Case Studies for EMDR & Art Therapy
Lee Anna Simmons, 22nd May 2015
SA&T, Greater London Social Services
These case studies were written for a Social Services provision, which then provided funding for in-house resources to use EMDR with people who hoard.
The outlines were written independently at the SA&T clinic, using samples from work previously undertaken from within the services. The studies are shared here to help increase practitioner awareness of how Art Psychotherapy and EMDR can be used together as well as how hoarding can be addressed in the therapy room.
Case study 1
EMDR & Art Psychotherapy with someone who hoards
*Mary was referred to me by a Lead Community Social Worker, who was working with her as she was considered at risk due to her hoarding behaviour.
Context
Mary was suffering from depression, often feeling suicidal and suffering from anger management problems. She was feuding with some of her neighbours and lived alone. She was over 80 and a widow.
I telephoned and arranged an assessment session, which Mary attended. We then agreed to embark on Art Psychotherapy and EMDR (Eye Movement Desensitisation and Reprocessing), based in an NHS building.
Building a therapeutic relationship and history taking using art
Mary started off by using the art materials and talking. She painted a scene that included mountains, and her embarking on climbing the mountain. There was a tree and a meadow nearby (these later came up during her EMDR processing). As Mary painted she talked a lot and I mapped the subjects that she discussed on a piece of paper of my own. She did not talk about her hoarding habits until quite far into the therapy; when she did it was of her own choice.
In her second session she made a pencil drawing of a boat, she said she could not fly, so she had given herself the boat. It again represented her difficult journey. Mary spoke about her life history in some detail; often talking about a situation unrelated to the question that I had asked, but important to her. We completed this second session with a light-stream exercise, to be calming and meditative.
Mary then missed two sessions, the first as she had lost her bus pass and the second she said she had forgotten. I explained that I would not be able to keep the slot open to her if she did not attend. She then used all of the scheduled appointments except for one, which was agreed in advance.
We identified a safe place / special place, Mary was in touch with her emotions as well as feelings in her body. The safe place installation seemed to work effectively and Mary reported back later in the programme that she had been using it to calm herself in a variety of situations. We identified numerous traumas throughout Mary’s life. We chose to focus on the earliest one, which had a theme running through many of the others of being a victim.
The early trauma was a memory where Mary was watching a little girl playing with toys that Mary had brought with her when she was moved from place to place as a child in wartime. In this new home the lady looking after her had taken Mary’s toys and given them to her own child. As Mary looked on she felt hard done by and not good enough. She would prefer to feel contented and in much of the therapy she expressed wanting to feel more relaxed.
Moving into EMDR work: Bilateral stimulation
We went through the EMDR assessment using the traditional protocol and them moved on to the bilateral stimulation in processing.
In the training that I received for EMDR I was told that eye movements are the most time effective. We began with these, but Mary struggled to follow as her eyes tired easily. We then used tapping, whereby I tapped the side of Mary’s knees in place of eye movements. This also triggers right and left brain stimulation, which is how EMDR is considered to overcome blocks and speed up healing of past trauma.
During the processing Mary went through a lot of her current trauma and was often tearful. She had not been crying during the art making and speaking, though she had been very distressed. In a session directly after a close family member died Mary fed back that she was feeling suicidal. We went straight into art making and as she drew I tapped her on the shoulders to trigger the bilateral processing and help her get into a more manageable frame of mind.
Mary continued with the processing over four sessions, until her disturbance level was reduced to zero. She also reduced her feeling of not being good enough to completely false and her feeling of being contented reached completely true.
During the processing Mary seemed to have a revelation, where she cried out “logic!” and said it was logical that her caregiver had to share the toys between the children. She did not have much money, it was wartime and she had two of her own children and three of the war children. It probably helped the very young child to be playing with the toys. This was a very different viewpoint to that which Mary had presented in the earlier stages of the therapy.
Mary then started applying logic to other areas of her life, including clearing her house and maintaining the clear space that she had created. She said it was logical she had to do this or her windows would not be fixed; also if something happened to her she feared nobody would sort through her belongings, but would throw everything out. It was logical she needed to clear up and she did seem to be enjoying the space.
