An Adult with Childhood Medical Trauma Treated

2ORIGINAL
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Perspectives
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An Blackwell
AdultUSA ARTICLE
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Publishing
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Inc2006
Childhood Care
Medical Trauma Treated with Psychoanalytic Psychotherapy and EMDR

with Psychoanalytic Psychotherapy and EMDR:

A Case Study
Robert D. Broad, PhD, and Kathleen Wheeler, PhD, APRN

PROBLEM. Adverse childhood experiences have Robert D. Broad, PhD, is a Psychologist/Psychoanalyst in

been found to be a strong predictor of emotional
and physical problems in adulthood. However, the
long-term sequelae for children who have suffered
critical illness and exposure to invasive medical
procedures are less well documented.
METHODS.
who sought treatment for depression and
attention deficit disorder. The psychotherapy
treatment is discussed and the use of eye
movement desensitization and reprocessing
(EMDR) is described targeting a memory of a
medical trauma resulting from a tonsillectomy
when the client was 8 years old.
CONCLUSIONS.
were attained as a result of the therapy, i.e.,
decreased depression, less hypervigilance, and
increased ability to concentrate, which resulted in
the discontinuation of medication for depression
and ADHD as well as significant improvement in
overall functioning.
Search terms: Childhood trauma, EMDR,
psychodynamic psychotherapy
Private Practice, and Kathleen Wheeler, PhD, APRN, is a
Professor at the Fairfield University, School of Nursing,
North Benson Road, Fairfield, CT.
A dverse childhood experiences have been found
to be a strong predictor of emotional and physical
problems in adulthood (Felitti et al., 1998). In a study
This is a case study of an adult client
of almost 10,000 participants in a medical setting,
those with histories of being abused as a child were
found to be at 1.6–2.9 times greater risk for cancer,
chronic lung disease, skeletal fractures, hepatitis,
diabetes, stroke, liver disease, and ischemic cardiac
disease. In addition to these findings, the incidence of
alcoholism, depression, drug abuse, and suicide was
4 –12 times greater than for those without a history of
abuse. Risk factors such as smoking, obesity, and pro-
miscuity also increased significantly for adults who
have suffered trauma as children.
Perry (2002) says that long-term consequences of
childhood trauma include: attachment problems, eat-
ing disorders, depression, suicidal behavior, anxiety,
Significant healing outcomes
alcoholism, violent behavior, mood disorders, and
posttraumatic stress disorder. When left untreated,
childhood trauma contributes to a multitude of physical
and mental health problems throughout the life span.
Researchers have found that trauma causes lasting
neuronal and hormonal changes which shape brain
structures and functioning, which then can have pro-
found effects on all dimensions of development,
social, cognitive, biological, and emotional (van der
Kolk, 2003).
However, the long-term sequelae for children who
have suffered critical illness and exposure to invasive
medical procedures are less well documented. Short-
term behavioral responses have been documented
during hospitalization. It is thought that the severity
of the illness and the developmental level of the child
most likely influence the subsequent responses to such

Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006 95

An Adult with Childhood Medical Trauma Treated with Psychoanalytic Psychotherapy and
EMDR

