1 “When a child enters the clinic he or she is a patient. How do we view that child? More importantly, how can we be certain that we are not addressing the future Secretary General of the United Nations or, from the vantage of the future, a revered person from history?” (Attributed to Nelson Mandela)

2 Two re-presentations of conferences papers: Updated version of: Blore DC., (2009) What happens after successful EMDR? Post Traumatic Growth becomes ‘Network Growth’. 10 th EMDR Europe Conference, Beurs van Berlage, Amsterdam, The Netherlands -June 2009 Blore DC., (2011) Which, how and why memory networks combine: A Plasticity of Meaning (PoM) extension to Adaptive Information Processing. Research symposium, EMDR UK & I Association Conference: Bristol, UK - March 2011 Both are derived from the author’s PhD thesis: An IPA investigation into PPC including PTG, for RTA experiences treated with EMDR

3 What happens after successful EMDR? Post Traumatic Growth becomes ‘Network Growth’ David Blore Research symposium: EMDR Europe Conference: Amsterdam, the Netherlands - June 2009

4 Observation  What do we know of the eventual outcomes to any psychotherapeutic outcome?  EMDR clinicians rarely get to see what actually happens in the weeks, months and even years following the installation of positive cognitions…  …this is hardly surprising given the understandable objective of healthcare to reduce the suffering of negative symptomatology… but this has given rise to a ‘lop-sided’ view… recognised y Maslow over 50 years ago…

5 Research questions  What is the lived experience of clients who have been in a traumatic experience, subsequently undergone a course of EMDR and experienced ‘positive’ outcomes?  How did they get there?  What can be learnt about the role of EMDR in that process?

6 Methodology  Phenomenological investigation of Road Traffic Crash victims, who had reported ‘positive’ outcomes subsequent to receiving EMDR  Snowball recruitment of participants via treating EMDR clinician resulted in n=12 interviews of “experiential experts”  An Interpretative Phenomenological Analysis (IPA) framework for data analysis to facilitate the generation of hypotheses

7 6 7

8 Results  1589 Second hermeneutic ‘summary phrases’  Generating 19 ‘Sub themes’  Clustering into: –2 ‘Super-ordinate’ themes and –1 ‘Over-arching theme’

9 Collated findings grouped by super-ordinate theme 9

10 Why ‘Navigational Struggle’ ?  Themes that make this category effectively describe the individual’s ‘battle’ to get from the traumatic event to some semblance of normality and the ‘route’ taken had to be ‘navigated’

11 Why ‘Network Growth’ ?  Because channels of associations (networks) are expanding, or as Maslow would put it: –“…his potentialities, his virtues, his achievable aspirations and his full psychological height…” are being achieved

12 ‘Figurative Language Use (FLU)’  “Metaphor depends largely on encyclopaedic knowledge” (Griffiths 2006)  Encyclopaedic knowledge = myriads of networks  The individual who has been traumatised finds their existing networks unable to cope with the reality of what has happened (see Solomon 2004 re socially acquired FLU)  To comprehend what has happened, the individual generates new networks (about 25% of FLU related directly to the RTC/ driving/roads etc.…)  …of which a proportion seemed to be grounded in the RTA experience!

13 Related to the RTA itself or an RTA in general Related to the road, road conditions etc. (instances cited involve the word ‘track’ are interpreted as ‘racing track’) Related to a vehicle, its maintenance, or component of the vehicle Related to driving? Positive impact/ impact on other people/ a significant impact/ the actual impact Crashed every 5 minutes (computer)/ bloody thing kept crashing / cause it to smash I was a wreck Hit me a few months down the road A push-over / bump it up Cut my Dad up Knock-on effect The last brick in the wall (inevitability of the RTA) Solicitors blew it out of the water (RTA was in a swamp) Trying to clutch at straws (describes accident site) Spin-off of the RTA Don’t go down the road of…/ taking a dangerous route Resistant to going down the road/ Going down the road Went downhill from there On the crossroads at the moment/ at a crossroads in my life I turned a corner in January/ come round a corner/ what’s round the corner? Bypassing orthodox medicine Verging on strange things In a roundabout fashion Light at the end of the (road?) tunnel What’s that person doing across the road? Fast tracked for promotion Traffic jam/ come to a full stop Slippery conditions One way (to do things)/ No way I want to survive this I’m the Mark 2 version Vehicle to social reintegration/ No vehicle to do this (mentions wing mirror and then adds)… ‘but looking back’ Over-inflated opinion (tyres) There was the imaginary brake/ put the brakes on (brakes) Bleed it off (brake fluid) Clutch at straws (the clutch) Get behind a wheel (steering wheel) My neck locks up (steering) Geared towards growth/ geared towards helping people/ Brain not in gear as much (gearbox) Osteopathy doesn’t involve clunk clicking (old seat belt advertisement) Propel me forward spiritually Full MOT (to describe a full examination in hospital) He fixed me Taken on board I’ve been kick started Up and running/ running a home and workshops Became more driven/ driving people away/ had the drive in me/ drove us out one way I started to go downhill Sit on the tail of other drivers Pull yourself up/ in a traffic jam My neck locks up Demonstrates hand signal In a safety zone A glass too many (drunk driving) Keeping an eye on the road Pace myself Those who have pushed themselves

