Volume VI, Issue 3, Article 2 (October, 2000)


Book Reviews: Three EMDR Books On Children and Adolescents
Personal Introduction
        It was with keen anticipation that I awaited the arrival of the Tinker & Wilson book, having experienced both authors' specialist presentation on using EMDR with children in Scotland, very shortly after my EMDR training (in Belfast, courtesy of the HAP) following the Dunblane tragedy of 1996. I was also delighted to review books from two other distinguished authors. I remain indebted to the fellowship of many EMDR colleagues around the world including the EMDR UK and Ireland Committee and, in particular, to David Grand for his ever-available transatlantic guidance.
        Becoming a facilitator opened my eyes further to the great wealth of published and unpublished knowledge. I have worked mainly with children since 1970 in two careers, changing to psychology in 1975 and worked in Central Scotland for twenty years specialising in child clinical psychology but retaining an interest in adult, particularly maternal cases. My interests include bereavement and trauma, psychosomatic disorders and child management.
        Please note that these reviews reflect my personal views and were mostly based on pre-publication manuscripts that will have undergone revision since writing this.


Through the Eyes of a Child: EMDR with Children by Robert H. Tinker, Ph.D. and Sandra A. Wilson, Ph.D. Publisher:  W. W. Norton & Company  (New York and London), 1999.
        Recent studies relating to the neurobiology of trauma are examined with comment on the dilemmas regarding the fit of science to clinical practice and speculation about the mechanism of action of EMDR, with clever use of metaphor. Diagnostic relevance to prognosis was considered along with the pitfalls of using specific criteria in isolation, resulting in under reporting of childhood trauma. The authors reflect on society's inability to recognise traumatic sequellae.
        It was good to see crystallised, six parameters of predictability of EMDR success (with trauma treatment) drawn from literature and observation. Clear case examples demonstrate ways to prepare children and families for EMDR. EMDR is used in appropriate clinical context to demonstrate its brilliant effectiveness without extravagant claims. The book seems particularly honest in its case examples, pitfalls and successes.
        My favourite explanations and demonstrations pertained to an associative chaining, where a child's limited capacity to make spontaneous connections during processing is skillfully teased out. Excellent dialogue is presented with an unresponsive child demonstrating skill and persistence born out of years of experience of changing non-productive sessions to therapeutic ones. I must confess to losing some guilt about interacting with children during EMDR sessions, because the necessity was made explicit for some child cases. Developmentally appropriate examples augment the standard knowledge available in the original Shapiro (1995) text. Recognition and control of dissociative phenomena during sessions is described without discussion of the more severe dissociative identity disorders.
        Bereavement and phobias are explored with illustrations of children acting out feelings in behaviour. Case studies illustrate how to clarify the minimal or confusing answers one gets from children through a good protocol to the finished therapy. The complexity of more long-term therapy was shown, using attachment issues as one example. Hypotheses on the mechanics of EMDR are combined with practical illustrations in the Troubleshooting chapter. Ubiquitous yawning, (not on the part of the therapist) was said to be a sign of processing and working hard but I have sometimes found this to be a signal that processing was not taking place but that the child is tired and has stopped processing. Further case examples included blocking beliefs, self-control and ADHD.

        Strengths:  Excellent EMDR dialogue is presented with difficult cases. The most comprehensive and informative regarding reviews of psychobiological and empirical research data alongside skilled casework. It was sprinkled with humour and easy to read.

        Other Comments: A full account of all aspects of EMDR with children, but with some topics addressed briefly towards the end. Tinker & Wilson are a rare hybrid of gifted researcher and compassionate effective clinician.

Primary audience: This book is particularly recommended for the already skilled therapist wishing to advance his or her understanding of EMDR. Despite the child focus, I believe it is essential reading for all EMDR users due to its developmental perspective, which also influences much adult trauma. It is an important reference for all.

Opinion: The text is well-referenced with practical case examples, theoretical and neurophysiological overview and literature review, neatly packaged to maintain interest. Innovative interactive techniques illustrate when to accept (and how not to accept) appropriate and inappropriate cognitions for children. The flow from protocol to therapy is often seamless. The hallmarks of expertise were met by the authors' conversion of complexity to simplicity with minimal loss of data. I unreservedly recommend the book to all users of EMDR with either adults and children due to its wide perspective, comprehensive theory and evidenced based reference. It contains a wealth of knowledge.