events. The younger the child, the more seriously ill
and invasive the procedures, the more likely the child
is to have ongoing adverse affects and posttraumatic
stress disorder (Rennick, Johnston, Dougherty, Platt,
& Ritchie, 2002). One study of 43 children from ages
5–12 found that children undergoing cardiac surgery
are at risk for developing PTSD, especially if the ICU
stay is prolonged (Connolly, McClowry, Hayman,
Mahony, & Artman, 2004). Postoperatively, PTSD
symptoms increased in 23% of the children, with 12%
meeting the criteria for a diagnosis of PTSD. No child
had PTSD preoperatively. Wintgrens, Boileau, and
Robacy (1997) believe that emergency interventions
after accidents and painful, repeated medical proce-
dures are traumas that could lead to posttraumatic
stress reactions, but this has not been tested.
In addition to the effects of the trauma on the child,
the parents are also affected, which in turn affects the
child. Parental uncertainty related to survival of their
child has been found to have a profound impact upon
the child after a life-threatening childhood illness
(Santacroce, 2003). A parent, who has had to face the
loss of a child, suffers from an emotional trauma that
may interfere with the ability to connect and nurture
and the parent may unknowingly distance, which affects
caretaking ability. This paper presents a case study of
a client who suffered a significant medical trauma when
he was 8 years old and his treatment as an adult in
psychoanalytic psychotherapy using eye movement
desensitization and reprocessing (EMDR) to target
that trauma.
EMDR
Eye movement desensitization and reprocessing
(EMDR) has emerged as one of the most innovative
approaches to treat the symptoms of posttraumatic
stress disorder. EMDR was developed by Francine
Shapiro in the late 1980s and is based on an adaptive
information-processing model. Two tenets of this model
are: (1) present problems are based on earlier experiences
that have been stored in the brain (state dependent
learning) and these old feelings, thoughts and bodily
sensations need to be reprocessed, and (2) clinicians can
facilitate profound therapeutic change much quicker
than was ever thought possible with EMDR (Shapiro,
2001).
Therapists trained in EMDR ask the client to focus
on a traumatic event, the negative cognition associated
with it, and emotions and bodily sensations connected
with the incident. (See Table 1 for a summary of the
structured protocol.) In EMDR, all dimensions of the
memory—the image, the thoughts, the emotion, and
the body sensations—are accessed while the client
focuses on a dual attention bilateral stimulation; with
either eye movements (client’s eyes following the thera-
pist’s moving finger back and forth across their field of
vision), auditory tones (listening to an audiotape with
headphones to alternating sounds in each ear), or tapping
(therapist alternating tapping usually on the client’s
hands which are placed on their knees), while at the
same time paying attention to the memory. The client
then free associates according to structured protocols in

Table 1. EMDR Structured Protocol

Utilizing an eight-phase structured protocol, the practitioner guides the client through a description of a disturbing event
related to his or her presenting problem(s). The practitioner asks the client to identify and focus on the image, cognitions,
emotions, and somatic distress associated with the traumatic memory.

While the client is engaged in eye movement or some other form of bilateral stimulation, he or she is experiencing various
aspects of the initial memory or other related memories.

The practitioner pauses with the eye movements or bilateral stimulation at regular intervals to ensure that the client is
processing adequately on his or her own.