14 ‘Figurative Language Use (FLU)’  EMDR is about connecting networks –Dysfunctional/ traumatic memories linked to an adaptive network –Cognitive interweaves acting as ‘bridge’ between networks –Insights –…and just possibly every time the client uses a metaphor to explain something that can’t be explained literally ”Metaphor is a neural phenomenon… neurons that fire together wire together ”Metaphor is a neural phenomenon… neurons that fire together wire together ” (Lakoff & Johnson 1980)

15 Where to next?  8 Conceptual models of positive change (O’Leary et al 1998) were reviewed to see if they could describe the positive changes reported after EMDR – none fitted – most had helpful elements.

16 NG component themes (this study) Approximate equivalent: PTGI subscales (Tedeschi & Calhoun 1996) Comments on differences HINDSIGHTING No equivalent subscales Theoretical differences as wisdom considered to be a product of growth and thus not part of PTG, (Tedeschi & Calhoun 1995 p. 86-7) PARADOX FORESIGHTING DEVELOPMENT of SUCCESS HEURISTIC NEW POSSIBILITIES IN LIFE DSH is more akin to Maslow’s (1943) self actualising tendency or OVT’s completion tendency (Joseph & Linley 2005) EXPANSION of SOCIAL NETWORKRELATING to OTHERS ESN has more emphasis on expansion rather than purely relating SPIRITUAL and PHILOSOPHICAL DEVELOPMENT SPIRITUAL CHANGE SPD has less to do with religion and more to do with personal philosophy (e.g. Frankl 1963) APPRECIATION of LIFE Roughly equivalent to each other GRATITUDE for the LITTLE THINGS in LIFE No equivalent subscales Probably included within APPRECIATION OF LIFE ASPIRATIONSTheoretical differences Comparisons between component themes of Network Growth from this study and Tedeschi & Calhoun’s (1996) PTGI subscales representing Post Traumatic Growth as defined

17 Where to next?  A model is thus needed to adequately describe the lived experience of positive outcomes after EMDR for psychological trauma – preferably one that uses Adaptive Information Processing (AIP) as a foundation…  The ‘Network Growth’ model ‘takes root’ here…

18 Figurative Language Use RTA The ‘Network Growth’ model to explain positive outcomes following EMDR (Blore 2009)

19 Conclusions and some implications for EMDR practice  EMDR treatment outcomes are considerably more than merely a reduction in negative symptomatology or resolution of diagnostic entities  Assessment of positive assets should be included as routine in history-taking  Secondary traumas were frequently cited in the ‘ navigational struggle ’ after the road crash by those developing positive growth.  25% of metaphor use related to the trauma itself suggesting adaptive meaning-making as per AIP model and therefore growth started within treatment itself

20 Conclusions and some implications for EMDR practice  PCs could be usefully viewed as ‘ incremental ’ in nature to facilitate further reassessment of the PC at the end of the first cycle of the installation phase. Installation should continue until this process is exhausted. This may result in the need for an ‘ incomplete session ’ protocol for Phase 5.  ‘ Post Traumatic Growth ’ (PTG) is too restricting a label to fully describe the lived experienced of positive outcomes following EMDR … instead ‘ Network Growth ’ is proposed to describes the ‘ invisible ’ (i.e. adaptive network expansion occurring during EMDR) and ‘ visible ’ (akin to the ‘ visibility ’ of PTG thereafter) processes involved in EMDR positive outcomes

21 Which, how and why memory networks combine: A Plasticity of Meaning (PoM) extension to Adaptive Information Processing David Blore Research symposium: EMDR UK & I Association Conference: Bristol, UK - March 2011

22 Introduction … This presentation on an AIP ‘ hypothesis expansion ’ was derived from a study which investigated Positive Psychological Change (PPC) (including PTG) after EMDR for RTA experiences.

23 EMDR is a client centred approach and the basic EMDR protocol incorporates a positive cognition installation … as standard So why isn ’ t AIP more explicit about PPC?

24  What do we know about what happens as a result of this installation? Not a great deal … partly because: Presumably PPC occurs well after the client ’ s discharge and Presumably to be accepted, EMDR had to prove it ’ s ‘ negative- reducing ’ credentials  However, are these assumptions correct?

