David Blore PhD student

1. The Range and Diversity of Post Traumatic Growth (PTG) following EMDR for involvement in a Road Traffic Accident (RTA) David Blore PhD student School of Health and Population SciencesCollege of Medical and Dental Sciences, University of Birmingham 2009 EMDR UK & Ireland Association Conference, Manchester

2. What is PTG? • What it isn’t… • It is not a DSM or ICD diagnosis • Nor is it a set of criteria that neatly fits into a ‘label’ • So what is it? • “something positively new that signifies a kind of surplus compared to precrisis level” (Zoellner & Maercker 2006)

3. 30 years and 14 labels: • Stren conversion (Finkel 1974, 1975) • Drawing strength from adversity (McCrae 1984) • Positive reinterpretation (Scheier et al 1986) • Positive psychological changes (Yalom & Lieberman 1991) • Perceived benefits or construing benefits (e.g. Calhoun & Tedeschi 1991) • Transformational coping (e.g. Aldwin 1994) • Thriving (O’Leary & Ickovics 1995) • Post traumatic growth (Tedeschi & Calhoun 1995) • Stress related growth (Park et al 1996) • Discovery of meaning (Bower et al 1998) • Flourishing (Ryff & Singer 1998) • Positive illusions (Taylor & Brown 1998) • Positive emotions (Folkman & Moskowitz 2000) • Adversarial growth (Linley & Joseph 2004)

4. Is there consensus on the negative side of psychological trauma? • Well possibly! • Acknowledged that mental health is not a precise science • DSM diagnosis of PTSD since 1980 • Criteria set by committee not by microbiology, pathology or cut-and-dried criteria • ‘Fashion’ influences empirical criteria for general agreement • Apparent consensus masks tensions (e.g. DSM V)

5. As regards ‘PTG’: • “…the more we know about posttraumatic growth, the more we know that we do not know very much.”Calhoun & Tedeschi (1998) • 11 years later we aren’t much further on despite a huge increase in interest in positive psychology since 2000 • There is a general acceptance that trauma acts as a trigger to ‘leaps’ in growth, but trauma is not the sole cause of growth. • Trauma isn’t even a prerequisite for growth (Park et al 1996) so perhaps ‘PTG’ is misleading?

6. Aim of the research, research questions • Aims of research: • To investigate the lived experience of PTG post EMDR amongst RTA victims • To inform EMDR practice about PTG as an outcome to treatment, over-and-above the reduction of negative symptoms • Sample research questions: • What is PTG? • Does EMDR generate PTG and if so what part does it play in promoting PTG? • What stages do those who experience PTG go through that may be relevant to clinical provision of EMDR? • Is the efficacy of EMDR being constantly underestimated?

7. Methodology overview • Phenomenological study using an IPA (interpretative phenomenological analysis) format • 6 stage development of semi-structured interview • Ethical approval obtained in 2005 followed by a pilot study • Accredited EMDR therapists (Practitioner and above) who had provided EMDR were asked to invite their clients to take part in research if the therapist had noticed: • “something more than purely a reduction in negative symptoms”,

8. Methodology overview • 17 clients showed interest, 1 had not actually had EMDR leaving 16 • 13 had EMDR following involvement in an RTA and 3 had EMDR for sexual abuse • The 13 ‘RTA’ interviews took place, but 1 interviewee was unable to answer all the semi structured interviews and the interview was aborted • 12 RTA interviews were subject to transcription, ‘cleaned and confidentialised’, validated by the interviewee and went forward to the hermeneutical (interpretative) data analysis phase

9. Methodology overview • Result of hermeneutic analysis to: • 1589 summary phrases were sorted into: • 19 ‘themes’ which clustered into: • 2 superordinate themes: • ‘Navigational Struggle’ • ‘Navigational Discovery’ • These superordinate themes had a cyclical relationship: ‘Navigational Struggle’ RTA ‘Navigational Discovery’