96 Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006

order to elicit information. Clients are then able to
process painful memories and integrate new informa-
tion, and this allows healing to occur.
EMDR as an effective treatment for trauma is based
on the adaptive information process model, which
posits that new experiences are linked with similar
ones within the memory network as associations in
order to make sense of the information. However, in
traumatic experiences, intense affect occurs and the
experience may be isolated with the thoughts, emotions,
and sensations “locked” into the memory network. Later
similar experiences may then activate this material
(Shapiro, 2001, 2002). The exact mechanism of action
in EMDR is unclear but it is thought that the dual
attention, while focusing on the traumatic memory,
facilitates interhemispheric connection, thus disrupting
the traumatic memory network and facilitates infor-
mation processing of the dysfunctionally stored infor-
mation/memory. Dual attention refers to the client
paying attention to the external cue (eye movements,
tapping, or sounds) and at the same time remembering
the trauma. The accessing of adaptive information and
the integration of memory networks has been linked to
the processes of REM sleep and there is some empirical
support for this explanation (Christman, Garvey,
Propper, & Phaneuf, 2003; Kuiken, Bears, Miall, &
Smith, 2001–2002; Shapiro, 2001; Stickgold, 2002).
Numerous practice guidelines include EMDR as an
efficacious treatment for trauma (American Psychiatric
Association, 2004; Bleich, Kotler, Kutz, & Shalev, 2002;
Chambliss et al., 1998; CREST, 2003; Department of
Veterns Affairs & Department of Defense, 2004; Dutch
National Steering Committee Guidelines Mental Health
Care, 2003; Foa, Keane, & Friedman, 2000). Randomized
clinical trials have shown that EMDR is superior to wait
list controls (Rothbaum, 1997; Wilson, Becker, & Tinker,
1995, 1997), biofeedback relaxation (Carlson, Chemtob,
Rusnak, Hedlund, & Muraoka, 1998), active listening
(Scheck et al., 1998), and various forms of individual plus
group psychotherapy (Marcus, Marquis, & Sakai, 1997).
When comparing exposure and cognitive behavioral
therapy and EMDR, it has been found that all are
Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006
equally effective but that EMDR is less time intensive
and requires no homework between sessions (Ironson,
Freund, Strauss, & Williams., 2002; Lee, Gavriel,
Drummond, Richards, & Greenwald., 2002; Power,
McGoldrick, Brown, et al., 2002; Rothbaum, 1997; Taylor,
et al., 2003; Vaughan, Armstrong, Gold, O’Connor,
Jenneke, & Tarrier, 1994). Studies of single trauma, in
contrast to complex multiple trauma, indicate a 77–
100% remission of PTSD after three to six sessions (Lee
et al., 2002; Marcus et al., 1997; Scheck, Schaeffer, &
Gillette, 1998; Wilson, Becker, & Tinker, 1995, 1997). In
a combat study which provided a full treatment of
EMDR, 77% of the veterans no longer had PTSD after
12 sessions (Carlson et al., 1998).
Case Study
Mr. S. is a 42-year-old man referred for possible
ADHD. His presenting problems were lethargy, work
performance deterioration, and concentration problems.
An initial workup revealed that he might have a coex-
isting attention deficit disorder. Test findings were
equivocal, i.e., the Brown ADD scales indicated that
given his self-ratings of various symptoms of this dis-
order, ADD was probable but not certain. Depression
affecting cognitive functioning was felt to be the central
cause of his previously described presenting complaints.
Mr. S. was started on Wellbutrin 75 mg and Ritalin
10 mg Q.D.
Mr. S.’s childhood history was unremarkable except
for two injuries during his childhood, the first was a
dog bite when he was approximately 18 months of age
and a difficult tonsillectomy with evidence of bleeding
at the age of 8. These events were reported as history
and never discussed in any detail as the focus in therapy
was on his work dysfunction. As a child, Mr. S. was
very active, feisty, “into everything,” a “handful,” as
his mother described him. His activity level had no
effect on his academic functioning. He was a straight
A student. What emerged was a picture of an adult
who was compulsively driven to be productive in all
areas of his life. He strove for perfection in himself
97
An Adult with Childhood Medical Trauma Treated with Psychoanalytic Psychotherapy and
EMDR
and demanded perfection in others, especially women.
His deepest relationship in college ended when his
girlfriend wanted a greater commitment. Women dis-
cussed during treatment were described as cold and
unreachable, and it puzzled Mr. S. that he continued
to pursue people seemingly incapable of having a rela-
tionship.
The first 2 years of psychoanalytic psychotherapy
treatment focused on his history and his current
painful disenchantment with his career and the organ-
ization he had devoted himself to for 20 years. His
