Deep Abreactive Experience: “Into the Abyss”

This is a full case example of one of the most deeply moving EMDR experiences I have been part of.

Stephanie is a 43-year-old mother of three children ranging in age from 7 to 14. She described her marriage as a good solid partnership, and her only complaint was wanting her husband, Steve, to be a little more psy- chologically minded. Stephanie had her master’s degree in hospital admin- istration and was director of the task force for the homeless in her community. The focus of her work was to strengthen social systems, encourage healthy lifestyles, and improve the quality of life for children. She worked part-time, during school hours, so she could spend plenty of time with her children, as she regarded motherhood as her primary occu- pation. She also had holidays and summers off.

Stephanie had been raised as a Catholic, but she was not currently prac- ticing. She had a strong social support network and had good relation- ships with five of her six surviving siblings (all female). Her only brother died tragically of a pulmonary embolism. Stephanie is the sixth of seven in birth order. She had numerous medical problems at the time I saw her, but she had obtained medical clearance to do EMDR work. Her younger sister, Ruth, referred Stephanie to me after successfully completing her own EMDR treatment with me. Ruth, Stephanie, and all their sisters had been sexually violated multiple times by multiple perpetrators in their home and neighborhood.

Stephanie traveled from out of town and stayed with Ruth while she was in treatment with me. She had come with her children, and her hus- band was to join them later during the visit. She had a very clear intention for herself in treatment and wanted to work on specific dreams that haunted her nightly. Before arriving, Stephanie wrote me a very moving letter. Here is an excerpt from that letter:

Ruth is going to help me arrange care for my children while I am working with you so that I will have the freedom to work each day as long as necessary. Ruth has explained to me some of her sessions with you that have included periods of journaling until I have resolved or can deal with issues that have been raised by your style of counseling. I don’t know any counselors in Boise that work in this style.

I am anxious to meet you and experience your style of counsel- ing. I can tell from Ruth that it is effective. However, I am not a novice at therapy, and the thought of dragging up more of my past isn’t pleasant or even appealing. I am doing this to put some faded skeletons in my memory closet in their proper place [italics mine] and to enhance my family life. It is hard to be a happy loving parent or spouse when ungrounded fears and reactions, as well as night- mares, plague you. I have come a very long way since my discovery of the term “adult child of an alcoholic.” My family life is very good, and my husband is a loving, kind, and gentle man. My life today is drastically different than the life I was raised in, and I’m proud of that. My children are loved and cared for well. However, there are ghosts that are keeping me from having the life that I want, and I have decided that it is time to confront them.

This introductory letter, along with my initial evaluation, confirmed to me that this was a woman who had suffered deeply as a child and young adult. She also impressed me as someone who had done much healing work for a number of years. Yet she was still haunted by the ghosts and dreams of her childhood.

After completing Phase 1 and Phase 2 (her DES was low at 7.5, and she had completed her Safe Place exercise successfully), I felt that we had developed enough trust so that the working alliance and the therapeutic relationship had taken root, and believed it was time to begin the second stage of EMDR treatment: active trauma work.

Stephanie had memories of being vaginally, orally, and anally raped. With the help and guidance of many clinicians and healers over a period of 25 years, she had been able to overcome much of her pain and dysfunction

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resulting from complex PTSD. However, she still had more work to do. For the past 30 years, she had the same nightmare every single night.

She dreamed that she was at the top of the stairs (or sometimes in the kitchen) in the house she grew up in, and she was being chased by a mon- ster or a stranger. She tried to run for her life down the stairs, but her legs felt like lead, and she could not get away. She was knocked down. It felt as if bones had been broken. She kept getting up and trying to fight back. Just before she was going to be killed, she woke up, drenched in sweat and the bedcovers in disarray. Her husband bore scars and black and blue marks from Stephanie’s nightly battle with this demon.

Stephanie came to me with the skepticism common back then (1995) that some “silly” hand waving in front of her eyes could ever “erase” the misery of her traumatic nightmares. It was only having witnessed a dra- matic shift in her beloved sister Ruth that had gotten her to my office. Our sessions doing Phase 1 lasted for a while. During the history taking, Stephanie recounted every act of abuse she had experienced from her father, her brother, her grandfather, her neighbor, and her first husband. In addition to sexual trauma, there was physical trauma. She had even been thrown out of the house by her first husband and had to live in her car for weeks in the bitter cold. I listened to her in awe at her courage to survive.

Also during Phase 1, Stephanie challenged me about my credentials and my ability to deal with the devastation she had suffered. She had always been treated by women, and she did not have much faith that a male clinician could understand or feel sufficiently empathic to be of service. Again, it was only Ruth’s faith in me and the results she had seen from our work together that gave Stephanie any cause for hope. I experienced myself in empathic attunement to this poor woman’s plight and her doubt that she could be assisted by a man. (That has never been one of my “buttons.”) I was more concerned about getting a good history, asking good questions, and getting a good enough feel for who this person sitting in front of me was.

By this time, I was not only on the faculty of the EMDR Institute but also a graduate of an excellent training program in interpersonal psycho- analysis (at the Manhattan Institute of Psychoanalysis). What also helped was that during the 1980s I had worked in hospitals, taught consultation psychiatry on the faculty of the Mount Sinai School of Medicine, and served as director of mental health consultation services at the Bronx Vet- erans Administration Medical Center.

