What is meant by a flashforward? The mental representation of an - PDF document

4/11/2014 1 2 3 What is meant by a flashforward?   The mental representation of an  The mental representation of an  The mental representation of an The mental representation of an unlikely (irrational) future feared unlikely (irrational) future feared catastrophe catastrophe 4 1

4/11/2014 This type of imagery (‘flashforwards’) may be a core Two studies examined whether EMDR affects recurrent, aspect of most anxiety aspect of most anxiety intrusive images about potential future catastrophes g p p (‘flashforwards’) disorders  Two samples of students who suffered from recurrent Two samples of students who suffered from recurrent Vividness distressing intrusive images about impending danger distressing intrusive images about impending danger (n= 28 + n= 37) (n= 28 + n= 37)  Two negative visual images about events they feared Two negative visual images about events they feared might happen to them in the future (e.g., the funeral of a might happen to them in the future (e.g., the funeral of a loved one, being hit by a car) loved one, being hit by a car)  These flashforwards were randomly distributed to either These flashforwards were randomly distributed to either ‘recall with eye movements’ or ‘recall only’ condition ‘recall with eye movements’ or ‘recall only’ condition  Four sets of 24  Four sets of 24 Four sets of 24-s each with 10 Four sets of 24 s each with 10 s each with 10-s breaks in between s each with 10 s breaks in between s breaks in between s breaks in between Recall only Recall + Eye movements Post-test Pre-test Emotionality/V Emotionality/V ividness ividness + EM Emotionality Note that these effects were found after just 96 seconds of j recall + eye movements 2

4/11/2014 IMAGES OF IMPENDING How to do a flashforward? DOOM • Use patient’s flashforward as a target for DISASTER IMAGES processing with the Standard EMDR Protocol • The NC is standard and in the domain of EXPECTED CATASTROPHES control (“I am powerless” (against my flashforward) • Use as standard PC “I can handle this FLASHFORWARDS (image)” How to do a flashforward? Essential elements of a • It is important to create a framework that allows flashforward and enables the patient thinking about the impending doom of the worst case scenario. For example:  A detailed and still picture A detailed and still picture  Contains catastrophic elements of what  Contains catastrophic elements of what Contains catastrophic elements of what Contains catastrophic elements of what • "What we need to figure out is what kind of image is in What we need to figure out is what kind of image is in your mind that makes you fearful about a future might happen in the future might happen in the future confrontation with the thing/the one you fear. What do  Context specific, and conceptually Context specific, and conceptually you fear that will happen, and will go wrong when you are related to client’s symptoms related to client’s symptoms confronted with the situation you are avoiding now? In the worst case. So basically we should look for your ultimate  Intrusive and disturbing Intrusive and disturbing doom scenario, the worst thing that could happen to you. Please make a still picture of that disaster image” Flashforwards: where do they Wat is je vraag aan de patiënt? come from? " “Wat wij moeten uitzoeken is wat je nu vreest dat er gebeurt (of eigenlijk dat er misgaat ) als Fear and avoidance je ……….(met het object of situatie dat men vermijdt wordt geconfronteerd; bijvoorbeeld een j g j vogel ziet). Dus eigenlijk zoeken we naar de vrees, of noem het ‘het ultieme schrikbeeld’, dat je verhindert om te doen wat je wilt doen. Wat is Past events: Modeling expe- Other sources dat?................ [de ramp; de vogel die je aanvalt previous riences: having of negative confrontations seen something information: stories en verwond] . Hoe zit dat rampscenario of with a traumatic happening of others, books, schrikbeeld precies in je hoofd? …..” stressor movies etc. Situations that actually went wrong or nearly went wrong 3

4/11/2014 Spider phobia What do many people (women) fear when they are confronted with a spider? “It (he) will crawl into my private parts… ” 28 29 tarantula-spider-poecilotheria-metallica When to use a flashforward in clinical practice? FLASHFORWARD  If all relevant memories of past events have been fully processed, and it is not possible to find any other memory that is at the root of client’s current symptoms  When the patient still experiences anticipatory fear of confrontations with certain objects or situations 4