depression seemed to be triggered by a growing
awareness that he received little recognition for his
efforts and that he felt betrayed by a supervisor. As he
clarified these issues, questions were raised about his
commitment to such an unrewarding career path
and he began to entertain thoughts of leaving his job,
which he eventually did.
Mr. S.’s job required that he fly a great deal and he
began to develop sinus infections, which caused con-
siderable pain during flights. After exhausting various
treatments, he opted for surgery. Returning home
following the surgery, he was conversing with someone
on the phone when he developed a severe panic attack.
During the exploration of his panic attack in our next
session, he was asked if he was swallowing blood. Mr.
S. confirmed this. Perhaps the swallowing of blood
postoperatively after his sinus surgery had triggered
unresolved feelings related to his earlier operation, a
tonsillectomy, which involved excessive bleeding.
Mr. S. thought that may be true and recounted that
during the tonsillectomy his artery had been nicked.
He had awakened in his room vomiting blood. Clamps
were inserted in his throat in an effort to control the
bleeding. This however, elicited the gag reflex trigger-
ing torrents of blood. He recalled great confusion in
his room, doctors and nurses coming and going, another
little boy in his room being abruptly removed, and
blood-soaked sheets being repeatedly changed. These
efforts went on for an entire day. Mr. S. lost 8 pints
of blood undergoing multiple transfusions and was
resuscitated three times. Blood supply of his type was
98
running out. Mr. S. spent the day struggling to stay
alive. He was eventually transferred by ambulance to
another hospital that specialized in the treatment of
children and was reoperated on successfully. The
following are verbatim excerpts from sessions that
illustrate Mr. S. remembering and reliving his experi-
ence in psychoanalytic psychotherapy.
In one session, Mr. S. said: “Whenever we get near
tonsils, I see the light and I leave. I’m cognizant of
what’s around me but not quite, no fear, very comfort-
ing when I fixate on the light. It must have been a trau-
matic moment when I was fighting to survive, [I] can’t
recall because it’s not clear or I don’t want to, for an
hour or so I’m in another world . . . the feelings coming
back right to my head. I’m choking so bad, I’ll be sick,
a fear when that’s happening, I won’t get another breath.”
Therapist: Possibly a memory of a state you were in at
the time?
“That makes sense. I can remember knowing what’s
going on but the conscious part of my mind is some-
where else, my chest hurts, my legs are heavy, I can’t
lift them. I feel heavy like someone was punching
down on me all over, that’s when I see the light and
get away from it. I feel chilled, cold, my head feels
fine, the body feels cold. Did you see me move? It was
like a jolt through my body, pressure on my chest up
to my neck, it hurts.” This may have been a memory of
Mr. S. being resuscitated. He distinguishes the light
from the operating room light because it moves. “If
you try and pull away, it’s there.” I wondered if this
was the light ENT surgeons wear on a hat while per-
forming surgery. “I’m feeling now like I’m all alone,
just me. Don’t feel the presence of the doctor. He’s not
helping, not on my side, just me and I’ve got to do it.
I’ve got to protect myself. They are hurting me. Tender
spot there, my eyes welled up with tears. I pulled
away from it. Now it’s gone. I’m looking around for
my parents.”
Therapist: What are you feeling as you’re looking around
for your parents?
“Where is everybody? I’m scared. I keep hearing,
don’t cry, and be a big boy. I thought if I lie quiet, it
Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006
will go away. I know others are there but they don’t
do anything, don’t see how much it’s hurting (crying)
hurts so bad. I’m so scared. I don’t know what will
happen. If I can hold these feelings, I can control what’s
happening. No one ever saw me upset. It was there
but inside me. When I do that, I don’t feel the pain
anymore. I get away from it. No emotions, not upset,
no pain. I control it. You can’t be a little boy and cry.
Now over the years, anything that is upsetting, I’m
close to tears, I’d feel I couldn’t do it because you’d
lose control and go back to that time. Why couldn’t I
show emotion then? Was it dangerous?”
Therapist: It was dangerous. Your parents being upset
frightened you.
“I have two pictures, the look on the nurse’s face,
panic on her face. And I opened my eyes; they had been
shut for awhile. The minister is there. They’re all around
the bed. They seemed surprised that I opened my eyes.”
Outside of therapy Mr. S. made considerable progress
in personality growth in that he began to view himself
more positively. He could no longer tolerate his adverse
work environment and understood that it seemed
“normal” for him to need challenging circumstances.
