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 One: Target Lists
This first installation in the series focuses on how to create symptom informed target lists. To begin, let’s look at the connection between a client’s presenting symptoms and their trauma history.
The ‘Symptom + History’ Connection
When a client comes to my office, one of the first questions I ask is “why therapy now?”. Meaning, what brings them in; what do they want ‘more of’ or ‘less of’ in their life — behaviors, beliefs, emotions, somatic sensations, urges, aversions, etc. Their answers will give me a good idea of what symptoms we need to resolve in our work together. Their responses also guide the history taking process.
For every symptom, I ask follow-up questions: “When did the symptom begin?”, “What was going on in your life at that time?”, “How has the symptom evolved (gotten better or worse) over time?”, and “What current experiences trigger this symptom?”. These questions are a launching point for learning about a client’s history, and help keep my focus tethered to the client’s presenting symptoms.
As I listen to their history, I am beginning to formulate a first draft of a target list of memories for future reprocessing — all the while considering which past experiences connect to which current symptoms. Ultimately, I want to be able to organize clusters of past experiences that connect to present day symptoms.
If there is a symptom, such as a belief of being ‘not good enough’, that doesn’t connect with past experiences, I know I need to ask better questions for, as I tell my clients, “Nobody is born believing they aren’t good enough; we have to learn it somewhere along the way.”
Let’s look at an example of a client who comes to therapy with the following symptoms:
- social anxiety
- feelings of worthlessness and the negative belief “I’m not good enough”
- fear of authority figures
- phobia of dogs
After the client has shared this information, I use the follow-up questions (previously described) to ask about the origin, evolution, and current triggers for each symptom. This is the beginning of the history taking process. My goal here is to not only learn about the client’s history, but to begin to connect past events to current symptoms. As with any good detective, I am taking notes and making a list of memories.
Clusters & Symptom Informed Target Lists
Returning to the above example, let’s imagine that history taking reveals that the first three symptoms on the list began at an early age and are related to the client’s experiences with their verbally and physical abusive father. We learn that these symptoms were further exacerbated when the client was repeatedly bullied in middle school, and then, as an adult, passed over for multiple promotions at work — this due to a resistance to taking on more challenging tasks for fear of failure and a general sense of being ‘incompetent and worthless’.
Given this, we can hypothesize that the first three symptoms are part of the same memory network and, consequently, will generate memories that belong on the same target list. This is our first cluster — a grouping of related symptoms, past memories, and current triggers — in this case, the cluster is around self-worth because it is the lack of self-worth which generates the symptoms of 1) social anxiety, 2) feelings of worthlessness, and 3) fear of authority figures.
To keep the work organized, I create a ‘Symptom Informed Target List’ that I use to document individual clusters of memories and current triggers for reprocessing. Here’s an example of what this client’s target list for THIS particular cluster (self worth) might look like:
Symptom Informed Target List — worthlessness
Date or age
|3 y/o||Dad spanking me in public for wetting pants||Shame and self blame|
|5 y/o||First day of kindergarten — left on my own||Anxiety and feeling I didn’t belong|
|9 y/o||Little league tryouts — dad screams in the car, then hits me at home||Fear, shame, I’m not good enough|
|13 y/o||Bullied on playground at school||First time bullied — it happened for two years|
|17 y/o||Dad gets drunk and gives me a black eye||**worst memory|
|24 y/o||Can’t apply for the ‘good’ job — take the lesser one instead||I’m not good enough|
|26 y/o||Tried to ask for a raise — chickened out||Not good enough and fear of what boss will say|
|30 y/o||Passed for promotion because I didn’t step up||
** most recent memory
- Social gatherings with unfamiliar people
- Seeing groups of teenagers (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
This is the client’s first target list; however, if you’ll recall, the client came to treatment with a fourth symptom — dog phobia — that does not relate to this first cluster. Their fear of dogs has little to do with the internal experience of ‘worthlessness’; their fear of dogs is its own, separate cluster.
By asking the symptom follow-up questions during history taking — “When did the symptom begin?”, “What was going on in your life at that time?”, “How has the symptom evolved (gotten better or worse) over time?”, and “What current experiences trigger this symptom?” — I created a ‘dog phobia’ target list of experiences (past and present) that contribute to the fear.
Symptom Informed Target List — dog phobia
Date or age
|5 y/o||Bitten by neighbor’s dog at birthday party||Didn’t see it coming|
|10 y/o||Chased by dog in park – ran on top of parked car||* worst memory *|
|11 y/o||Dogs running off leash at campground||Fear and out of control — not safe!|
|17 y/o||Backyard neighbor’s dog snarling through the fence||Fear, not safe|
|22 y/o||Girlfriend brought dog to sleep over — I didn’t sleep at all — the dog hates me||Fear and confusion|
|27 y/o||German Shepard jumped up at me||
Out of the blue — no control, not safe
- Hearing a dog bark (especially if can’t see the dog)
- Seeing unfamiliar dog in public, especially big ones
- When girlfriend brings her dog over
- Seeing dogs off leash
Separate, but not equal
I hope this information helps you better navigate the waters of how to use the history taking process to create symptom informed target lists. For our example client, we’ve created two separate target lists that distinguish between the past experiences and current triggers that relate to: 1) the feeling of worthlessness, and 2) the fear of dogs.
Our next task will be to determine in which order we begin the reprocessing work — for not all symptoms and their accompanying target lists hold equal weight, urgency, and importance in the lives of our clients. So, stay tuned for the next installment in this three part series: treatment planning.
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Please do get in touch if you’ve any questions or comments regarding this work. We are always happy to hear from you!