25 So what does AIP say about PPC? AIP hints at PPC, but doesn ’ t predict very much: EMDR results in “… forging new associations within and between memory networks. ” … not to be confused with Reduction in Negative Psychological Change (RNPC) e.g. numerous references to “ self healing ” … so what ’ s the difference?

26 The presenter ’ s research in a nutshell …  An IPA study using a snowball sample of 12 participants interviewed to investigate PPC, post RTA, post EMDR  Results indicated psychological ‘ change ’ is not a unitary phenomenon that evidence-based research would have us believe, but …  There is a fairly consistent change process roughly: T > NPC > NPC ↓ > PPC ↑ > PPC max  However, clinicians necessarily expect, and are asked to focus on: T > NPC > NPC=0

27 The results: themes constituting ‘change’… Navigation Struggle (=NPC) Assumptive world and struggle with assumptions; Spirituality to resolve struggle; Hankering; 2ndry traumatic experiences; Struggles to cope with NPC and to gain control of readjustment Network Growth (=PPC) Hindsighting, Paradox and Foresighting. Development of success heuristic; Expansion of social network; Personal and Spiritual development; Appreciation of life and Gratitude; Aspirations Not directly either NPC or PPC FLU and NDFLU More on these findings can be found at:

28 A unifying method of conceptualising ‘change’… Key:Predominance of yin i.e. NS Predominance of yang i.e. NG A Taoist framework for conceptualising change from the onset of NPC to maximum PPC

29 An IPA The frequency of FLU throughout the 15 SSIQs

30 “It’s almost like somebody puts a pair of spectacles on you and you go from this half blurred vision and knowing that people are there, to some sort of clarity… I think I’ve become much more focussed.” ( ‘ Robert ’ : lines 261-3, 279) Assumption: FLU is an observable result of PoM Analysis of FLU…

31 A Plasticity of Meaning hypothesis extension… [1] Current network being expressed by ‘Robert’: Family [2] ‘Robert’ encounters difficulty expressing a concept [3] Concept held in the body/emotions prior to ‘word search’ [4] ‘Robert’ searches memory networks to overcome expressive difficulty [5] Networks have an idiosyncratic hierarchy depending on what is important to the individual Most important / readily accessible network(s) win ‘competition’ for access [6] ‘Trading’ occurs once network selected. Sight correction/Eyesight ‘feels right’. PoM occurs [7] Family and Sight correction/Eyesight networks are now adaptively linked [8] Sight correction/Eyesight network exports literal contextualised words, which are imported by Family network. The transfer from literal to figurative is PoM. The use of imported words in their new network is FLU [9] ‘Robert’ now able to describe concept in FLU terms and apply to Family network [10] Further expressive difficulties [11] Direct trading until insurmountable expressive difficulty encountered “Neurons that fire together wire together” Lakoff & Johnson (1980/2003, p.256)

32 PoM at a glance  PoM is built on and is consistent with the foundations of AIP  PoM predicts individuals are driven to find meaning and to express that meaning  Expressive difficulties are stored in the body (the ‘ expressive default ’ )  Expressive defaults trigger concept/word searches  The network requiring words is the ‘ consumer ’ network  The located network with a literally held word is the ‘ supplier network ’  ‘ Trading ’ words requires a word to be shared between the supplier network (literal usage) and the consumer network (figurative usage) – the result is a plasticity of meaning and linking of networks – the observable result is FLU  The ‘ rules ’ of trading are governed by idiosyncratic usage See handout for more details

33 Some clinical implications of PoM  It is necessary for each clinician to reflect on whether PPC is a ‘ clinical issue ’  Philosophical underpinning of EMDR more akin to an Aristotelian view of health than the currently held, post-Hobbesian view  ‘ Dual listening ’ during history-taking and feedback in processing phases particularly phase 5  A more balanced perspective on assessing contraindications in phase 1  Vast array of FLU-based interweaves  Potential tiering of PCs  Confronting Hankering, Paradox and Aspirations … all of which will need researching in depth

34 Points to ponder …  Clinical practice is largely evidence based (NICE reports).  NICE reports are universally based on research into RNPC and  PPC isn ’ t part of NPC, then …  Ultimately all evidence based research needs redoing so as to obtain a true reflection of the full capabilities of the treatments it is both recommending and declining!  This won ’ t happen because NICE exists to guide the government on how best to spend money on healthcare the relief of suffering being paramount (Richards 2008, personal communication with presenter - see also Cochrane 1972)  … therefore, it is logical to warn clinicians about relying on NICE reports if they wish to study the total beneficial outcome of a given treatment, especially EMDR …

35  Overall thoughts about the day?  Any questions?  Have personal objectives been met? Conclusions about today ’ s presentations

36 Thank you for listening and your interest ! Contact details: E: W: M: Suite 303 Clifford House 7-9 Clifford Street, York YO1