7-minute read
Welcome to The 51st Minute – a newsletter for EMDR therapists navigating complex trauma in their daily work. We get to reflect together on the impact of sessions, clinical patterns, and stuck points we wrestle with after the session ends.
I’ve been working with trauma for over 25 years—EMDR, attachment, neglect, dissociation, all of it. I’m a gardener at heart and curious about structuring and sequencing therapy to nurture growth. I’m awed by how growth emerges from reservoirs of pain. In each issue, I’ll dig into something worth thinking about—clinical patterns, research, and industry forces impacting our work…or frameworks that help make sense of what we’re seeing. I consider this a conversation and welcome your response.
A note: This newsletter is a thinking space to discuss clinical patterns and emerging concepts in trauma treatment. Its role is not to replace or function as consultation – still the best place to unpack cases.
The pattern you keep seeing
Maybe this scenario sounds familiar.
You’re an EMDR therapist working with a client with attachment wounds whose mother abandoned them as a toddler.
She left for the store and never returned home to your client and his two older siblings.
Therapy has progressed more slowly than expected, but after eight months, you’ve established resources. Since they can’t tolerate imagining people as relational resources, they chose a bear from a video game they often play. They liked how, in the game, it was soft, strong, but protective. It was ‘nice’ having it there.
“How do you feel?” you ask.
Their eyes dart around. (ever misplace keys?…” they SHOULD be here…where are THEY?!”)
“Did anything come up this week where you had the chance to use your Calm Place?”, you ask.
“No, I don’t get upset, so I haven’t used it.”, your client replies.
Later in the session, you summon your courage to begin Phase 4 Desensitization, but after several passes on a memory of their brother burning their hand on purpose, you repeatedly hear:
“Nothing’s coming up.”
“I don’t feel anything.”
Their face remains expressionless.
“On this next set, consider bringing your bear in to help the boy.” , you offer.
They fidget with a hangnail while glancing at your diplomas on the wall.
Are they dissociating or questioning if I’m a good therapist?, you think.
Squirming in your office chair, you take a deep breath to resist going down the rabbit hole.
You feel stuck and start to wonder: Am I doing something wrong?
What the research shows about child-onset trauma and EMDR outcomes
As a new college graduate, I bought my first car with a $1,200 budget and my dad’s help. We kicked the tires and test-drove this cool number, decked out with gloss fake wood trim. As a 22-year-old, it wasn’t my first choice, but I deferred to experience.
Back at home, dad’s eyes surveyed the car.
Then stopped.
“Huh, it looks like the side panel is a shade lighter. It looks like it’s been in an accident, and the front panel was replaced.”
‘WWWHHHAAAAT’?
A horror film filled my head—
The car engine sputtering,
Sounds of sharp metallic knocks from under the hood,
The dashboard lighting up in red and amber.
Scowls from angry drivers late to work.
Up until now, I assumed the car was roadworthy, but with his observation, I needed to verify with a master mechanic that all internal systems were operating as they should. I feared the car lurching and dying in the middle of a traffic lane.
But, truth be told, the other part of me said I could ignore dad’s observation.
Do I really need to be worried?
After all, I drove the thirty miles home without incident.
In fact, knowing about potential accident damage changed everything. At the first sign of trouble, I’d criticize myself for not being proactive,
for taking unnecessary risks,
and jeopardizing my time and sanity.
I needed expert eyes to check which systems were vulnerable and needed repair, and which could handle the commute.
When we work with clients who have early-life trauma, we need the same approach. Just like I needed to assess which car systems were damaged before driving it daily, we need complex trauma assessments to gauge healthy vs. compromised domains as it impacts treatment planning.
Car-shopping with dad taught me that knowing about prior damage changes what you do next
The same is true with trauma clients. Here’s what the research shows about therapy outcomes when we don’t account for when relational damage occurred:
In 2007, Bessel van der Kolk and colleagues published the largest randomized controlled trial comparing EMDR, fluoxetine, and placebo for PTSD. The study had equivalent numbers of patients with child-onset (N=45) and adult-onset (N=43) index traumas. Child-onset traumas were defined as we do in our daily work—physical, emotional, or sexual abuse occurring before age 18. It turns out that in the 8-week EMDR condition:
Participants endorsing child-onset trauma:
- Were more likely to drop out
- Only 33% achieved complete symptom remission at 6-month follow-up
Compare that to outcomes for adult-onset trauma clients (trauma after age 18):
- 100% lost their PTSD diagnosis
- 75% achieved complete symptom remission at 6-month follow-up
Why such dramatically different outcomes with the standard protocol?
Because child-onset trauma amplifies damage… It creates adverse memories while it damages the internal systems needed for EMDR processing to work. This is why your client keeps saying “nothing’s coming up.” The affect regulation system that should help them identify and tolerate emotions is underdeveloped.
The researchers concluded that what was needed was a better understanding of “treatment sequencing”—understanding what needs to happen first for those whose internal systems were distorted by early experience.
We’ll be exploring treatment sequencing in future issues.
The one intake question that changes treatment planning
So how’s it relevant to you?
Consider adding one assessment question to your next trauma intake—a question that reveals whether your client developed affect regulation with relational support, or learned to manage distress alone:
“When you were growing up, and you got upset about something, what typically happened?”
Answers that suggest they developed regulation with support:
“My dad would lie next to me on my bed until I calmed down, I liked him there, he’d talk to me.”
“I could go to my mom when I was upset, and she’d drive us around for a while. In the car we could talk.”
“I could always go to my older sister’s room…she’d make room for me on her bed, listen and help me figure out what I was feeling.”
Answers that suggest they learned to manage alone:
“I’d go to my room until I felt better. A few times the dog would come in and lie at the end of the bed” (learned to manage alone)
“I don’t really remember getting upset…it’d drive my older brother crazy, he said I needed to react more…he thought people took advantage of me.” (emotional shutdown)
“My parents had it hard for the times they were living in; I’m really grateful to them, they were good parents who were dealing with their own stuff” (unavailable)
“I don’t know what you mean, only grandma could show emotion.” (emotional expression = unsafe)
“Nobody really noticed” (emotional neglect)
Once you start listening for these patterns, you’ll hear them everywhere—and it’ll change how you plan treatment. It’s a lot better than hearing “Huh, it looks like the side panel is a shade lighter….”
Okay, it’s after midnight, so I’ll leave you with that for now.
If you have comments on the topic or what you’re seeing in your sessions, shoot me an email.
And we’ll be sure to pick up the thread in two weeks.