The%20Range%20and%20Diversity%20of%20Post%20Traumatic%20Growth%20(PTG)%20following%20EMDR%20for%20involvement%20in%20a%20Road%20Traffic%20Accident%20(RTA)

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 Sciences College
  of Medical and Dental Sciences, University of
  Birmingham
• 2009 EMDR UK Ireland Association Conference,
• Manchester

2
What is PTG?

• What it isnt
• 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 (OLeary 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 arent 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 isnt 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 hadnt 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
  doesnt involve clunk clicking and the
  orthobionomy which is a muscle balancing
  technique 3238-40
• 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 353-6
• It was like having a traffic jam in me head. If
  youve 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 wouldnt come, thoughts wouldnt come, and
  then I would have to back off it and shut it
  down for a long time 3107-114
• Most people I suppose are geared towards growth
  and enlightenment 4403-4
• You dont know whats round the corner I mean we
  never thought we would be going down on that
  train then ending upside down in the car
  6571-3xamination

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
  its 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 Im totally messed up 3213-6
• 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 hadnt 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 thats released it
  would come straight down. Well if it had it would
  have come straight through the windscreen and
  guillotined me 1170-9
• 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.
  1377-9

15
Examples of Hindsighting

• Well I didnt really know a great deal about it
  obviously because Ive never been in an accident
  before and the traumatic bit I didnt really
  expect it to be as bad as what I thought the word
  trauma meant 197-9
• Id been driving a number of miles for the last
  7 plus years and you know, you get a little bit
  blasé 1725-7
• 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 10412-3
• 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 dont be ridiculous I see it everyday
  and... I was surprised that I was affected so
  badly. 1276-9

16
Where does PTG start?

• Tedeschi and Calhoun (1995) contend that wisdom
  is a process leading to PTG, but surely wisdom
  wouldnt have occurred without the trauma and it
  isnt a negative outcome.
• Consider the following example
• if theres 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 youve
  actually been through it you can have all the
  sympathy in the world but no empathy and no real
  understanding 31108-11
• 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 1492/3

17
Data analysis overview
18
PTG becomes Navigational Discovery
Comparison with PTG (Tedeschi Calhoun 1995)

• 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

• 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 1492/3
• 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
4664-6 I would definitely recommend the EMDR
treatment that I had, definitely. It improved how
I was feeling before, I cant really recommend it
enough 6617-9 ----------------------------------
--------------------------------------------------
- No instances of stated paradoxical wisdom.
All examples were inferred I consider every
cloud has got a silver lining so if the accident
hadnt have happened I wouldnt be doing what Im
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
..its the kind of work that I do that has
enabled me to start building a whole new life
thats brought me in. So actually Im enjoying
life and accepting who I am as I am
31018-20 Id like to practice EMDR with
people. Id like to treat people for trauma in
the future. At the moment Im still in my old
trade as a plasterer and Im quite good at that
still, but I do realise that I cant sort of stay
in that position so Im at the crossroads at the
moment 4696-9
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
1868-70 I know it sounds really awful, but it
just makes you wonder whether things happen for a
reason. I mean now shes 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. Were a lot more closer
to my sister, without a doubt I think we all are
closer in general 6309-13, 57-8 Im much
closer to my immediate family now than I probably
ever have been. I appreciate the people around me
and Im less of a self-determined person. I look
at things as a as a group rather than an
individual 17274-6
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 connections so much
better and its given me the biggest biggest
bonus of all, its given me time to work on my
spiritual growth and development 3785-7 It
came about as a direct result of that EMDR and
Ive figured out that I it wasnt a self-blame
thing I figured out that I probably didnt
actually know people that well or recognise the
signs of peoples physiology so I thought Id
embark on a course of discovery if you like
4418-21
SD
PD
LA
SPD
DSH
EPE
AD
25
Life Appreciation
Navigational Discovery
Wisdom and paradoxical wisdom new networks
NDD
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. 15334-6 I suppose thats
another positive, Im definitely more wary Im
still a bit worried about driving over little
animals and things 6591-2 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 9165-7
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
31056 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 couldnt work,
then I could allow myself to do what I really
wanted, which was my spiritual growth. 31064-9
SD
PD
LA
SPD
DSH
EPE
AD
27
Expression of Positive Emotions
Navigational Discovery
Ive never had any anger, everyones said you
must have been angry look what its caused you
its 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
its obviously meant to happen and he was
actually an instrument in giving me a gift rather
than something thats destroyed me life...
31046-51 Well I cant 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 14335-8
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
Ive become much more focussed because I want to
do so much more including represent my country at
the 2012 Olympics 17278-80 I would
dearly love to teach people what Ive learnt
31176-7 Every step I take along that road is
more of a realisation of an ambition and a
dream 17523-5
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 therapists 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 clients 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 wont 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

1. PTG, albeit dubiously named, is a real
   phenomenon but is entirely missed by the
   negative only orientation of evidence-based
   practice
2. The total beneficial outcome of EMDR (and
   probably other treatments) is being consistently
   underestimated because of the focus on the
   negative only
3. 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.
4. As a consequence, Navigational Discovery is
   suggested as better able to catch the essence of
   the processes involved at least in post RTA
   trauma
5. EMDR is unique in having a standard-as-positive
   component (the Installation phase), embedded
   within the basic protocol
6. EMDR routinely accesses networks during the free
   association component and interweaves, and in
   doing so, creates new networks

35
Summary

1. 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
   ts) and hindsighting all of which precede
   wisdom.
2. 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.
3. Navigational Discovery is often invisible to
   clinicians because clients have long since been
   discharged.
4. 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.