His interest in unavailable women diminished and he
Figure 1. EMDR Assessment and Components
Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006
realized that he had always thought something was
wrong with him. This pathogenic belief served a pro-
tective need to renounce the hope that he could ever
recapture what he had lost, the “safe, loving mother.”
However, a complex area of distress and sadness
remained that seemed impervious to therapeutic inter-
ventions. EMDR was introduced as a way to process
these feelings. After explaining EMDR and creating a
safe place, Mr. S. had his first EMDR session.
Mr. S. began the EMDR session by recounting and
summarizing our work. He discussed going to the
hospital as an adventure, exploring the floor he was
on, having a soda with the nurse. His favorite flower
was placed in the room. Mr. S. approached the hospital
with an adventuresome spirit. He next recalls awaken-
ing back in his room. When we focused on the events
of this time period, Mr. S. would experience a deep
sadness and frequently cry. With EMDR the following
scene was targeted: Mr. S. is on the gurney and hears
his mother comment: “You’re sending him there to die.”
See Figure 1 for assessment and schematic image of
the target and components. The following is a verbatim
session integrating EMDR in order to process this
traumatic medical incident.
99
An Adult with Childhood Medical Trauma Treated with Psychoanalytic Psychotherapy and
EMDR
Therapist: See if you can slow it down as if you are
watching a movie with a remote control.
“I hear my mum’s comment, shaking her head. I see
my parents and aunt. I should be happy to see them.
I know they’re upset. Don’t worry. It’s all right, but I
can’t tell them.”
Therapist: What’s the worst part?
“My mom saying: ‘You’re sending him there to
die.’ It’s the first time I understand there is something
wrong.”
Therapist: What words best go with the picture that
express your negative belief about yourself now?
“Something’s wrong with me. I have no control.”
Therapist: When you bring up that picture of you lying
on the gurney, what would you like to believe about yourself
now?
“It’s over. I’m safe now.”
Therapist: When you think of lying on the gurney, how true
do those words “It’s over. I’m safe now” feel to you on a scale of
1–7 scale, where 1 feels completely false and 7 feels totally true?
“2.” (Validity of cognition scale (VOC)—the VOC
will be the basis for inserting the client’s positive cog-
nition “It’s over. I’m safe now” once the dysfunctional
material is processed. This allows for the positive cog-
nition to associate with previous traumatic memories.)
Therapist: When you bring up that image of you lying on
the gurney and those words “I’m helpless. I have no control,”
what emotion do you feel now?
“Scared.”
Therapist: On a scale of 0 to 10, where 0 is no disturbance
and 10 is the highest disturbance you can imagine, how dis-
turbing does it feel now?
“10.” (Subjective units of disturbance scale (SUDS)—
the SUDS will also be checked later in the session in
order to determine the effectiveness and thoroughness
of the processing.) It didn’t scare me before. This
changes that, seeing them upset, something is wrong,
the minister is there. There is a bible on the bed.
I’m trying to figure out what’s going on. Nothing fits
into what I understand. I hear my aunt . . . “Is there
nothing you can do? When I hear that, I’m off in the
distance.”
100
Therapist: Where do you feel it in your body?
“I feel myself on the stretcher all tightly bound.
I feel really hot physically. My shoulders and neck are
hot. My mind is jumping back and forth evading the
middle part. I can feel them moving me around. I hear
them talking. Mum and the doctor.”
Therapist: Now bring up that picture and the words “I’m
helpless. I have no control” and notice where you feel it in
your body. Now follow my fingers with your eyes. (Eye
Movement #1)— (the clinician holds two fingers upright,
about 12–14 inches from the client’s gaze and slowly
moves his fingers horizontally from the left to the
right of the client’s visual field while the client fol-
lows with his eyes for approximately 28 bidirectional
movements.)
“I open my mouth and blood pours out. There is
commotion, doctors and nurse, putting tubes in, taking
my blood pressure, forceps in my throat, packing ice
around my neck, changing the sheets from the blood.”
He recalls noticing that his aunt is upset. Noting a flower
nearby in his room, he tells her: “Don’t worry, the
flower made me sick.” Mr. S. describes these recollec-
tions as not being upsetting but like well-sequenced
pictures with some gaps. “I have a burning in my
neck, stiff, something is there, I don’t know what it is,
couldn’t sense it, like if you’re angry and tense up.”
Therapist: Go with that. (Eye Movement #2)
“For a few seconds, I felt relaxed and then my
muscles tighten up in my neck right through my head.”
Therapist: Go with that. (Eye Movement #3)
“Got more tense, the left side of my neck, not as much
