Jennifer, a 31-year-old married woman with a 15-month-old toddler, underwent a traumatic experience while delivering her second child, Jake, 6 months earlier. Jennifer had told the doctors that she could actually feel what they were doing in preparation for the C-section and needed more anesthesia. However, the anesthesiologist denied that Jennifer could feel anything given the medication dose he had administered and made a unilateral decision to proceed with the C-section despite her protests. As she was cut open, Jennifer screamed from the intensity of the pain. It was only then that the doctors stopped, administered more medication, and waited until she was sufficiently anesthetized to proceed. She also described how disoriented she felt in the recovery room from the effects of the amount of anesthesia she was ultimately given.

The history-taking phase of EMDR therapy during the first appointment revealed that Jennifer was happily married, with no previous trauma history, and a stable childhood. However, her clinical complaints were textbook symptoms of PTSD: nightmares of the event, flashbacks, avoidance of reminders of the event, hyperstartle response, hypervigilance, irritability, difficulty concentrating, and sleep disturbance. She ruminated about the event often, wondering how things could have gone so wrong in the delivery room despite her best efforts to communicate. She was upset that her doctors had ignored her feedback and that her husband, who was there at the time, had failed to intervene on her behalf. She reported having difficulty bonding with Jake, since being with him brought on feelings of anxiety and fear. She also reported being short-tempered and irritated with her husband since the birth.

During the preparation phase, Jennifer was given a brief overview of trauma and the AIP model. She was then taught a safe place, one of the EMDR therapy self-control techniques (Shapiro 2001, 2012a) to ensure that she was able to achieve a state of calm both during and between sessions. In this technique, the client is asked to identify a real or imagined place of safety or calm and concentrate on deepening the experience until it is fully developed. The client is then asked to think of a mild irritant, focus on it for a few moments and then shift back to their safe place. This technique is often taught with short, slow sets of bilateral stimulation, both to facilitate a deepening of the experience and to introduce the client to the stimulation itself. The goal of this technique is to assess the client’s ability to effectively shift states on demand as well as increase access to positive affective states. The client is encouraged to apply this technique on their own as a tool to manage stress responses.

Based on multiple factors, including readiness and motivation for treatment, no previous trauma history, mastery of the affect regulation skill, and the need to restore a level of functioning that would allow her to bond with Jake, it was decided to commence with EMDR reprocessing during the next meeting. At the beginning of that session, Jennifer was further prepared for processing by reminding her that she was in complete control and that if she needed to take a break, she had only to raise her hand as a signal. During processing, she was asked to “let whatever happens, happen.” A standard EMDR therapy metaphor was used to support her ability to do this, as she was asked to imagine that she was on a train and that whatever emerged in consciousness was simply the scenery passing by.

In the assessment phase, the components of Jennifer’s childbirth memory were identified. Additionally, she is asked to choose a positive cognition she would prefer to have at the end of treatment:

The desensitization phase is initiated by asking the client to bring to consciousness the image, the negative belief, and the body sensations. Jennifer held in mind the image in the delivery room; the word, “I am powerless”; and the negative feelings in her throat, jaw, and stomach. She was instructed to maintain a dual awareness, noticing whatever might emerge internally as she followed the sets of eye movement and to indicate with her stop signal if she needed a break. She then began to follow the therapist’s hand for a set of approximately 24–36 bilateral repetitions of eye movements. The length of each set is customized to the client’s needs by observing nonverbal responses.

At the end of each set of stimuli, the therapist asks, “What are you noticing now?” The clinician is looking for indicators of change in the client’s experience, making sure that processing is taking place. These range from changes in the initial memory (e.g., less emotional distress, unclear visuals, a change in reference point) to associations to other similar experiences. For example, if Jennifer or a close relative had previous negative experiences in childbirth, those associations would likely emerge. Other associations might involve experiences of powerlessness having nothing to do with childbirth per se. Depending on the response, the clinician may offer emotional support to the client by reminding them they are safe in the present or simply instructing them to “go with that (association or experience)” during the subsequent set of stimuli. At various times during the session, according to structured protocols, clients are asked to attend to various elements or to focus attention back on the original target to ensure that the entire memory has been fully processed.

