Target Selection: Pitfalls and Best Practices

The first activity in the launch sequence is selecting the target from among the 10 worst memories that are linked to the presenting problem. These memories should have been elicited from the client in Phase 1. Although Shapiro has stressed the importance of linking the old target memory to the presenting problem, I have talked to too many clinicians who do not do this rigorously. Instead they simply ask which old memory the client wants to work on. The problem with this is that the clinician and client may end up targeting the client’s state of mind that day, not the character trait the client came into therapy to address (and the old memories that started these traits). Targeting a state of mind will not ensure successful resolution of the presenting problem.

Another cause for concern is that after processing is underway, many EMDR clinicians will open a session by asking, “What old memory would you like to work on today?” So what is wrong with that? It sounds relational, doesn’t it? The problem is that because we need to finish one protocol before moving on to the next, we cannot leave this decision entirely up to the client. Opening too many wounds at once, before finish- ing work on the original target memory, may cause flooding or shutting down. Instead the clinician needs to continue working on the first target and its associational channels until they are completely processed. That does not sound too relational, does it? But when experience shows that certain elements of a procedure need to be followed with fidelity because they create more safety and better outcomes, that is relational.

The goal for targeting a memory is to select from one of these two categories:

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1. The oldest memory (of the worst and most painful memories elicited in Phase 1) that intensifies the problem(s) the client came in for. (Remember, it is not enough that the target memory be the oldest; it must also be associated with painful emotions and negative cogni- tions.)

2. The worst of those memories.

The client and clinician should decide together, in a co-participatory way (neurobiologically, this is co-regulation), which memory to target. If the client is unsure, I ask him or her to think of a related memory, then close his or her eyes, and do a quick body scan to determine what is most disturbing, using the SUDS Scale as a measure.

Although the oldest painful memory is usually targeted first in EMDR, it may not be the most accessible. It may carry implicit fears connected to other state-dependent memories. This may not be obvious to the client — or to the clinician. That is why starting with one of the oldest memories that hurts now seems to be a better choice. As I tell my clients (and it is something I have learned from years of experience), “It ain’t gonna sing if it ain’t got that zing!” And, it is only going to “zing” — hurt — when state-dependent memory is “singing.”

Many times clients want to work on a present-day traumatic event. This may not be the wisest course of action. In 14 years of doing EMDR, I have seen that clients often get stuck and block during the next phase, when they actively process their traumatic memories. For example, a 42-year-old woman may walk into a session and want to work on her tough day at the office when her boss was irrationally on her back. Since I already know the client’s history and her worst memories, and we have completed process- ing the memory we were working on, I recognize that this experience is similar to her childhood when she was often harshly and unfairly criticized by her alcoholic father. If this is the case, a possible strategy is to use a “floatback technique” (this is similar to Watkins and Watkins’ [1997] affect bridge and is discussed in depth in the next chapter) to elicit the implicitly associated childhood memory of being harshly criticized. Once the client has processed the childhood feeder memory of her father’s drunken irrationality and released her pain about it, we can more directly focus her attention on current-day referents to her childhood trauma. She might spontaneously develop a solution to her problem. If not, we can figure out together appropriate ways to deal with the situation with her boss, such as giving her assertiveness training. If not, we can then assess what is not finished in terms of other associated trauma.

It is vital to recognize that the interaction between client and clinician at this stage is as important as which memory is selected for processing.

88 • EMDR and the Relational Imperative

If the clinician is not attuned, aligned, and resonating with the client in the moment, it will be much harder for the client to successfully process the trauma. Having an attuned heart and mind enables the client safely to open the door to hidden depths. One of the organizing principles of Phase 3 work is an affectively and cognitively shared agreement by both parties on where to begin. The clinician is the agreed-upon expert on methodo- logy; the client is the agreed-upon expert on his or her life. Deciding where to start a protocol is a judgment call that you, the clinician, have input into, but that the client has the final say in. I believe that not just what you and your client decide to target, but how you work together to focus on the target memory, pictorial representation, and appropriate neg- ative cognition is a good predictor of outcome. Relatively speaking, the cli- nician should instruct the client carefully on the proper procedures to follow (i.e., starting with the oldest memory), but once clinicians have given our instructions and rationale, I believe that we should respect our clients’ wishes about which target memory to start with. Any exceptions must be spelled out very carefully and conceptually to the client so he or she understands them on an energetic and emotional level, as evidenced by somatosensory changes that are either noticeable to the clinician or reported by the client.