as before . . . feels like my brain is tingling, like shivers
through my body. If there was more of that, it would
be better, get rid of something.”
Therapist: Go with that. (Eye Movement #4)
“Felt better, better able to concentrate . . . like when I
look back a few minutes ago, it was irritating, not
now. Tension is always in the back of my neck that
just came to me.”
Therapist: (Eye Movement #5)
“My head feels cloudy, confusion. Got more tense,
tightening top of shoulders, for a second my mind
Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006
wanted to go off and I didn’t feel the tightening. The
eye movements keep me on something. I’d like some-
one to take me and stretch me to get rid of that (pause)
I can hear my mum, the doctor.”
Therapist: Go with that. (Eye Movement #6)
“Very strong emotion. I am so angry . . . so mad. I
can’t tell where it came from, angry inside.”
Therapist: Go with that. (Eye Movement #7)
“Anger again, overwhelming tension, mad, I want
to yell. Then all of a sudden I wanted to cry and the
anger lessened. I wanted to cry.”
Therapist: (Eye Movement #8)
“I didn’t have a sensation of anger or sadness, a little
stiffness, sadness then nothing. The anger is triggered
by their talking. It’s the doctor’s voice, not my mum’s
(that is the trigger for his rage). I’m raging inside. I just
wanted to scream. I could hardly tolerate you moving
your hand. I wanted to yell. I couldn’t do that then, why?”
Therapist: (Eye Movement #9)
“I was so angry and I couldn’t scream or I would
have bled some more.”
Therapist: Notice how your body feels now. How scared
do you feel now?
“Not so scared.”
Discussion
Numerous theorists and clinicians have stressed the
importance of an early trusting relationship between
parent and child (Bowlby, 1988; Lachman & Beebe,
1997; Lichtenberg, 1983; Stern, 1985). This relationship
is comprised of co-constructed expectations of being
understood, accepted, and protected in a reliable,
responsive world. Despite Mr. S.’s first traumatic
experience with the dog bite, his recollections of his
early childhood are warm, detailed, and humorous.
“I’m feeling really happy-go-lucky, safe, not a worry
in the world. I remember trucks. I had bulldozers,
building things I remember lying on the grass with my
dog, feeling his fur. He put up with all kinds of stuff.
My backyard was fenced in. Mum had a time with me
running away. I was also notorious for running and
Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006
stripping my clothes off. For a time, she would not take
me out without a harness. It just wasn’t safe. I’d dart
away. I was also a climber and jumper. After the tonsils,
I never felt that way again. It was like I was all grown
up. I never trusted the same way again. When you’re
little, you trust blindly, just doing and exploring.”
For an event to be understood as traumatic
Lachmann and Beebe (1997) state: “The traumatic event
precipitously violates expectations of being reliably,
positively responded to. The concept of violation or
betrayal of expectations mediates between the trau-
matic event(s) and the state of the self which is imme-
diately, dramatically, and at times, irrevocably,
transformed through the trauma” (p. 275). With the
adverse medical procedure, Mr. S.’s faith in the safety
and predictability of his world was transformed.
Returning to that time late in that day when he experi-
enced a terrible sadness and the fury evoked through
EMDR, what is the nature of this rageful state? Pos-
sibly the growing awareness that he might be dying,
seeing the sadness in his relatives’ faces, the comment
he overheard from his mother to the doctor (“You’re
sending him there to die”) and the doctor’s superficial
attempts to calm his mother down all contributed to
the sadness and rage. However, there was another
thought he recovered: “What have you done to my
mother?” Recall his depiction of his early childhood as
warm, fun, and loving and his comment about life after
the trauma: “I never trusted in the same way again.”
Trauma is bidirectional, that is, it affects both participants
in the dyad and destabilizes the relationship. Mr. S.’s
mother was with him throughout this nightmare, a
botched operation, transfusions, additional surgery,
which did not help, and three resuscitations. In her
own words, she fully expected him to die. Upon his
return home from the hospital, life went on. Little
mention was made of his experience. Occasionally he
asked a question related to his experience in the hos-
pital. His mother, he recalls, only gave answers with an
emphasis on how fortunate he was to be well. Relatives,
neighbors, even the doctor who operated on him,
stressed how “lucky” he was.
101
An Adult with Childhood Medical Trauma Treated with Psychoanalytic Psychotherapy and
EMDR
Mr. S. knew, however, that his father was enraged
with the doctor. This doctor had functioned as the
family’s general practitioner. The father never returned
