson, S.A., Becker, L.A., & Tinker, R.H. (1995). Eye movement desensitization and reprocessing (EMDR) treatment for psychologically traumatized individuals. Journal of Consulting and Clinical Psychology, 63, (6), 928-937.

Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.

Wolpe, J. & Abrams, J. (1991). Post traumatic stress disorder overcome by eye movement desensitization: A case report. Journal of Behavior Therapy and Experimental Psychiatry, 22, 39-43.

DISTRIBUTION ADVISORY: "Eye Movement Desensitization and Reprocessing Treatment of Rape Trauma: A Case Report" appears in Treating Abuse Today ,Vol 7 No 2, March ? April 1997, pp. 9-12. Copyright 1997 by Survivors And Victims Empowered (SAVE), P.O. Box 3030, Lancaster, PA 17604-3030, (717) 291-1940. SAVE shall not be liable to the purchaser or any other person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by this publication. Authors are solely responsible for the statements made in their work. The editorial staff of Treating Abuse Today has sole authority for the contents of the publication. Those with comments, inquiries and/or complaints should contact SAVE. This article may be forwarded only in its entirety and, when forwarded, must include this Distribution Advisory.

Treating Abuse Today is a bi-monthly publication directed toward professionals working in the field of trauma treatment. Each issue features broad-ranging views within the psychotherapy profession. The magazine includes clinical, theoretical, and research articles as well as news analyses exploring social and political developments.

Return to Main Page

Hosted by www.Geocities.ws