Closing with Art Making
In her final therapy session Mary made art and talked to me about how she was feeling and the progress she had been making at home. She had been doing a lot of clearing and though finding it hard reported satisfaction from the process and a desire to keep the spaces clear. She drew a floor plan of her home, saying out loud ‘CLEAR!” in a celebratory way as she wrote it across a room on her plan. Mary then had a review session, to which she voluntarily brought some handwritten feedback for me. I told her that she could take her paintings and she considered where they would go, as she was trying not to take new things into her home. She thought about it for a fortnight and then took her few pages of artwork away to reflect on.
Conclusion
Over 17 sessions, one assessment and one review Mary made real progress in her emotional and physical situation. I believe that Art Psychotherapy and EMDR used together aided the effectiveness of overcoming the blocks and supporting the therapeutic alliance we had formed. I also believe that the intervention of the Social Worker in preparing Mary for the therapy was important - the practical support she received at home in her clearing processes. Mary reported one lady being helpful and supportive but was upset about a voluntary group who she believed had been too pushy with her - it seemed that this hampered progress. A joined up approach that is sensitive but with forward momentum is what I would recommend in this work. Rushed and forced clearance is likely to lack sustainability and even make things worse.
There were areas of Mary’s life where she was in the middle of controversy with people, which were not completely resolved, but the amount of anger Mary was feeling seemed to reduce and be more understandable in the present day context. I could have offered one or two more sessions following a comment about the feeling of being demeaned by this, following specific EMDR protocol, but Mary might also make some of the connections for herself over time. It is not uncommon for people to feel shaky at the end of therapy and put out hooks to continue the contact.
Name *Mary is not the client’s name, her identity is protected with respect to confidentiality.
Case study 2 - EMDR with someone who hoards
Context
Karen was referred to me by her Social Worker, whom had been working with her around the issue of hoarding.
Karen had filled a building with things and was making good progress clearing it due to sustained support from a Community Social Work Team. Karen was not interested in doing Art Psychotherapy with me, but she said she would try EMDR (Eye Movement Desensitisation and Reprocessing therapy).
Karen
Karen was a low to midrange hoarder but did not consider herself to be; rather she saw herself as someone with a lot of items causing chaos in her home environment. She had a long trauma history, going back to the age of five and was in her sixties when we worked together. She believed issues that arose from these unresolved traumas were contributing to her feeling out of control – which was contributing to the hoarding activity.
I was informed that Karen had experienced depression since early adulthood and had suicidal ideations in the past. She had been a victim of gang rape as teenager, she had been frequently bullied in the work setting and had debts of thousands of pounds. She stated the she hates to feel out of control, had tried Cognitive Behavioural Therapy (CBT) but did not continue with it to completion and had attended psychotherapy for more than a year. She had responded well to task setting with her social worker and in relation to EMDR said “ if it will help me, it’s worth a go.”
Therapeutic Situation
Karen was referred to me towards the end of my contract, I was concerned about the short time-scale but agreed to work with Karen as it sounded like she was in the right place in her life to do this and opportunities for therapy without having to pay were becoming more rare so I wanted to give her this chance. I had an established working relationship with her Social Worker, whom I felt could support Karen if it was difficult for her and after I left my post.
Karen agreed to work intensively, having three sessions a week and processing using the eye movements. In EMDR there is evidence that it is an effective therapy, but there is not evidence it is eye movements that make it so successful. In my training and supervision it is generally reported that eye movements do seem to speed up the processing, more so than other bilateral stimulation (such as tapping, or use of buzzers or sound), so we used eye movements.
Process
A total of eight sessions were held at an NHS building. We did not have art materials available as Karen had expressed she was not interested in using them.
In the first session we did a history taking, which left more to be covered in session two. I was clear with Karen that it was important she gave me as full a trauma history as possible, so that there were as few surprises as possible when processing. This took us 90 minutes, during which time we identified three trauma clusters, comprising of 12 significant traumatic events,
The earliest were from under the age of six at school, which set up a theme of being out of control and humiliated. Family dynamics also aligned with later trauma; being left to fend for herself, feeling unwanted and unloved was the background that Karen set up her life from. Group rape was not an isolated incident but Karen was subjected to such abuse for more than a year and being bullied at work was also chronic.