        The book is blended like a fine, smooth malt whisky. It has a unique combination of evidence based fact, neurobiological overview, excellent clinical case description, instruction and anecdote based on many years of skilled experience with a rare style that makes it extremely palatable, with continued satisfaction when you resample it.

        Eye-movement Desensitization and Reprocessing (EMDR) in Child and Adolescent Psychotherapy by Ricky Greenwald Psy.D., Publisher: Jason Aronson (New York), 1999.

        The first Chapters establish the author's interests, with EMDR protocols examined and Resource Installation methods described. EMDR is seen to be effective for a range of conditions when trauma is viewed in its wider perspective as a common development from early upsetting experiences. The accelerated information-processing model is used to illustrate. Disruptive behaviour is viewed with an impulse control model and its links with ADHD are examined.

        Essential skills to engage non-communicative children are well illustrated with examples of necessary preliminary work prior to EMDR. This text demystifies therapy and makes explicit the introduction of treatment to families. The importance of consistent child management is explained to parents, keeping the fine balance of illustrating inconsistencies while encouraging their strengths. Rules and limits for therapy, managing parental disagreements and engagement of families are presented. Concepts including reinforcement are explained without jargon to clients. Greenwald shows clear skills in communicating essential principles to families with illustrative and inventive metaphors in highly successful formulae. Indeed, this book does not simply present EMDR but it examines the absolute basics of interviewing children and adolescents.

        Inventive techniques of engagement are used to entice the patient into eye movements. Gaining street credibility by mastery of small but important elements such as installation of safety mechanisms (an advancement on A Safe Place for children) are among the well-practised techniques. Obtaining Negative and Positive cognitions by extracting elements of a movie make this also a jargon-free interaction.

        Protocols are obtained conversationally and installations occur almost casually. Positive outcome is methodically assured at the outset. Examples such as wearing a sign  (which employees might also find useful with managers) tempt the unwary (with a curiosity killed the cat principle) to follow Greenwald's line of argument. One can imagine an adolescent who, faced with an interesting proposition without quite being able to figure the therapist's angle, has to be taken in. The early-warning system begins with: "You know how in the movies an attacker can sneak right up to the house, and maybe even inside before anyone ever knows he is there?" The purpose is to illustrate a route into the young psyche. Attention is captivated, eye movements are added and the first stages of therapy are completed before they notice! Skillful integration of conversation with cognitive-behavioural sequences of treatment and EMDR are neatly combined. Other easy to remember illustrations include tease-proofing (a form of resource installation) and the "Who's in charge of you?" dialogue to demonstrate the inadvertent reactivity of us all.

        In Part Two, Technical Repertoire, the standard protocol as applied to children is reviewed in detail. I do not always agree with the terminology, but the message is always clear. Dilemmas about when to start therapy to prevent blocking are discussed, with discussions of the advantages of safety devices and safety issues. The collective inventiveness of several clinicians is shared and credited, showing ways to encourage eye-movements. Protocol components are discussed and expanded. Topics include other modalities of bilateral stimulation, the complexity of litigation and potential interaction of EMDR and memory. More metaphors are illustrated including "The Dislocated Finger"  and  "The Chest of Drawers." I enjoyed the "Stuffed Animal Mode," a projective method of engaging in therapy without overt reference to the identified targets. A variation of the safety device, uses letters to make believe it was a dream. This device could help to overcome impasse due to concrete thinking. Examples then moved to the wonderfully surreal sibling rivalry with an animal allowing it to interact with a manipulative child.

        Part Three, Special Applications, looks at Infants and Toddlers and mentions a 4 step diagnostic routine that I could not find in my pre-production copy. In the Young Children section, I found an excellent explanation of the development of magical thinking and the Terrible Twos (coincidentally on page 222 of my copy). Chapter 11 uses “bed-wetting” as one example where work with the whole family is necessary to good effect, but I do not agree there should be even minor consequences for bed-wetting, such as washing sheets. How to explain basic concepts to parents without making them appear inadequate, is solved by a demonstration to the child with the parent present. It would be interesting to be a fly on this consulting room wall to observe an interactive demonstration.