10. The ‘Navigational Struggle’ category • After the RTA the client ‘struggled to find their way’ just as though a series of interconnecting metaphors permitted a second journey but without maps and in territory that was unfamiliar to them… in essence a navigational struggle • ‘Navigational struggle’ also succinctly included the components that made up this category: • Assumptive world pre RTA ( the metaphorical ‘Departure point’) • Peri-RTA struggle with assumptive world (‘Losing sight of familiar territory’) • Spirituality to resolve struggle (‘Calling on higher resources for help’) • Use of figurative language to make sense of what is happening • Hankering (‘Wishing he/she hadn’t left the departure point’) • Secondary traumas and iatrogenesis (‘Adverse weather and road conditions’) • Struggle to cope (‘Dealing with mechanical failures’) • Struggle for control of readjustment (‘Wrestling with the steering’) • Hindsighting (‘On arrival, what had been learnt?’)

11. Data analysis overview

12. Building a model to explain the development of positive outcomes in relation to EMDR ‘Navigational Struggle’ to integrate experience into understanding and ‘move on’ Pre-RTA Use of figurative language RTA 2TEs Hindsighting + 6 others

13. Examples of Figurative Language Use, utilising driving and road based similes and metaphors • “…an alternative technique to osteopathy which doesn’t involve clunk clickingand the orthobionomy which is a muscle balancing technique…” 3:238-40 • “I would lose all track of what I was saying it was almost as if there was a traffic jam and I had to pause then something else would come through…” 3:53-6 • “It was like having a traffic jam in me head. If you’ve got 3 lines of traffic I got a traffic jam in 2 of those lanes but providing I took everything very slowly then information could get through. If I tried shoving information in it was like having a car accident and my head just built up you know a traffic jam built up in me head and words wouldn’t come, thoughts wouldn’t come, and then I would have to back off it and shut it down… for a long time…” 3:107-114 • “Most people I suppose are geared towards growth and enlightenment…” 4:403-4 • “You don’t know what’s round the corner I mean we never thought we would be going down on that train then ending upside down in the car…” 6:571-3xamination

14. Examples of Secondary Traumas and Iatrogenesis • Description of having an MRI scan:“…then I had the MRI scan… I vibrated in my head for 2 months afterwards because that again is a vibration and it’s an up and down vibration which is unusual I can sway from side to side and it does nothing but if you vibrate me up and down (like in the RTA itself) then I’m totally messed up…” 3:213-6 • Description of giving evidence and hearing testimony in Court:“I had to give evidence… I found it really distressing because I heard things in the hearing that I hadn’t realised. The Policeman said he was expecting to see a fatality. Apparently the metal platform that comes down at the back of the lorry is sort of that thick [demonstrates with hands] and he said the impact was so hard that it released the catch and he said normally once that’s released it would come straight down. Well if it had it would have come straight through the windscreen and guillotined me…” 1:170-9 • Description of being taken off medication suddenly:“I got this really bad diarrhoea… and the doctor was absolutely appalled and that what should have happened was I should have been slowly taken off the antidepressant I was on.” 1:377-9

15. Examples of Hindsighting • “Well I didn’t really know a great deal about it obviously because I’ve never been in an accident before and the traumatic bit… I didn’t really expect it to be as bad as what I thought the word trauma meant” 19:7-9 • “I’d been driving a number of miles for the last 7 plus years and you know, you get a little bit blasé…” 17:25-7 • “Looking back, I was definitely depressed before I went to see the EMDR therapist. I mean I think a lot of people would probably turn to the doctor for pills” 10:412-3 • “…if someone had said prior to the accident if you were ever involved in a bad accident you would go through this fear I would have said oh come on don’t be ridiculous I see it everyday and... I was surprised that I was affected so badly.” 1:276-9

