By Jeff Dwarshuis LMSW ACSW
A Vietnam Veteran with chronic Posttraumatic Stress Disorder (PTSD) and Major Depression was referred to the writer from the treating staff of a local psychiatric hospital. The veteran had a history of numerous inpatient hospitalizations for PTSD and despite decades of individual, group and psychotropic therapy the client could not find relief from his traumatic memories of Vietnam. The referral source thought Eye Movement Desensitization and Reprocessing (EMDR) could be of benefit. (For a description of EMDR see blog article “Eye Movement Desensitization and Reprocessing”.)
Following an assessment the client agreed to EMDR therapy but due to past treatment failures the client felt hopeless of any change.
EMDR treatment began with complications. During the treatment of the first identified disturbing memory the client quickly responded with intense fear that caused frequent occurrences of nausea. With the treatment disrupted the possibilities for success were in question.
The Puzzle Method
Because of the complications the writer developed “The Puzzle Method” which is an extension of the EMDR Safe Place exercise combined with techniques of Ericksonian Hypnotherapy.
Milton Erickson is the father of modern hypnotherapy and developed a unique method of hypnosis that concentrates on multilevel communication and client capacity. Regarding trace states involving memory he explained that deepening a trance state occurs when the therapist deliberately limits their own helping directives and instead teaches the client to themselves move in and then out of a trance state using their own abilities.
Erickson also taught that client safety is increased when the client has more choice regarding both self disclosure and the extent to which they want to think about something that is disturbing. Within this framework Erickson argued that the client should be given choice about treatment pace and the self disclosure of memory. Based on Erickson’s understanding of client resistance to change he also suggested the therapist intensify the client’s sense of safety by instructing the client to “hold back” from focusing on particular memories thus eliciting the client’s natural opposition which indirectly influences the client to focus more on their memory.
The Puzzle Method combines Erickson’s techniques of self initiated focus and increased safety with the EMDR Safe Place exercise in an effort to increase the likelihood of success for clients dealing with intense reactions to traumatic memories. This is done by telling the client to imagine that the traumatic picture is broken into several pieces like a puzzle and to focus only on a few pieces of the puzzle at one time. If the client becomes emotionally overwhelmed by the traumatic memory they should stop their focus on the memory and return their thoughts to the safe place picture until they feel relaxed. Following the relaxation the client should return their focus to the traumatic memory, focus on a little more than before and continue this process until the whole traumatic memory can be imagined. When using this method the client is in charge of their level of traumatic exposure as well as their level of relaxation.
The client returned to EMDR therapy, followed the steps of the Puzzle Method and was able to successfully reprocess the first memory in thirty minutes without any disturbance of nausea. The client returned to treatment for six more sessions to reprocess other traumatic memories of Vietnam using the EMDR Protocol and the Puzzle Method only when needed. The client ended therapy after seven EMDR sessions with no symptoms of PTSD or Major Depression. Follow up sessions showed a continuation of symptom reduction. The client reported that he had not felt so good since before going to Vietnam.