4/11/2014 MENTAL REPRESENTATION OF UNCONDITIONED STIMULUS UR A flashforward is FLASHFORWARD not a picture of the CS US person UR experiencing his symptoms US CS TOWER FALLI NG + but SCHOOL VOMI TI NG the actual DENTAL TERRI BLE ANXI ETY disaster image DRI LL PAI N What is possible with a flashforward? Clinical approach: What is in the brain of the client,  A scary fantasy (catastrophe beyond A scary fantasy (catastrophe beyond that needs to be removed to the catastrophe; fear of the dead) or the catastrophe; fear of the dead) or diminish the current (positive) fantasy (positive) fantasy symptomatology?  A ‘feeling’ or ‘physical sensation’ A ‘feeling’ or ‘physical sensation’  Fright (Balloon phobia, bird phobia) Fright (Balloon phobia, bird phobia)  Falling (height phobia) Falling (height phobia) 5

4/11/2014 Balloon phobia Bird phobia targeting targeting the explosion the sudden attack Birds (Hitchcock, 1963 ) Bridge phobia What to do when there is nothing there? targeting  Targeting any mental representation Targeting any mental representation the depth itself that seems ‘key’ that seems ‘key’ Many people experience an inborn susceptibilty for exposure to a height-related stimulus ”Visual height intolerance has a considerable impact on daily life and interpersonal interactions. I t is much more frequent than fear of heights, which is defined as an environmental subtype of a specific phobia. There is certainly a continuum stretching y g from acrophobia to a less- pronounced visual height intolerance, to which the categorical distinction of a specific phobia does not apply.” 6

4/11/2014 Height phobia Height phobia gets conditioned rather easily! Height phobia may be an excellent example of gene x environment interaction Highlights en questions (1) Questions, highlights, • The memories of etiological events first? • What are the potential mental and take home and take home representations to target? messages • Always look for ‘the disaster behind the disaster’ Look for the catastrophe beyond Case # 1 the catastrophe (driving phobia) What could be a potential target? A young woman has a severe fear, and A young woman has a severe fear, and obsession about forgetting to turn off g g obsession about the gas before going out Panic Getting a Crashing Killing an Burning Children attack heart with the innocent in the car left alone Funeral during attack car person without driving parents 58 7

4/11/2014 Mental representation of the (neutral) stimulus situation. Memory from But one in which she does not the past check (exposure and response prevention) Leaving without checking Can we do EMDR, and if so, Mental representation of what might happen what would be an appropriate (go wrong) Memory from FUTURE TEMPLATE when she does not check the past the past target? Explosion? FLASHFORWARD Memory from the past 61 Potential use of flashforwards in Highlights en questions (2) clinical practice • Dog phobia (being attacked by a dog) • Don’t forget the future template! • Dental and medical phobias (extreme pain, being powerless, bleeding to death) • Indications for the use of flashforwards? • Social phobia (being rejected or other embarrassing situation) b i it ti ) • Obsessive compulsive disorder (being contaminated; house in flame) • Body dysmorphic disorder (a negative remark about appearance) • Hypochondriasis (the end phase of a termimal illness) • Psychosis (delusion) Highlights en questions (3) Other examples • Fear of childbirth (death of the • What to do when there are still child) complaints, or avoidance behavior, after the flashforward has been applied the flashforward has been applied succesfuly? • Loss of desire in having sex (painful experience, failure) 8

4/11/2014 Treatment strategy EMDR treatment Fear and avoidance Memories Memories Flashforward Flashforward Future template Future template Video check Video check Behavioral Behavioral Events that Directly on the (des. + install.) (des. + install.) (des. + install.) (des. + install.) (install.) (install.) (install.) (install.) experiment experiment Event that caused worsened the disaster fantasy Future the fear fear (flashforward) template 2 3 1 4 Reprocessing of targets 9