Below is the transcript of Jennifer’s EMDR reprocessing session, which encompasses phases four through six (desensitization, installation, and body scan). While every reprocessing session is structured to include phases three through seven, not all reprocessing is completed within the time frame of a single clinical session. In this case, the processing was completed in this one session. After each set of bilateral stimulation (BLS), Jennifer reports her associational experience:

The reprocessing indicates the comprehensive changes in cognitive, emotional, and somatic domains, including insight regarding her husband’s reactions, a recognition that event is in the past, and an elimination of disturbing physical sensation. In the installation phase, the previously identified desired positive belief about the self, or a preferred one that may have emerged, is processed along with the neutralized memory. This enhances the self-affirming evaluation in the context of the memory and strengthens the affective connection to the client’s adaptive memory networks.

During the body scan phase, Jennifer was asked to hold the positive belief and memory of the delivery room in her mind as she scanned her body to identify any residual negative sensations. She reported that her body felt, “Clear and relaxed.”

During the closure phase at the end of the session, Jennifer was told that additional associations might emerge during the week as processing continued and was asked to briefly jot down any disturbance in a log (e.g., indicating image/thought/affect). She was also reminded to use her self-control technique if needed.

At the next session, during the reevaluation phase the memory is reaccessed to evaluate whether further processing is needed. The clinical symptoms are evaluated, and the client is asked to report any changes that have occurred since the last session. This indicated that Jennifer’s symptoms were resolved. In the subsequent session, Jennifer reported that she was sleeping well again and was no longer preoccupied with the events of the delivery nor hypervigilant or hyperaroused about potential danger and uncertainty. There had been no more flashbacks, nightmares, or avoidance of stimuli that reminded her of the incident. When asked about the relationship problems she had had with Jake and her husband, she reported that they were now resolved. For example, she was no longer experiencing anxiety or fear or reminded of the delivery when she was interacting with Jake. Further, the irritation she had felt with her husband over various random events had completely vanished. Instead, she actually had a long talk with him about her experience of his role (which she had not disclosed to him before) and how that had shifted as a by-product of the reprocessing. When she considered the thought of having another baby, she remarked, “If we decide to have more children, that will be our choice. This experience has nothing to do with what we decide for ourselves and our family.” She confirmed in a telephone follow-up that she felt “like herself” again.

Although unnecessary with Jennifer because of the comprehensive generalization of treatment effects, additional procedures used to complete the three-pronged protocol involve the processing of current triggers and imaginal templates for positive future actions. These will be described in the next case.

Developmental trauma refers to the category of early life experiences that are formative, pervasive, and have a significant negative impact on self and psyche. As illustrated in this case, the eight phases of EMDR therapy and standardized three-pronged approach involve a thorough evaluation of the comprehensive clinical picture, client preparation, and the processing of (a) past events that set the foundation for pathology, (b) current situations that trigger disturbance, and (c) skills needed to address future challenges.

Carla is a 30-year-old woman, twice divorced, who came for EMDR therapy to deal with anxiety and depression due to her off-again, on-again relationship with Joe, her current boyfriend of 5 years, who often ignored her needs. She had struggled during this time to do “whatever it takes” to make the relationship work. After two failed marriages, she believed that this was her last chance to have a family of her own.

Carla grew up as the youngest of four children, with three older brothers. Her parents both worked full-time, leaving her at home with her grandfather who lived with them until he died when she was 6 years old, devastating her. Subsequently, she spent a great deal of time at home alone with the family dogs. Even when others were home, she experienced an overwhelming sense of loneliness. She gave up asking; she gave up wanting. She would dress herself in the mornings to get herself to school, often forced to wear the same clothes day after day to the point where the school called to see if her family needed financial assistance. Her mother never took an active interest in parenting her. When she paid attention to Carla, it was to scold her or blame her for her unhappiness. Her father was passive and detached. Her brothers bullied her or ignored her altogether.

From an AIP-informed perspective, Carla’s symptoms of anxiety, depression, low self-esteem, and poor relationship skills stem from her unprocessed memories of neglect and abuse as well as early loss of a primary attachment figure. It was clear that she was an unwanted pregnancy and that her mother resented having to care for her. So, when her boyfriend ignored her, it triggered the childhood feeling that she is not good enough to warrant his attention, causing her to shut down emotionally rather than considering that there may be something wrong with the situation or with him. Reacting the same way in the present as she did when she was a child, feeling not good enough, and powerless to do anything about it, she again gives up asking, gives up wanting.