Strengths: Excellent ways of engaging non-communicative children and adolescents are illustrated. This book contains essential basics of interview and assessment techniques for any child worker and shows how to progress smoothly into EMDR, introducing clever modifications to the protocol.

Other Comments: Engaging to read, maintaining your curiosity about what is coming next. It has a direct and open style and credits others when the ideas form an amalgam of techniques. The book is occasionally repetitive, but this helps you to find what you need.

Primary Audience: The text is almost equally suitable for EMDR and non-EMDR child-workers due to its excellent ways of engaging difficult or non-communicative families. I highly recommend this book for all child disciplines honing their craft and those wishing to gain insight into rapport-building and engagement. Mandatory for my trainees, I also recommend it to seasoned therapists.

Opinion: This is the book I wish had been written when I was training. It might have prevented some of the grunts and blank stares we occasionally had to observe during interviews. The captivating dialogue baits, leads, baits again and hooks you, inexorably, as the child would be in therapy. It de-jargonises and demystifies therapy but also shows new angles. EMDR child protocols are examined in detail with many case examples. This text is especially suitable as a primer for new therapists of any child discipline. Detailed interactive, engagement skills and communication basics, are made explicit. Empirically-based techniques of self-control training, rapport, and relationship-building are illustrated using structured choice methods. Dr. Greenwald's experience and enthusiasm for working with a young population shine through.

        All therapists learn to manipulate and child therapists become arch manipulators, but this text inspires me to quote a Scottish poem my daughter recently recited, "A Dug A Dug" by Bill Keys. "A Ah don't think thur's ever been embdy like you. Ye could wheedle the twist oot a flamin coarkscrew."

Small Wonders: Healing Childhood Trauma with EMDR
Joan Lovett, M.D., Publisher: The Free Press(New York), 1999.

        Dr. Lovett tells her own moving story in the first revealing chapter with the captivating title: Why am I afraid of the sound of carrots crunching.  By placing her credentials on the table, she convinces you that she understands trauma. Her integrative approach with children begins with positive installations set in a backdrop of play therapy. Cautions were given that a year's work might be done with a family before introducing EMDR and only then with permission. An example of the consequences of affect overload in a child was portrayed by the response: I would rather die than do EMDR again.  Due to excellent therapeutic rapport, the child trusted enough to continue in other therapy. This shows the essential component of any EMDR therapist, that one can work at the child's pace and know when and when not to apply EMDR.

        "Educational interweaves" are presented as an advantage over straight "cognitive interweaves."  When asked a rhetorical question (that would successfully stimulate an adult into resolution of an issue) a child might see an impossible dilemma. An educational component built into the "interweave" obtains the desired outcome.

        The book sensitively portrays how over concerned parents might unwittingly reinforce difficulties or perceive setting boundaries as too harsh for their child. Children's loyalty to their parents is highlighted as being of the utmost importance in the hierarchy of the psyche's priorities for protection. EMDR is shown to work as the child's situation allows. "Cascades of trauma" is introduced by Lovett to describe multiple overwhelming trauma that might (in my words) later compress to become "layers of an onion" in an untreated adult.

        Cases in Part Two describe how sensory perceptions during a critical incident leave us with triggers to a full danger reaction. Parents are helped to write a simplified story and suggest negative and positive cognitions for the therapist to use. Using stories about children's favourite characters to illustrate a therapeutic point is not new but here they are cleverly combined with EMDR. Ways to motivate and hold the fearful younger child in therapy are well demonstrated. For example, a child's bravery in using a toilet is discussed while the child plays and listens. Behavioural principles of modeling and exposure are combined with EMDR in safe settings (e.g., "turning on a faucet" was used as a reminder of water dousing flames.

Using various examples, the author illustrates the power of soothing or compensating behaviours such as over eating for comfort and how common childhood occurrences such as "Nits" might result in trauma, loss of social relationships, parental phobic reactions and possible misdiagnosis of conditions such as OCD Integrative skills using the sand tray and EMDR make the techniques look simple with EMDR making a significant shift, and the author shows a combination of EMDR and play therapy to be more effective than either one alone for dealing with severe somatic symptoms.