to this doctor for his care, referring to him as the
“butcher.” Mr. S.’s mother, in contrast, continued to
bring her son to this doctor and received her own
medical care from him. At the most basic level of ana-
lysis, this behavior suggests a massive denial of what
happened. Denial served the function of shoring up her
identity following a confrontation with the ultimate
horror for a parent, the loss of a child. Unfortunately,
this protective state impedes the processing of the
traumatic event, blocked communication regarding
those events, invoking what some have referred to as
a covert conspiracy of silence, thus irrevocably altering
the positive, loving, affective coloring of their bond.
The depth of her emotional investment in him is pro-
tectively regulated because it is entwined with the
unbearable. On his side of the equation, Mr. S. had lost
his mother. They both emerged from the hospital
transformed. As Mr. S. said, “I was all grown up.”
Unfortunately, what is also transformed in trau-
matic contexts is the self-representation and associated
beliefs about the self. An answer must be found, an
explanation must be forged that accounts for frighten-
ing changes in the personality or behavior of the care-
taker. Due, in part, to basic cognitive immaturity, the
child draws the conclusion that something is wrong
with him or her. This preserves the image of the care-
taker as omnipotent, which is crucial for the child to
believe so he can continue to exist.
In the session following the EMDR, Mr. S. was asked
to return to the troublesome scene. He reported that he
no longer felt “in it.” He could picture it but did not
feel the experience as he did previously. Mr. S. com-
mented: “If I think how we pieced it together, now it’s
like looking at photographs, matter-of-fact, no sense
of anxiety . . . I can think of her being upset but that
upset is not now . . . I never remember seeing her
upset to the same degree again. She’d feel bad if some-
one died, but she was really upset when I was on the
stretcher.”
102
Therapist: We touched on your father’s anger and your
anger, what about your mother’s anger?
“It’s funny when you say that … like I was an adult
around my parents. There was no spanking, telling me
to do things. Like I was grown up and didn’t need
advice.”
Therapist: You were special. They didn’t cross you.
“They never said I should or shouldn’t, whatever
you want.”
Therapist: Your boyhood had ended. Perhaps you didn’t
feel loved in the same way again.
“I jumped from being a baby to an adult. I guess a
situation like that could make that happen. I felt like
an adult my whole life, always cognizant of what’s
going on around me.”
Subsequently after the processing of this traumatic
incident, Mr. S. recognized that he lost trust in the peo-
ple who were supposed to love and protect him. Lack
of trust perpetuated experiences that made the world
seem unsafe through a wary, avoidant façade that kept
Mr. S. in a state of isolation. He was able to mourn the
loss of his mother and expressed anger towards the
doctors and his family. Overall, he experienced a greater
sense of compassion for himself and an increased sense
of self-respect as a survivor. Prior to his psychotherapy
and EMDR processing, Mr. S. did not realize the
impact and extent of this event on his functioning. In
addition, the disruptive effects of trauma affected his
ability to concentrate.
In the case of an adverse medical experience, there
may be a conscious awareness of the traumatic nature
of the event, or as in Mr. S.’s case, there may only be
other presenting issues related to trust and relation-
ship development with symptoms of depression and
attention deficit disorder. His panic attack after his
nasal surgery served as a trigger for the unprocessed
frozen traumatic memory of his botched tonsillectomy.
It may only be in the course of treatment that the client
becomes aware of the significance of the event particu-
larly if it occurred in childhood.
In the context of psychotherapy Mr. S.’s readiness
for identifying the appropriate EMDR targets for
Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006
processing was determined and he was given informa-
tion about the EMDR procedure. In general, targets for
processing may include a dream, a memory, or current
behavior that the clinician and client have identified as
problematic and indicate dysfunctional memory
networks. These targets can be identified in the initial
history by asking the person about traumas they have
suffered or they may only become apparent in the
course of treatment as was the case with Mr. S. when
he suffered the panic attack after his sinus surgery.
It is important that the client be prepared for the
potentially intense nature of the treatment and a safe
place identified. The safe place exercise is an important
preliminary component prior to EMDR processing so
that client safety is ensured. Shapiro (2001) describes a
protocol which involves selecting an image of a safe