For example, suppose a 38-year-old male client has had a trauma- processing session about his father. The session was incomplete in that the client’s SUDS level did not reach 0. However, definite progress was made. The starting SUDS was 9; the ending SUDS was 4. During closure the client remembers that there was a very important way in which his father let him down: by not attending any of the client’s basketball games. In the next session, when client and clinician are in the reevaluation phase, the client states that he has made enough progress on this issue. Now he wants to work on his professional and future issues. His SUDS on the original issue in the following session is a 5. What judgment call needs to be made? It would appear that the client either has dissociated or wants to disassoci- ate the painful affect related to his father’s lack of love. The client’s reac- tion to the previous session gives the astute clinician a roadmap of his psyche. Remember, this is the “Zen” of EMDR: “Be here now.” Clearly, to me, the starting point is the client’s desire to avoid feeling the effects of active trauma work. I would suggest that clinician intervention is appro- priate here.

Once the best target has been selected, the clinician asks the client what picture represents the worst part of the memory. This is to enable the client to have as clear a visual representation as possible in the hopes of potentiating the trauma activation sequence. Asking for the picture,

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however, is not an invitation to explore the meaning of the event. There are times when the client may want to say something more about a particular picture. But talking or telling stories at this point can actually defuse the pain of the memory. It is probably a method of implicit avoid- ance as well. In as gentle a way as possible, the clinician should guide the client back to the procedural steps.

How specific does the target image need to be? Must it be real, or can it be representative of a group of memories? How detailed should it be? Does a part of the picture trigger any other old trauma? If so, which part and what trauma? All the client and clinician really need is an image that is focused enough to start the activation sequence. It should be enough to answer the question, What old memory is being accessed and stimulated to activation by the procedural steps outline?

Often an EMDR consultee who is consulting with a more experienced colleague will present a session that “did not go well,” meaning the client showed no — or little observable — shift in affect or insight. My experi- ence is that this is often the result of the target image’s being cloudy or vague and the clinician’s struggling unsuccessfully to help the client be more specific. This is usually a sign of negative psychoform dissociation (cloudy image) and negative somatoform dissociation (lack of feeling, numbing). When material is not accessible enough, it should be a sign to both parties that more resourcing needs to be done, specifically on resources that will lower negative hyperarousal so the image and sensation can be present along with negative cognition. There are other times when the clinician is not clear about how to use the procedural steps outline properly. The antidote for this frustrating situation is to ask oneself, What are we working on? Clarity counts.

Here is an example. An EMDR clinician presented a case of insomnia. There was no target memory. The target picture was of the person in the present day having trouble sleeping. So there was no specific memory, just a symptom. And “the EMDR was not working.” As we discussed the case, it also came out that the client, a combat veteran, was actively drinking. Clearly, the consultee’s trauma case conceptualization had not been fully thought out. The client’s insomnia was both a symptom of PTSD and the consequence of using alcohol abuse to wipe out the feeling states that PTSD stirred up. After the client had a period of sobriety and training in relapse prevention, a possible target would be the worst or earliest upset- ting combat memory. The clinician had not thought through the task- centered need in the working alliance to do his due diligence.

The clearer the EMDR clinician is in the trauma case conceptualization, the more focused the target will be, and the better the chance for a successful

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and robust outcome. In general this case shows us that the clinician needs not to note the client’s symptoms but to find out what painful memories, thoughts, and sensations those symptoms are connected to. This, of course, takes place after the client and clinician have addressed the client’s need to attain sobriety. This may take a considerable amount of time. Then client and clinician, with relapse prevention strategies in place, can begin active trauma work safely. This is where having access to the EMDR Chemical Dependency

Treatment Manual and A. J. Popky’s DeTUR protocol is invaluable.

Once the target memory is chosen and the picture comes into focus, trauma activation begins. At the same time, the client is quite aware that he or she is sitting in my office with me, safe in present time. Being able to create this dual awareness of traumatic past and safe present is the founda- tion that will enable the client to process traumatic memories and release traumatic stress permanently.