Target lists, treatment plans, and the three-pronged protocol
Part Three: the Three-Pronged Protocol
One of the most challenging aspects facing newly trained EMDR clinicians is how to organize the information they learn in phase one of the EMDR 8-Phase protocol — history taking. To help, this three part series looks at how to coordinate target lists, treatment plans, and the three pronged protocol.
Part Three: the Three-Pronged Protocol
The first part in this series looked at the nuts and bolts of how to create symptom informed target lists. In part two, we examined key points in designing a treatment plan that best meets the needs of our client. Now, in part three, we will discuss Shapiro’s Three-Pronged Protocol and how to reprocess the past, present, and future within a single target list.
But first, a brief review
As a quick recap — we began our work by learning how our client’s symptoms connect to their past experiences, present day triggers, and future goals; from this, we created symptom-informed target list(s); and, finally, we decided on the best course of action, by creating a treatment plan that prioritized the target list that would give the client the greatest symptom relief. Along the way, it is important to note, that we also must consider the client’s preparation needs and adjust the pace and path to ensure that our client meets readiness criteria prior to beginning the work of reprocessing.
The Standard Three-Pronged EMDR Therapy Protocol
With our prioritized target list in hand, we now need to decide how to begin. According to Shapiro (2018) in Eye Movement Desensitization and Reprocessing [EMDR] Therapy, Basic Principles, Protocols, and Procedures:
While the standard EMDR procedures take place during each reprocessing session, the standard three-pronged EMDR therapy protocol guiles the overall treatment of the client…the generic division of the targets are….(1) the past experiences that have set the foundation for the pathology, (2) the present situations or triggers that currently stimulate the disturbance, and (3) the positive templates necessary for appropriate future action (p. 71).
What Shapiro is proposing is that we work within a single target list (cluster) in the following order:
- PAST: we begin by reprocessing disturbing memories that laid the foundation for the client’s current symptoms.
- PRESENT: after we have reprocessed all relevant past experiences, we move on to reprocessing those present day situations (either external events or internal cues) that trigger the related symptoms.
- FUTURE: we complete the cluster by reprocessing future experiences for which the client holds any anticipatory anxiety.
The PAST — where it all began
If you’ve ever taken one of my trainings, or worked with me in consultation, you’ll know that I’m a fan of metaphors. In explaining to clients why we need to start ‘where it all began’, I love to use the metaphor of a cut that has become infected because it holds a piece of dirt. If the client comes to therapy with an infected cut, which, in this metaphor, would be the symptom, we can treat the cut with an antibiotic cream and cover it with a band aid, much in the way that, as therapists, we might only focus solely on the client’s symptoms. However, because there exists a piece of dirt lodged down at the core, the wound will never truly heal until we open it up and begin to clean out the dirt. The ‘opening up’ of the wound is the work of phase three — assessment of a target; while the task of ‘cleaning out the dirt’ is phases four, five, and six — reprocessing of a target.
Organizing the past
When reprocessing past memories on a target list, one of the most efficient ways to work is to reprocess: FIRST, WORST, and REMAINING. What this means is that we begin by reprocessing the earliest memory on the list. We do this to clear the disturbance where it originated. Once complete, we then reprocess the worst experience on the list. The argument for doing the ‘worst’ second is twofold: one, desensitizing the worst event will often have a powerful generalization effect that lowers the disturbance level of other memories on the list; and two, by tackling ‘the big one’ early on, you eliminate the elephant in room and free the client from knowing that the worst is yet to come. Following the successful reprocessing of the worst memory, we then reprocess any memories from list that remain disturbing — we work with these in chronological order.
By way of example
If we refer to the client example from parts one and two of this series, you’ll recall that the client had two target lists — one with a negative belief of ‘worthlessness’, and the other with a ‘dog phobia’ — and we decided to work with the ‘worthlessness’ cluster first because reprocessing those experiences (past, present, and future) would give the client the greatest symptom relief.