We started processing with the earliest trauma memory, then working through further traumas mainly in order of severity - starting with those that presented the most continuing disturbance and disruption in the present.
Measuring Tool
In the monitoring Karen went from feeling worthless to feeling respected, and feeling powerless to feeling in control. She also went from feeling unloved to feeling loved, as recorded in the EMDR protocol worksheets that have an inbuilt measuring scale and backed up with the HADS scales.
The Hospital Anxiety and Depression Scale (HADS) results consistently went down from session to session. EMDR protocol forms also measured levels of stress reducing as trauma clusters were processed.
Conclusion
The EMDR sessions were incredibly effective with Karen. Disturbance levels reduced to nothing in three trauma clusters (all that we accessed) and HADS results dropped remarkably over an eight hour intervention. The joined up approach with Community Social Work was important for this timescale, with Karen feeling ready and supported for in her therapy and with the practical work at home.
The EMDR processing seemed to open up and tap into early memories that were being overshadowed by the adult experiences: being neglected by a mentally ill mother in parallel to being humiliated at school were the background against repeated group rape, suicidal ideation and hoarding habits. Addressing the very early memories seemed to take the pain out of the later trauma too. Karen still felt anger, but she said it was more of a righteous anger and less painful, for example when reading in the newspaper about something that had happened to somebody else that was similar, or talking about the family background, she could now manage it.
We also recorded distressing bodily responses and were able to recognise and alleviate those too, using eye movements and talking and ending with the safe place exercise.
I did consider the dramatic reduction in emotional disturbance as a possible detachment from difficult memories or even dissociation, but as Karen was able to identify feelings in her body and bring up the image of the most traumatic parts of the memories as well as talk about it, it seemed she had genuinely processed the trauma in a way that was effective for her everyday life and in the timescale that we had. Her social worker reported to me that the progress continued to be substantial some months after therapy had ended.
Name *Karen is not the client’s name, her identity is protected for confidentiality.
Lee Anna Simmons, 22nd May 2015
SA&T, Greater London Social Services
These case studies were written for a Social Services provision, which then provided funding for in-house resources to use EMDR with people who hoard.
The outlines were written independently at the SA&T clinic, using samples from work previously undertaken from within the services. The studies are shared here to help increase practitioner awareness of how Art Psychotherapy and EMDR can be used together as well as how hoarding can be addressed in the therapy room.
Case study 1
EMDR & Art Psychotherapy with someone who hoards
*Mary was referred to me by a Lead Community Social Worker, who was working with her as she was considered at risk due to her hoarding behaviour.
Context
Mary was suffering from depression, often feeling suicidal and suffering from anger management problems. She was feuding with some of her neighbours and lived alone. She was over 80 and a widow.
I telephoned and arranged an assessment session, which Mary attended. We then agreed to embark on Art Psychotherapy and EMDR (Eye Movement Desensitisation and Reprocessing), based in an NHS building.
Building a therapeutic relationship and history taking using art
Mary started off by using the art materials and talking. She painted a scene that included mountains, and her embarking on climbing the mountain. There was a tree and a meadow nearby (these later came up during her EMDR processing). As Mary painted she talked a lot and I mapped the subjects that she discussed on a piece of paper of my own. She did not talk about her hoarding habits until quite far into the therapy; when she did it was of her own choice.
In her second session she made a pencil drawing of a boat, she said she could not fly, so she had given herself the boat. It again represented her difficult journey. Mary spoke about her life history in some detail; often talking about a situation unrelated to the question that I had asked, but important to her. We completed this second session with a light-stream exercise, to be calming and meditative.
Mary then missed two sessions, the first as she had lost her bus pass and the second she said she had forgotten. I explained that I would not be able to keep the slot open to her if she did not attend. She then used all of the scheduled appointments except for one, which was agreed in advance.
We identified a safe place / special place, Mary was in touch with her emotions as well as feelings in her body. The safe place installation seemed to work effectively and Mary reported back later in the programme that she had been using it to calm herself in a variety of situations. We identified numerous traumas throughout Mary’s life. We chose to focus on the earliest one, which had a theme running through many of the others of being a victim.