place that the person can easily evoke, feeling the asso-
ciated emotions and sensations connected with that
place, doing a series of short eye movements while
focusing on the memory, identifying a cue word for
the safe place, and then practicing returning to the safe
place image both in the session as well as at home.
Once the target of Mr. S. on the gurney was accessed
for processing, the relevant components were identi-
fied (see Figure 1). Ratings of his distress (SUDS) and
cognitive assessment (VOC) were obtained in order to
monitor his progress. At the beginning of the procedure,
his VOC of “It’s over. I’m safe now” was a 2 on a 1–7
scale with 1 representing entirely untrue and 7 repre-
senting completely true. His beginning SUDS on a
0 –10 scale, with 10 representing the worst feeling of
being scared he could imagine and 0 representing no
distress, was a 10.
During processing, sets of eye movements were ini-
tiated using standardized procedures, as illustrated in
the EMDR session, that have been designed to facili-
tate information processing until the scared feeling
was no longer felt (SUDS of 0) and the positive cogni-
tion was felt to be completely true (VOC of 7). Through
these ratings Mr. S.’s progress was monitored so
installation of the positive cognition “It’s over. I’m safe
now” with further eye movements can proceed. For a
Perspectives in Psychiatric Care Vol. 42, No. 2, May, 2006
full delineation of the eight phases of EMDR treatment,
see Shapiro (2001).
Other targets identified for EMDR over the course
of Mr. S.’s treatment included situations that triggered
his hypervigilant state, such as unexpected situations
at work and elements of surprise and betrayal. Through
the reprocessing of his medical trauma and processing
these current triggers, profound healing outcomes
have occurred in all dimensions of his life. Mr. S. was
able to connect the dysfunctionally stored traumatic
memory with more adaptive information in other
memory networks. He became significantly calmer,
less vigilant, more adventuresome and no longer needed
medication. Because the hypervigilance of unproc-
essed trauma may appear to be the distractibility and
difficulties of attention of ADHD, it is important for
the clinician to screen for trauma whenever ADHD is
suspected. Please see Table 2 for healing outcomes.
Application for Advanced Practice Psychiatric
Nurses
This case study illustrates the successful use of
EMDR in psychoanalytic treatment for an adult who
suffered a medical trauma as a child. The effect of the
trauma on Mr. S. as well as on his family was pro-
found. This is consistent with theoretical speculations
(Santacroce, 2003) and recent research on children who
have undergone invasive medical treatments (Connolly
et al., 2004; Rennick et al., 2002). Advanced practice
psychiatric nurses need to be cognizant of these areas
of trauma in an adult’s history as oftentimes the client
is unaware of the impact of earlier medical trauma.
Even more important are the implications for preven-
tion. Perhaps children who have undergone significant
invasive medical procedures need to be screened for
PTSD and treated immediately in order to ameliorate
the long-term sequelae of trauma. In addition, parents
may need screening and treatment in order to process
their own trauma.
The integration of EMDR into psychoanalytic psy-
chotherapy has been discussed previously (Wachtel,
103
An Adult with Childhood Medical Trauma Treated with Psychoanalytic Psychotherapy and
EMDR
Table 2. Healing Outcomes
Emotional:

Decreased depression, no longer taking Wellbutrin

Less anger at the carelessness of others

Less guarded
Intellectual:

Able to concentrate better

Procrastinates less

More productive

No longer on Ritalin
Physical:

Less hypevigilant

Able to relax

Increase in energy
2002), and as illustrated here, is an important adjunct
for effective treatment. EMDR can also be used in the
context of many other treatment approaches including
cognitive behavioral, family systems, experiential, and
transpersonal (Shapiro, 2002). Recent research suggests
that trauma is a right brain phenomenon and most
psychotherapy is largely a left brain endeavor; thus,
there may be significant areas that are not accessible
with talking therapy only. The bilateral stimulation
inherent in EMDR may assist in reconnecting these
neural pathways that have been dissociated from each
other.
Acknowledgment. The authors wish to acknowledge
the consultation and discussion with Peter Purpura,
PhD, during the treatment of this case.
Author contact: kwheeler@mail.fairfield.edu with a copy to
the Editor: mary@artwindows.com
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Spiritual:

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Vocational:

Changed from old job which he considered “abusive” to
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Environmental:

More adventuresome

Seeks out new experiences & activities
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