Stephanie and I survived our initial sessions and had made a deep enough connection; we were ready to begin the second stage of the work. The target was the dream of the monster chasing her and threatening her

life. She knew that it related to the sexual abuse she had suffered as a child. Here is the trauma activation sequence:

Picture: I am at the top of the stairs in my nightmare and a monster is trying to kill me.

Negative cognition: I am going to die. Positive cognition: I am a survivor. VOC: 2

Emotion: terror SUDS: 8 Body: all over

Stephanie initially processed a series of pictures of her childhood; then she started to relive one day when she was 4. She was in her parents’ room being raped orally and vaginally by both her father and her grandfather; she had almost choked to death. In that moment she made what seemed to be a pedestrian comment: “This is what my dream is about.” But there was nothing pedestrian about the surprise she exhibited. “Of course it is! Why didn’t I make that connection before?”

Over the next few sessions, Stephanie had deep abreactive experiences interspersed with periods of calm and consolidation. She remembered the graphic details and was amazed at the clarity of the pictures that flashed through her mind: seeing her grandfather pulling his zipper down, her father holding her down and shoving his penis deep into her throat. Stephanie was exhausted after each double session.

Then, as the pictures got sharper, she started to have a gag reflex. I was prepared for what might occur. I also counseled Stephanie to come to ses- sion on an empty stomach. At a pivotal moment during the next session, she put up her hand in a stop sign. We dialogued, and Stephanie expressed concern about fully re-experiencing this all-too-real nightmare. She was afraid she might choke to death or go crazy. I suggested we get medical clearance again; having worked in hospitals, I tend to be very careful with my clients’ bodies. Stephanie called her physician, who assured her that she would not choke to death. At the same time I asked her for permission to consult an EMDR colleague. I contacted one of the local trainers (William Zangwill), who was kind enough to give me his support and good advice on various containment strategies to help Stephanie get through this chal- lenging part of her treatment.

In the next session, Stephanie told me the reason for her fears: She had had a near-death experience during one of these rapes. She started to lose consciousness and then left her body and watched what was happening to her from the ceiling of the room.

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This was our sixth session of trauma processing; we called it “Into the Abyss.” Stephanie started with this picture: I see my father’s penis coming

toward me while I am being pinned down to the bed. During processing

Stephanie avolitionally reexperienced choking to death. Her hands were on her throat, her head was thrown back, and her face was beet red. Her mouth was wide open, and she was alternating between choking and crying hysterically. She found herself gasping for air. I supported her verbally, reminding her that I was with her and she was here with me in my office. She occasionally signaled to me that she heard me through her terror.

Then came a 15-min period when all she was doing was choking. (We were using audio stimulation.) Do you know how long those minutes were? They were probably the longest 15 minutes of my life. That moment remains the deepest level of trauma release I have ever witnessed. As Stephanie started to come out of her choking episode, she remembered another dissociated part of her memory: Her father had told her that he would sew her mouth closed if she told anyone. She remembered being in a state of shock. Then her father and grandfather slapped her “awake” and dressed her. She had to go downstairs to help her sisters make dinner because her mother worked two jobs (her father did not work).

We spent time grounding and debriefing. Stephanie’s SUDS level was 3. I asked her what prevented it from being 0. She said she felt very sad for herself as that little girl. When our session ended, she was stable enough to drive to her sister’s house. She called me that night to say she was still sta- ble, though she expressed amazement at the depth of the details that had flooded back to her. In her words, “I was there again, and I was out of my body again.”

I saw Stephanie for her next double session the next day. We made it safe for her to reenter the experience again. I reminded her that she could stop at any time and that I was fully here for her for whatever she needed. It has been my experience that with higher-functioning clients who have been traumatized, the strength of the therapeutic relationship allows the greatest part of affect tolerance while they are processing the unspeakable. When we began this time, Stephanie started to sob for the deeply wounded little girl who was subjected to such immeasurable cruelty. By the end of the session, she told me she was okay. Her SUDS level was 0. Then I checked her initial positive cognition (I survived) and its VOC, which was 7. After a few more sets, we were assured that her positive cog- nition was strong and her body scan was clean, and we closed down the session. We finished with the remaining old memories and the present day issues that emerged — her reticence about talking to her husband on issues that deeply affected her. She realized that though she loved him and

wished him to be a bit more psychologically minded, it was her fear of emotional intimacy that had prevented her from reaching out more deeply. We completed the three-pronged protocol by having her imagine being safe having deeper conversations with her husband and processing this issue. Fortunately he was in town and very willing to come in for a few marital sessions where Stephanie practiced talking more deeply with him. Though he struggled a bit, he was able with some minimal coaching to open up to her in a way he had never had. Then they practiced on their own for a week, and we completed the three-pronged protocol.

After some termination sessions, Stephanie and her family went home. She sent me a thank you in the form of an orange-flavored tea called “Market Spice,” which I drink to this day. Over the years, Stephanie has consulted me on other matters when she has been back to her sister’s for visits. What continues to astound both of us (and her husband as well) is that she has never had that nightmare again, she has regained the ability to get good enough measures of sleep, and she no longer has startle sensitiv- ity. This has been sustained through the 9 years since we first worked together.

I will now go more deeply into the relational aspects of the desensitiza- tion phase of active trauma processing before moving on to Phase 5 through Phase 8. I will also cover issues of transference, countertransfer- ence, and the intersubjective in all eight phases, vicarious traumatization, active relational strategies, and self-care for the clinician.

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CHAPTER

8

Countertransference,