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What is meant by a flashforward?

 The mental representation of an unlikely (irrational) future feared catastrophe

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This type of imagery

(‘flashforwards’) may be a core Two studies examined whether EMDR affects recurrent, aspect of most anxiety intrusive imaggpes about potential future catastro phes (‘flashforwards’) disorders

 Two samples of students who suffered from recurrent Vividness distressing intrusive images about impending danger (n=28 + n=37)  Two negative visual images about events they feared might happen to them in the future (e.g., the funeral of a loved one, being hit by a car)  These flashforwards were randomly distributed to either ‘recall with eye movements’ or ‘recall only’ condition  Four sets of 24-sseachwith10 each with 10-s breaks in between Recall only Recall + Eye movements

Pre-test Post-test Emotionality/V Emotionality/V ividness ividness EM +

Emotionality

Note that these effects were found after just 96 seconds of recall + eye movements

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IMAGES OF IMPENDING DOOM How to do a flashforward?

DISASTER IMAGES • Use patient’s flashforward as a target for processing with the Standard EMDR Protocol EXPECTED CATASTROPHES • The NC is standard and in the domain of control (“I am powerless” (against my flashforward) FLASHFORWARDS • Use as standard PC “I can handle this (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  Contains catastrophic elements of what • "What we need to figure out is what kind of image is in might happen in the future your mind that makes you fearful about a future confrontation with the thing/the one you fear. What do  Context specific, and conceptually you fear that will happen, and will go wrong when you are 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 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 vermijjgdt wordt geconfronteerd; bi jvoorbeeld een 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 en verwond]. Hoe zit dat rampscenario of confrontations seen something information: stories with a traumatic happening of others, books, schrikbeeld precies in je hoofd? …..” stressor movies etc.

Situations that actually went wrong or nearly went wrong

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Spider phobia What do many people (women) fear when they are confronted with a spider?

“It (he) will crawl into my private parts…”

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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

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MENTAL REPRESENTATION OF UNCONDITIONED STIMULUS

UR A flashforward is FLASHFORWARD not a picture of the person CS US experiencing his UR US symptoms CS TOWER FALLING but + SCHOOL VOMITING the actual disaster image DENTAL TERRIBLE ANXIETY DRILL PAIN

What is possible with a flashforward? Clinical approach: What is in the brain of the client,  A scary fantasy (catastrophe beyond that needs to be removed to the catastrophe; fear of the dead) or diminish the current (positive) fantasy symptomatology?  A ‘feeling’ or ‘physical sensation’  Fright (Balloon phobia, bird phobia)  Falling (height phobia)

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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 that seems ‘key’ the depth itself

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. It is much more frequent than fear of heights, which is defined as an environmental subtype of a specific phobia. There is certainlyyg a continuum stretching from acrophobia to a less- pronounced visual height intolerance, to which the categorical distinction of a specific phobia does not apply.”

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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 representations to target? messages • Always look for ‘the disaster behind the disaster’

Look for the catastrophe beyond the catastrophe (driving phobia) Case #1

What could be a potential target? A young woman has a severe fear, and obsession about forgggetting to turn off the gas before going out PanicGetting Crashing Killinga Burning an Children attackheart with innocent thein theFuneral carleft alone duringattack carperson without driving parents

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Mental representation Memory from of the (neutral) stimulus situation. the past But one in which she does not check (exposure and response prevention)

Leaving without checking Mental representation Can we do EMDR, and if so, of what might happen (go wrong) what would be an appropriate Memory from when she does not check FUTURE TEMPLATE the past target? Explosion?

FLASHFORWARD

Memory from the past

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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 • Indications for the use of flashforwards? powerless, bleeding to death) • Social phobia (being rejected or other embiitti)barrassing situation) • 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)

Other examples Highlights en questions (3)

• Fear of childbirth (death of the • What to do when there are still child) complaints, or avoidance behavior, after the flashforward has been applied • Loss of desire in having sex (painful succesfuly? experience, failure)

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Treatment strategy EMDR treatment

Fear and avoidance

Memories Flashforward Events that Future template Video check Behavioral Directly on the (des. + install.) (des. + install.) (install.) (install.) experiment Event that caused worsened the disaster fantasy Future the fear fear (flashforward) template

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Reprocessing of targets

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