Symptom Informed Target List — worthlessness
|Date or age
|Dad spanking me in public for wetting pants
|Shame and self blame
|First day of kindergarten — left on my own
|Anxiety and feeling I didn’t belong
|Little league tryouts — dad screams in the car, then hits me at home
|Fear, shame, I’m not good enough
|Bullied on playground at school
|First time bullied — it happened for two years
|Dad gets drunk and gives me a black eye
|Can’t apply for the ‘good’ job — take the lesser one instead
|I’m not good enough
|Tried to ask for a raise — chickened out
|Not good enough and fear of what boss will say
|Passed for promotion because I didn’t step up
|** most recent memory
Following the FIRST, WORST, and REMAINING template, we would create the following treatment plan for reprocessing of this target list:
- Age 3 ‘Dad spanking me in public for wetting pants’ (FIRST)
- Age 17 ‘Dad gets drunk and gives me a black eye’ (WORST)
- Age 5 ‘First day of kindergarten — left on my own’ (REMAINING #1)
- Age 9 ‘Little league tryouts — dad screams in the car, then hits me at home’ (REMAINING #2)
- Age 13 ‘Bullied on playground at school’ (REMAINING #3)
- Age 24 ‘Can’t apply for the ‘good’ job — take the lesser one instead’ (REMAINING #4)
- Age 26 ‘Tried to ask for a raise — chickened out’ (REMAINING #5)
- Age 30 ‘Passed for promotion – didn’t step up ‘ (REMAINING #6)
While this would be the initial plan for reprocessing, we want to keep in mind that things may change along the way. For example, some of the remaining memories might not need to be reprocessed because they are no longer disturbing when we get to them. Or, perhaps, new memories have surfaced that need to be added to the list in the appropriate (chronological) place. Whatever the reason, bear in mind that target lists and treatment plans are not set in stone — we always adjust according to the needs of the client.
The PRESENT — current triggers and disturbances
Once the past has been fully reprocessed, we then move to the present situations that trigger the client’s residual symptoms. While we have taken a list of current triggers and experiences at the onset of treatment, we want to be sure to update this list along the way. At the start of each session, as we check-in with clients about the past week (think: phase 8 re-evaluation), we pay special attention to how the client’s current symptoms and triggers are evolving. By the time we get to the second prong of reprocessing the present, things may well have shifted. This is why, before we reprocess present situations, we want to check-in with the client to see what currently remains disturbing, and modify the original list of current triggers, as is appropriate.
Turning again to our client example, here is the list of triggers that relate to the target list of ‘worthlessness’:
-Social gatherings with unfamiliar people
-Seeing groups of teens (especially males) gathered together in public
-Presenting at meetings, especially if C-level people are present
-Speaking to boss one-on-one or in a group
-Thinking about applying for a promotion or better job
To organize this list for reprocessing, we can ask the client to rank the triggers in order from most-to-least disturbing or problematic. We then select the most disturbing trigger, and ask the client to think of the most recent example of that disturbing situation. We then target the recent experience of the trigger by using the standard protocol.
By way of example, let’s say that ‘Seeing groups of teenagers (especially males) gathered together in public’ is the most cumbersome experience that triggers the client’s symptom of anxiety. To begin, we ask, “What is the most recent experience, say from the past week, when you felt anxiety upon seeing a group of teens gathered in public?”. The client’s response will provide a target for reprocessing this current trigger.
The FUTURE — anticipatory anxiety related to future events
The third prong of the three-pronged protocol involves reprocessing future experiences, either planned or imagined, for which the client holds anticipatory anxiety. I like to think of the future prong as an EMDR dress rehearsal for achieving goals and living a fuller life, unencumbered by the past.
To create the list of future targets, we can draw from the client’s initial therapy goals, as well as their current triggers, and any other actual or imagined future experiences that the client deems important.
A possible list of future targets for our example client might be:
- An upcoming social gathering
- Being in public and in the presence of a group of teenage boys
- Presenting at a future meeting
- Speaking to the boss
- Applying for a better job
To reprocess future targets, we use the Standard Future Template, which is almost identical to the standard script for reprocessing past events. The only difference is with the language used when referring to the target memory during reprocessing. Meaning, any time we would normally ask about ‘the past event’, we modify the verbiage to reflect a ‘future event’ or ‘imaged future experience’. Other than these semantic shifts from past to future, the work of reprocessing future events is the same as with past experiences.
Cleared for take-off!
Once you have completed reprocessing of all three prongs — past, present, and future — within a single target list, you are ready to shift the focus of attention to other tasks. If your client has another target list, such as the ‘dog phobia’ cluster from our example client, you would follow the same three-pronged protocol to work through that specific list. If the client does not have another target list, the two of you might discuss the next best step — is there more work to be done, or is now the time to consider a thoughtful end to regular treatment? Whatever the answer, we collaborate with our clients to do what is best for them at that moment in time, remembering that, throughout this process, there are no right or wrong answers, only possibilities.
Stay in touch!
I hope that you have enjoyed and benefited from this three part series on target lists, treatment plans, and the three-pronged protocol. Please do get in touch if you’ve any questions or comments regarding this work. We are always happy to hear from you!