16. Where does PTG start? • Tedeschi and Calhoun (1995) contend that wisdom is a process leading to PTG, but surely wisdom wouldn’t have occurred without the trauma and it isn’t a negative outcome. • Consider the following example: • “if there’s head injuries without a shadow of a doubt I would get them to contact the Head Injury Association because they have a support team which everybody needs because until you’ve actually been through it you can have all the sympathy in the world but no empathy and no real understanding…” 3:1108-11 • Note the fine distinction between ‘prospective’ wisdom (above) and the following example of ‘hindsighting’ (or retrospective wisdom): • “when it comes down to career, it was the EMDR therapist that planted the seed…” 1:492/3

17. Data analysis overview

18. Prospective wisdom Paradoxical wisdom New directions discovery Social discovery Personal discovery Life appreciation Spiritual & philosophical discovery Discovery of success heuristic Expression of positive emotions Aspirational Discovery ‘PTG’ becomes ‘Navigational Discovery’ Comparison with ‘PTG’ (Tedeschi & Calhoun 1995) • Factor leading to PTG • Indistinguishable from wisdom • New possibilities in life • Relating to others • Personal strength • Appreciation of life • Spiritual change • ?Part of new possibilities in life • Not recognised • Not recognised

19. But just where does the ‘Navigational Discovery’ (ND) start? • Note it was the EMDR therapist that… “planted the seed” 1:492/3 • Perhaps the ‘seeds’ to the ND are really the new networks created during EMDR itself? The free association and interweaves linking the dysfunctional with the adaptive… • Perhaps hindsighting represented the right conditions for ‘germination’ (i.e. It ‘precedes’ wisdom)? • Perhaps ‘germination’ itself took place when wisdom occurred? • Perhaps PTG, as Tedeschi & Calhoun see it, are the ‘shoots breaking the surface of the soil’ – the visible plant – that subsequently ‘flowers’? • Perhaps the last stage of growth is the production of the ‘new seeds’ of aspirations of future growth?

20. A ‘Navigation Struggle and Discovery’ model to explain positive outcomes in relation to EMDR Navigational Discovery Navigational Struggle to integrate experience into understanding and ‘move on’ ‘Asymptomatic’ Pre RTA Wisdom and paradoxical wisdom contained within new networks NDD Use of figurative language SD RTA 2TEs EMDR PD LA Is this model applicable to the ‘journey’ through other traumas? Hindsighting SPD Accesses other networks helping make sense AND create new networks DSH EPE + 6 others AD AND create new networks

21. Wisdom and Paradoxical Wisdom Navigational Discovery “First of all go and see your GP ask them to see a trauma specialist and not a counsellor I would definitely not advise seeing a counsellor…” 4:664-6 “I would definitely recommend the EMDR treatment that I had, definitely. It improved how I was feeling before, I can’t really recommend it enough” 6:617-9 ------------------------------------------------------------------------------------- No instances of ‘stated’ paradoxical wisdom. All examples were inferred: “I consider every cloud has got a silver lining so if the accident hadn’t have happened I wouldn’t be doing what I’m doing now which I absolutely love” i.e. out of losing everything has emerged gaining something of great value. Also note the continued use of metaphor Wisdom and paradoxical wisdom = new networks NDD SD PD LA SPD DSH EPE AD

22. New Directions Discovery and Discovery of Success Heuristic Navigational Discovery Wisdom and paradoxical wisdom = new networks NDD “..it’s the kind of work that I do that has enabled me to start building a whole new life that’s brought me in. So actually I’m enjoying life and accepting who I am as I am” 3:1018-20 “I’d like to practice EMDR with people. I’d like to treat people for trauma in the future. At the moment I’m still in my old trade as a plasterer and I’m quite good at that still, but I do realise that I can’t sort of stay in that position so I’m at the crossroads at the moment…” 4:696-9 SD PD LA SPD DSH EPE AD

