Case conceptualisation and Target Identification

Fascinating musings from our colleague Alan Tidmarsh on Case Conceptualisation and Target Identification – prompted by Mark Brayne Focus webinar Feb 15 2021.

1. Case conceptualisation is the point where the information from meeting the client and taking history distil themselves into working hypotheses about the existence of ‘landmarks’ in the client’s  autobiographical memory – experiences that serve as “reference points for the organization of other personal experiences and thus become important components of the life story and personal identity” (Berntsen, Willert, & Rubin, * 2003, 689).  The working hypothesis needs to be held lightly but is a necessary discipline.
2. Your reference to the de Jong conceptualisation ‘routes’ illustrates the multiple potential access points for these landmarks, however they are notable by the confluence  of four channels – image, somatic, emotional and meaning.  Your disciplined evocation of these four channels at each point during the AI-EMDR process underlines the significance of ‘hot cognitions’ (Greenberg & Safran, 1986).  This ‘core synthesis’ (Van der Hart, Nijenhuis, & Steele, * 2006, 11) provides the experiential foundation from which ‘realization’ can take place.   From a focusing perspective I want to assert that attention to the experiential confluence (Gendlin, * 1978) seems to be a key marker at each stage.
3. You distinguished between targets and portals in the presentation on Monday, emphasising the ‘radical curiosity’ needed in the therapist.  This was an eye-opener for me.  Here you seem to be pointing out at least two probabilities perhaps associated with the particular combination of high significance and high avoidance seen in ‘landmarks’.  One is that most likely the presenting description of the problem may need to be enhanced and deepened experientially – to reach the nub of the matter beyond commonplace language.  The other is the developmental significance – that things are likely to be about an ‘attachment-related meaning’, the ‘absence of repair’, rather than the presenting trauma.
4. EMDR provides the structure that permits previously avoided experiential steps to occur – the ‘transformative emotional sequence’  (Welling, * 2012).  Your case studies seemed to suggest a radical trust in an unknowing process to achieve this – comfortable with surprises by carefully constructing the experiential bridging and attending to its outcome.  Yet you are also pushing us therapists at each point to feel around (‘laser-like’) for the real confluence when the person lands.  Don’t go off half-cock – test out the implicit experiential cogency of the portal so that the exact places of confluence are conserved.  
5. There is an impact of this precision on the processing.  It seems to suggest we need to be wary of extended ‘chains of association’ (Shapiro, * 2018) in a channel.  Presumably they bring an experiential nuance which, once noticed might enrich the core target.  I am hoping for more clarification of your ‘long-petal’ in Unleash II next month.  Just now it is confusing for me – seeming to allow a semi-side step rather than the more solid multiple bridges that may be needed.
6. This approach also seems to allow a better understanding of the processes that interweaves may serve:
   1. A long-avoided encounter with the personal experience of the rupture (‘personification’, Piedfort-Marin, * 2019), inviting the client to bear true witness and, doing so take ownership of it.
   1. Allowing a standing back to attend to the ‘situation as a whole’ (Purton, * 2013), being released from entrapment “where our feelings are living us rather than we living our feelings”, seeing the situation from a present-day perspective (‘presentification’, Piedfort-Marin, * 2019).
   1. Recognising the deficit in rupture repair and experientially trying out what is missing – activating mental representations of secure attachment relationships (Allen, * 2013, 75) reinforced by the therapeutic alliance.

I want to add a further suggestion from focusing – that the invitation after a BLS set might sometimes invite an experiential curiosity beyond what is immediately noticed –  “a matter of giving attention to one’s sense of what one might be able to say beyond what one currently says.” (Purton, * 2011, 13)

• In short I think you are saying:
  • Your job is to seek out the landmark, not being distracted by apparently important intermediate places.
  • Work from and protect the experiential process of the client, testing out the personal significance and richness of what happens with them.
  • Explore to the point where there is confluence and then stand out of the way.

References

Allen, J. G. * (2013). Mentalizing in the development and treatment of attachment trauma. London: Karnac.

Berntsen, D., Willert, M., & Rubin, D. C. * (2003). Splintered memories or vivid landmarks? : Qualities and organization of traumatic memories with and without PTSD. Applied Cognitive Psychology, 17(6), 675-693.

Gendlin, E. T. * (1978). The body’s releasing steps in experiential process. In J. L. Fosshage & P. Olsen (Eds.), Healing: Implications for psychotherapy (pp. 323-349). New York: Human Sciences Press.

Greenberg, L. S., & Safran, J. D. (1986). Hot cognition – Emotion coming in from the cold: A reply to Rachman and Mahoney. Cognitive Therapy and Research, 8, 591-598.

Piedfort-Marin, O. * (2019). Synthesis and Realization (Personification and Presentification): The Psychological Process of Integration of Traumatic Memories in EMDR Psychotherapy. Journal of EMDR Practice and Research, 13(1), 75-88.

Purton, C. * (2011). Being in the world: Felt sense, emotions and bodily sensations. Paper presented at the 23rd International Focusing Conference, Pacific Grove, Ca.

Purton, C. * (2013). Focusing-Oriented Therapy. In P. Sanders (Ed.), The Tribes of the Person-centred Nation: An Introduction to the Schools of Therapy Related to the Person-centred Approach (2nd ed.). Ross-on-Wye: PCCS Books.

Shapiro, F. * (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy : Basic principles, protocols, and procedures (Third ed.). New York: The Guilford Press.

Van der Hart, O., Nijenhuis, E. R. S., & Steele, K. * (2006). The haunted self : Structural dissociation and the treatment of chronic traumatization. New York: W. W. Norton.

Welling, H. * (2012). Transformative emotional sequence: Towards a common principle of change. Journal of Psychotherapy Integration, 22(2), 109-136.