The early trauma was a memory where Mary was watching a little girl playing with toys that Mary had brought with her when she was moved from place to place as a child in wartime. In this new home the lady looking after her had taken Mary’s toys and given them to her own child. As Mary looked on she felt hard done by and not good enough. She would prefer to feel contented and in much of the therapy she expressed wanting to feel more relaxed.
Moving into EMDR work: Bilateral stimulation
We went through the EMDR assessment using the traditional protocol and them moved on to the bilateral stimulation in processing.
In the training that I received for EMDR I was told that eye movements are the most time effective. We began with these, but Mary struggled to follow as her eyes tired easily. We then used tapping, whereby I tapped the side of Mary’s knees in place of eye movements. This also triggers right and left brain stimulation, which is how EMDR is considered to overcome blocks and speed up healing of past trauma.
During the processing Mary went through a lot of her current trauma and was often tearful. She had not been crying during the art making and speaking, though she had been very distressed. In a session directly after a close family member died Mary fed back that she was feeling suicidal. We went straight into art making and as she drew I tapped her on the shoulders to trigger the bilateral processing and help her get into a more manageable frame of mind.
Mary continued with the processing over four sessions, until her disturbance level was reduced to zero. She also reduced her feeling of not being good enough to completely false and her feeling of being contented reached completely true.
During the processing Mary seemed to have a revelation, where she cried out “logic!” and said it was logical that her caregiver had to share the toys between the children. She did not have much money, it was wartime and she had two of her own children and three of the war children. It probably helped the very young child to be playing with the toys. This was a very different viewpoint to that which Mary had presented in the earlier stages of the therapy.
Mary then started applying logic to other areas of her life, including clearing her house and maintaining the clear space that she had created. She said it was logical she had to do this or her windows would not be fixed; also if something happened to her she feared nobody would sort through her belongings, but would throw everything out. It was logical she needed to clear up and she did seem to be enjoying the space.
Closing with Art Making
In her final therapy session Mary made art and talked to me about how she was feeling and the progress she had been making at home. She had been doing a lot of clearing and though finding it hard reported satisfaction from the process and a desire to keep the spaces clear. She drew a floor plan of her home, saying out loud ‘CLEAR!” in a celebratory way as she wrote it across a room on her plan. Mary then had a review session, to which she voluntarily brought some handwritten feedback for me. I told her that she could take her paintings and she considered where they would go, as she was trying not to take new things into her home. She thought about it for a fortnight and then took her few pages of artwork away to reflect on.
Conclusion
Over 17 sessions, one assessment and one review Mary made real progress in her emotional and physical situation. I believe that Art Psychotherapy and EMDR used together aided the effectiveness of overcoming the blocks and supporting the therapeutic alliance we had formed. I also believe that the intervention of the Social Worker in preparing Mary for the therapy was important - the practical support she received at home in her clearing processes. Mary reported one lady being helpful and supportive but was upset about a voluntary group who she believed had been too pushy with her - it seemed that this hampered progress. A joined up approach that is sensitive but with forward momentum is what I would recommend in this work. Rushed and forced clearance is likely to lack sustainability and even make things worse.
There were areas of Mary’s life where she was in the middle of controversy with people, which were not completely resolved, but the amount of anger Mary was feeling seemed to reduce and be more understandable in the present day context. I could have offered one or two more sessions following a comment about the feeling of being demeaned by this, following specific EMDR protocol, but Mary might also make some of the connections for herself over time. It is not uncommon for people to feel shaky at the end of therapy and put out hooks to continue the contact.
Name *Mary is not the client’s name, her identity is protected with respect to confidentiality.
Case study 2 - EMDR with someone who hoards
Context
Karen was referred to me by her Social Worker, whom had been working with her around the issue of hoarding.
Karen had filled a building with things and was making good progress clearing it due to sustained support from a Community Social Work Team. Karen was not interested in doing Art Psychotherapy with me, but she said she would try EMDR (Eye Movement Desensitisation and Reprocessing therapy).