23. Social Discovery Navigational Discovery “I found people did the same as I did and go into complete overload so I tend to give them the advice on the experiences that I have had…” 1:868-70 “I know it sounds really awful, but it just makes you wonder whether things happen for a reason. I mean now she’s living in the countryside and my other sister goes round and is a carer for her and the relationship we have with her now is a lot better. We’re a lot more closer to my sister, without a doubt I think we all are closer in general” 6:309-13, 57-8 “I’m much closer to my immediate family now than I probably ever have been. I appreciate the people around me and I’m less of a self-determined person. I look at things as a as a group rather than an individual…” 17:274-6 Wisdom and paradoxical wisdom = new networks NDD SD PD LA SPD DSH EPE AD

24. Personal Discovery Navigational Discovery Wisdom and paradoxical wisdom = new networks NDD “…from a healing point of view… magical… absolutely magical and the connection’s so much better and it’s given me the biggest biggest bonus of all, it’s given me time to work on my spiritual growth and development…” 3:785-7 “It came about as a direct result of that EMDR and I’ve figured out that I it wasn’t a self-blame thing I figured out that I probably didn’t actually know people that well or recognise the signs of people’s physiology so I thought I’d embark on a course of discovery if you like…” 4:418-21 SD PD LA SPD DSH EPE AD

25. Life Appreciation Navigational Discovery Wisdom and paradoxical wisdom = new networks “It has made me look at my life and how I deal with life on a daily basis. I now take each day as it comes and look for positives in my live and in other people.” 15:334-6 “I suppose that’s another positive, I’m definitely more wary I’m still a bit worried about driving over little animals and things…” 6:591-2 “…if my arm was on the window then I would have lost my arm. I do value, I think I do value life more now than I did before…” 9:165-7 NDD SD PD LA SPD DSH EPE AD

26. Spiritual and Philosophical Discovery Navigational Discovery Wisdom and paradoxical wisdom = new networks NDD “I think the intention of the accident was actually to propel me on my spiritual path” 3:1056 “I can remember saying to her, or thinking, yes I would really like the opportunity to be able to spend more time on my spiritual growth, and within 10 years I had the accident which was why when I woke up in the car it was just [clicks fingers] yea you know, this is it, it was like great and because I couldn’t work, then I could allow myself to do what I really wanted, which was my spiritual growth.” 3:1064-9 SD PD LA SPD DSH EPE AD

27. Expression of Positive Emotions Navigational Discovery “I’ve never had any anger, everyone’s said you must have been angry: look what it’s caused you it’s made you lose all this that and the other. I have honestly hand on heart never had any anger to that man because even when I first surfaced after the accident I knew it was meant for a reason I just had that feeling this is intended it’s obviously meant to happen and he was actually an instrument in giving me a gift rather than something that’s destroyed me life...” 3:1046-51 “Well I can’t fault the NHS well I mean I was taken in an ambulance to the hospital I saw the first available nurse practitioner who gave me a very thorough going over and would not let me leave until my blood pressure was down and he had to take it 4 times before he was happy with it he was superb…” 14:335-8 Wisdom and paradoxical wisdom = new networks NDD SD PD LA SPD DSH EPE AD

28. Aspirational Discovery Navigational Discovery “I look at life completely differently and certainly from my competitive aspect. I think I’ve become much more focussed because I want to do so much more including represent my country at the 2012 Olympics…” 17:278-80 “I would dearly love to teach people what I’ve learnt…” 3:1176-7 “Every step I take along that road is more of a realisation of an ambition and a dream…” 17:523-5 Wisdom and paradoxical wisdom = new networks NDD SD PD LA SPD DSH EPE AD

29. Implications for EMDR practice The Five Golden Rules: • Always be aware of where you are in the trauma recovery process (the context) and be mindful of which EMDR phase you are in • Just as phase 4 always comes before phase 5, never lose sight that pain and suffering always precedes positive outcomes • The first role of healthcare, including EMDR, is and will surely remain, the relief of suffering • Never minimalise suffering or reason that suffering is worth the growth that is sure to come • The EMDR therapist’s role is a facilitator of change, never regard positive outcomes as an imperative, but as a bonus

30. Implications for EMDR practice Phase 1: Implications for History taking: • How is the client giving their history? • Are they using metaphors, similes, idioms or other forms of figurative language? • Have you identified secondary traumas? • Are secondary traumas seemingly more significant to the client than the RTA itself? • What is the client describing in the post RTA narrative? • Are they describing assets, strengths, resources, indications of resilience? • Do they recognise their successes in these areas? • Is the client describing blocks to progress in the navigational struggle? • Are there indications of growth already on which to build further?

