Once new EMDR therapists have completed basic training, I have found it helpful to review treatment planning and target sequencing. We will be looking at three different approaches towards target sequencing.1. The Top 10 – This approach involves asking the Client for his/her top 10 most disturbing memories or events. The clinician can ask for those during the session, or request that the Client complete the exercise between sessions. One thing to consider with the latter, is that such an exercise can be activating for the Client, so if we use this approach, we need to know that the Client can self-regulate independently. Along with the Top 10 worst events, it is important to follow that up with asking for the Top 10 best events. Lastly, using a containment strategy at the end of this session will allow the Client to stabilize before leaving the session, and will certainly help them between sessions. The use of containment is also helpful with the other two approaches we will cover. Once the clinician has obtained the top 10 list, there are different options for sequencing the events. The most straight-forward is sequencing them in the following way:
a. The First or Touchstone Event
b. The Worst
c. The Most Recent
d. All others
e. Present template
f. Future template
2. The Trauma Timeline – This approach involves the EMDR clinician asking the Client to identify targets based on chronological order. The Trauma Timeline can be particularly useful when working with a client who has complex PTSD with numerous potential targets. Additionally, seeing the events laid out chronologically makes it easier to identify themes of trauma, as the element of time provides more context to the events. Lastly, when the therapist starts desensitization, he/she can lessen the likelihood of feeder memories (memories that took place prior to the event being processed and that impede the event from being processed) as well as identify them as feeder memories based on the timeline. Once the timeline is completed, the clinician can sequence the targets in the same order as in option 1. 3. The Thematic Approach – During the history taking phase, the clinician will make note of the presenting problem and identify a potential theme within the Client’s narrative. For example, the Clinician might here the Client say “I am a loser (negative cognition)” or mention the emotion of “shame” several times. The Clinician could also ask, “Where do you feel that in your body (body sensation)?” Next, the EMDR Therapist can ask, “When was the first time you felt that sensation/felt that/ or thought that way about yourself?” After collecting the first event for the theme, he/she can then ask for the worst, most recent, all others, etc. If the first event did not happen in early to mid-childhood, it is often helpful to do an affect scan or floatback to capture the touchstone event. An example of a sequence based on the theme “I am a loser” might look like this:
b. The Worst – At 16 years old, Client was bullied and then beaten by a group of his/her peers.
c. The Most Recent – The Client’s boss expressed anger at a report that was not completed on time.
d. All others – Failing a class in college.
e. Present template – When Client sees his/her boss at work.
f. Future template – Client imagines going to work and having a conversation with his/her boss without being activated.This approach could be repeated with other themes as well, resulting in a comprehensive treatment plan. As an example, there could be another theme based on the emotion of guilt and another on the “feeling in the pit of my stomach.” The next choice point in this approach comes when deciding which theme to target first. Two elements to consider for this are the extent to which the theme affects the Client’s present day functioning the most, as well as which theme started earlier chronologically.
When comparing the 3 methods of target sequencing, each has their advantages and disadvantages. With the Top 10, the clinician is using a straight-forward approach that is easy to learn. However, the thematic approach allows for a more efficient approach because the themes are connected directly from the presenting problem. Therefore, the reprocessing effects could be greater sooner. The Trauma Timeline brings an element of organization to complex cases. Also, these approaches do not have to be mutually exclusive. For example, a clinician might gather a top 10 and then ask about context to the events to elicit negative cognitions, emotions, body sensations, which can then turn into themes.Ultimately, what I really like about Target Sequencing is that there is no such thing as “the perfect plan.” What really matters is that we use clinical judgement and develop a plan using a methodology versus just picking a memory and going with it. I have also found that Client’s like having and tracking the plan throughout the course of therapy. Also, the approaches in this post are not meant to be an exhaustive list of target sequencing methodology, rather a recap and a further conceptualization of this topic for someone who has completed basic training. Lastly, I would like to know what approaches you use for target sequencing. Robert Peacock, LCSW-S EMDRIA Approved Consultant
EMDRIA Certified EMDR Therapist