Karen
Karen was a low to midrange hoarder but did not consider herself to be; rather she saw herself as someone with a lot of items causing chaos in her home environment. She had a long trauma history, going back to the age of five and was in her sixties when we worked together. She believed issues that arose from these unresolved traumas were contributing to her feeling out of control – which was contributing to the hoarding activity.
I was informed that Karen had experienced depression since early adulthood and had suicidal ideations in the past. She had been a victim of gang rape as teenager, she had been frequently bullied in the work setting and had debts of thousands of pounds. She stated the she hates to feel out of control, had tried Cognitive Behavioural Therapy (CBT) but did not continue with it to completion and had attended psychotherapy for more than a year. She had responded well to task setting with her social worker and in relation to EMDR said “ if it will help me, it’s worth a go.”
Therapeutic Situation
Karen was referred to me towards the end of my contract, I was concerned about the short time-scale but agreed to work with Karen as it sounded like she was in the right place in her life to do this and opportunities for therapy without having to pay were becoming more rare so I wanted to give her this chance. I had an established working relationship with her Social Worker, whom I felt could support Karen if it was difficult for her and after I left my post.
Karen agreed to work intensively, having three sessions a week and processing using the eye movements. In EMDR there is evidence that it is an effective therapy, but there is not evidence it is eye movements that make it so successful. In my training and supervision it is generally reported that eye movements do seem to speed up the processing, more so than other bilateral stimulation (such as tapping, or use of buzzers or sound), so we used eye movements.
Process
A total of eight sessions were held at an NHS building. We did not have art materials available as Karen had expressed she was not interested in using them.
In the first session we did a history taking, which left more to be covered in session two. I was clear with Karen that it was important she gave me as full a trauma history as possible, so that there were as few surprises as possible when processing. This took us 90 minutes, during which time we identified three trauma clusters, comprising of 12 significant traumatic events,
The earliest were from under the age of six at school, which set up a theme of being out of control and humiliated. Family dynamics also aligned with later trauma; being left to fend for herself, feeling unwanted and unloved was the background that Karen set up her life from. Group rape was not an isolated incident but Karen was subjected to such abuse for more than a year and being bullied at work was also chronic.
We started processing with the earliest trauma memory, then working through further traumas mainly in order of severity - starting with those that presented the most continuing disturbance and disruption in the present.
Measuring Tool
In the monitoring Karen went from feeling worthless to feeling respected, and feeling powerless to feeling in control. She also went from feeling unloved to feeling loved, as recorded in the EMDR protocol worksheets that have an inbuilt measuring scale and backed up with the HADS scales.
The Hospital Anxiety and Depression Scale (HADS) results consistently went down from session to session. EMDR protocol forms also measured levels of stress reducing as trauma clusters were processed.
Conclusion
The EMDR sessions were incredibly effective with Karen. Disturbance levels reduced to nothing in three trauma clusters (all that we accessed) and HADS results dropped remarkably over an eight hour intervention. The joined up approach with Community Social Work was important for this timescale, with Karen feeling ready and supported for in her therapy and with the practical work at home.
The EMDR processing seemed to open up and tap into early memories that were being overshadowed by the adult experiences: being neglected by a mentally ill mother in parallel to being humiliated at school were the background against repeated group rape, suicidal ideation and hoarding habits. Addressing the very early memories seemed to take the pain out of the later trauma too. Karen still felt anger, but she said it was more of a righteous anger and less painful, for example when reading in the newspaper about something that had happened to somebody else that was similar, or talking about the family background, she could now manage it.
We also recorded distressing bodily responses and were able to recognise and alleviate those too, using eye movements and talking and ending with the safe place exercise.
I did consider the dramatic reduction in emotional disturbance as a possible detachment from difficult memories or even dissociation, but as Karen was able to identify feelings in her body and bring up the image of the most traumatic parts of the memories as well as talk about it, it seemed she had genuinely processed the trauma in a way that was effective for her everyday life and in the timescale that we had. Her social worker reported to me that the progress continued to be substantial some months after therapy had ended.
Name *Karen is not the client’s name, her identity is protected for confidentiality.