31. Implications for EMDR practice Phase 3: Implications for Assessment: • Be mindful that the PC identified in this phase will be a ‘level one’ PC – in other words a PC that is ‘just about feasible’ given the strength of the NC and the negative emotions involved • Give positive reassurance for identifying the PC even at this level • Remember that despite the client’s efforts you will not be revisiting the PC until phase 5 Assessing the future template: • What is the future template? Is it merely a return to a pre-RTA scenario or something partly or entirely different? • Does the client change the future template for a stronger version? • Does any version of the future template resemble realisation of wisdom?

32. Implications for EMDR practice Phase 5: Implications for Installation: • Remember: “The installation phase… appears pivotal for the comprehensive positive therapeutic effect” (Shapiro 2001, p74) so any positives emerging won’t be down to EMDR if the installation phase has been omitted. • Reassessing the PC at the start of the installation phase should give a ‘second level’ PC • Extensions of the VoC might be illuminating – why stop at 7? “aim for VoC of 6 or 7 or more if it continues to strengthen” (Shapiro 2005, p169) • Try reviewing the PC for a third time once you have reached a VoC of 7. Is there a third level PC to install? Or even higher level? Example of three levels of same PC: • Level 1: I can learn to succeed • Level 2: I can succeed / I am a success • Level 3: I will succeed, and grow further / more than I know etc.

33. Implications for EMDR practice Phase 8: Implications for re-evaluation: Experience suggests that clients will tend to be focussed on what is no longer negative unless specifically asked what is happening that is positive: • What is the client doing that is new, especially totally new, between sessions? • Instead of focussing purely on resolution of symptoms what indications are there that the client is, as Simon Weston (2003) puts it, “moving on”? • Have you “empowered (the client) in the present (so that he/she is) able to make choices for the future” (Shapiro 2001, p.202)?

34. Summary • ‘PTG’, albeit dubiously named, is a real phenomenon but is entirely missed by ‘the negative only’ orientation of evidence-based practice • The ‘total beneficial outcome’ of EMDR (and probably other treatments) is being consistently underestimated because of the focus on ‘the negative only’ • Authors acknowledge that what is referred to as ‘PTG’ stems more from the subsequent struggle than the trauma (see Tedeschi & Calhoun 2004, p414-5). However PTG as defined by Tedeschi & Calhoun may not adequately describe what happens following EMDR. • As a consequence, ‘Navigational Discovery’ is suggested as better able to catch the essence of the processes involved – at least in post RTA trauma • EMDR is unique in having a ‘standard-as-positive’ component (the Installation phase), embedded within the basic protocol • EMDR routinely accesses networks during the free association component and interweaves, and in doing so, creates new networks

35. Summary • Accessing networks, modifying them and creating new ones, specifically when focussed on the Positive Cognitions used in EMDR, are the precursor to ‘Navigational Discovery’. It seems likely that the first suggestion of this process is the amount of figurative language used throughout, the roles of secondary traumas (small ‘t’s) and hindsighting all of which precede wisdom. • Likewise, Navigational Discovery first manifests itself as wisdom but may not be obvious until a ‘realisation’ of wisdom takes place such as life appreciation, helping others, expressions of positive emotions etc. takes place. • Navigational Discovery is often ‘invisible’ to clinicians because clients have long since been discharged. • Navigational Discovery, unlike negative outcomes may prove to be a multi-dimensional phenomenon, quantification of which, is likely to need long term follow-ups conducted longitudinally as the ‘realisation of wisdom’ takes time. Even then aspirations of growth may still occur.