            Unresolved bereavement cases illustrate how grief locks into other life issues. I was pleased to see the caution that even after removal of anxiety, behaviour modification is often necessary to assist, and the author shows how external family issues need to be resolved before progress is made. An over eating problem was successfully dealt with by giving it a name and independent identity, but this is not a technique I favour.

            Assumptions of responsibility and magical thinking during childhood persist into later years with an adult who failed his bar examinations that he was due to retake in three weeks. The examples illustrate how children hold magical beliefs about their power to control. Often a practical demonstration (or cognitive or educational interweave) is needed to prove that their thoughts or actions do not control the behaviour of others. For this reason, I do not like the occasional reference to increasing a child's own magic, but I approve of assisting children to become stronger or increase their innate power.

        The book concludes with clear and useful Appendices: (1) general questions on EMDR (2) guidelines for parents (3) Story telling guidelines and (4) a clinicians' guide to story writing and planning the therapy sessions.

Opinion: Small Wonders presents a collection of clinical mysteries as warm, moving case stories, written in a style that is engaging and accessible to parents as well as clinicians. Essential information for the experienced therapist is subtly woven into the stories. The appendix contains useful guidelines for clinicians and instructive hand outs for parents. The innovative story telling method should please a wide audience. The book is sprinkled with wisdom, shows complete respect for the child's needs and illustrates well how children in 'good families' get problems. I could imagine relief to many families who think that their problems are impossible to solve.

Strengths: Warm, moving case stories offer insights (almost invisibly intertwined) into the child's mind, effectively illustrating how everyday events can become traumatising. A series of unusual complex cases introduce Dr Lovett's story-telling technique developed for use with EMDR.

Other Comments: Case examples throughout are of consistent quality. Minimal references in the text complement the undemanding story telling style that could be an advantage to the non-technical reader.

Primary Audience: This book is especially suited to parents who are concerned about their child's puzzling posttraumatic behaviours. It is also highly recommended for medical professionals who are interested but unsure about how EMDR might assist children.

Common Themes

        It was reassuring to see common, good practice in all the books, with cautions about the necessity to integrate EMDR as part of a complex therapeutic regime. What remains invisible to many outside our field is the enormity in the child's perception of the slightest embarrassment or rebuff as a child. These minor traumas are magnified and can remain locked in a time continuum distortion worthy of any science fiction script, incubating and expanding in power, until expert release is available.

        Non-child therapists might be tempted to try EMDR with children when techniques are so lucidly described, unaware of the effects of family dynamics, subtle signs or hidden symptoms, invisible to all but the most skilled therapist. I was reassured by cautions that therapy with children can be counter-productive without family co-operation, rapport-building, detailed preparatory work and complex interaction with parents to promote child improvement. A child will not work through a 10 on the SUDs scale, no matter that they agree to, without considerable preparation and a very careful approach. Each author recognised the need for a range of skills before using EMDR with children and demonstrated ways to elicit the deepest fears from children and resolve them.

        With the thousand or so pages reviewed, it is easy to pick a handful of sentences with which to disagree. We do not always have common understanding of terminology for this new science and similar terms have subtle differences of meaning, so I apologise if I have misinterpreted any. These publications confirm my views that one needs all the necessary adult skills and then considerably more to be effective with children. I also believe the converse, that child-focussed work improves adult work.

        I believe these books offer insight into the child's world while also providing an invaluable resource to those dealing with adult survivors of childhood abuse. EMDR has added a new dimension to my therapy and I believe that it often results in considerable modification to the way clinicians think about their patients. Once understood, there is no backtracking.

        I thoroughly enjoyed each of these books and I feel honoured to have been able to review them. I hope you get as much pleasure and guidance from them as I did.

Philip Dutton B.Sc., Dip. Clin. Psychol., C. Psychol., A.F.B.Ps.S.
Consultant Clinical Psychologist (Child, Maternal and Family Health)
www.synapse2000.com

Volume VI, Issue 3, Article 2 (October, 2000)