The Development and Uses of the “Blind to Therapist”

EMDR Protocol
David C. Blore
University of Birmingham, Teeside University, David Blore Associates Ltd., York, United Kingdom
E. Manda Holmshaw
Moving Minds Psychological Management & Rehabilitation Ltd., London, United Kingdom
Ann Swift
South West Yorkshire NHS Foundation Trust, United Kingdom
Sally Standart
Northumberland, Tyne and Wear NHS Trust, United Kingdom
Deborah M. Fish
Birmingham City University, United Kingdom

The blind to therapist (B2T) protocol (Blore & Holmshaw, 2009a, 2009b) was devised to circumvent
client unwillingness to describe traumatic memory content during eye movement desensitization and
reprocessing (EMDR). It has been used with at least six clinical presentations:

s 2EASSERTION OF CONTROL AMONG hEXECUTIVE DECISION MAKERSv

s 3HAME AND EMBARRASSMENT
s -INIMIZING POTENTIAL FOR VICARIOUS TRAUMATIZATION
s #ULTURAL ISSUES AVOIDING DISTRESS BEING WITNESSED BY A FELLOW COUNTRYMAN
s .EED FOR THE PRESENCE OF A TRANSLATOR VERSUS PREVENTION OF INFORMATION hLEAKAGEv
s 2EDUCING POTENTIAL STALLING IN PROCESSING CLIENT WITH SEVERE STAMMER
4HIS ARTICLE DETAILS THE HISTORY DEVELOPMENT AND CURRENT STATUS OF THE PROTOCOL AND PROVIDES CASE VI-
GNETTES TO ILLUSTRATE EACH USE #LINICAL ISSUES ENCOUNTERED WHEN USING THE PROTOCOL AND hDOVETAILINGv THE
"4 PROTOCOL BACK INTO THE STANDARD PROTOCOL ARE ALSO ADDRESSED

Keywords: eye movement desensitization and reprocessing (EMDR); blind to therapist protocol;
client-centered approach; shame and guilt; aphasia

rancine Shapiro (2001) has advised that divulg-

F ing information is not crucial to the success

of EMDR:
Sometimes a client is unwilling to concentrate
In the current authors’ experiences, there is a
fine line to tread between respecting clients’ wish-
es and knowing sufficient to engage the client in
EMDR. Indeed, it can be argued that this theme runs
on a particular memory because of shame or throughout several eye movement desensitization
guilt. The clinician should reassure the client and reprocessing (EMDR) protocols and forms the
that because the processing is happening inter- foundation for the basic EMDR protocols set out by
nally, she need not divulge the details of the F. Shapiro (1995, 2001) that have subsequently been
memory; merely reporting the fact she is with- supplemented by an array of modifications to accom-
holding something is sufficient. (p. 132) modate the individual needs of the client undergoing

Journal of EMDR Practice and Research, Volume 7, Number 2, 2013 95

© 2013 EMDR International Association [Link]
EMDR (see, e.g., Luber, 2009; R. Shapiro, 2005, 2009). (Blore, 1997) just as F. Shapiro had predicted (F. Shapiro,
This evolution supports EMDR’s credentials as a cli- 1995, p. 129; 2001, p. 132).
ent-centered therapy (e.g., F. Shapiro, 2007; see also The problem of withholding imagery content also
Dworkin, 2005, pp. 8–10), which implies that the onus arose in 2001 (first author’s unpublished case report;
is on the therapist to devise methods to circumvent see also Blore & Holmshaw, 2009b, p. 233) in relation
difficulties encountered by clients when undergoing to EMDR treatment for a ship’s captain involved in
EMDR rather than adopting an a priori expectation a near miss incident with another vessel. The same
that the client should adhere to preexisting require- strategy as with the coal miners was used, but only
ments of the EMDR protocol. later did the captain announce, “Everything I’ve been
The blind to therapist (B2T) protocol represents taught meant I must remain in control at all times.”
one of these attempts to accommodate client’s At the time, this comment was not followed up. With
wishes, and although its current use may be predomi- hindsight, the captain’s comments were to prove
nantly with shame and guilt issues, this was not the important. The basic dilemma was that although
starting point. he believed he “must” be in control of his ship at all
times, the “evidence” for the “must” was based solely
History of the Blind to Therapist Protocol within his training manual. How was the reality of
the situation that actually occurred (viz., that he’d
Problems with disclosure of target memories/
apparently lost control briefly) being handled? First,
images prior to conducting EMDR desensitization
Tedeschi and Calhoun (2004) have advised that thera-
in the literature dates back to at least 1993 (Blore,
pists need to “. . . have some degree of tolerance and
1997), in which an early version of the B2T proto-
respect for the use of some benign cognitive biases”
col was used among coal miners and mines rescue
(p. 413). The captain’s belief of absolutely being in
workers from the Bilsthorpe, United Kingdom,
control was one example. This “cognitive bias” was
Colliery disaster of August 1993. In a critical exami-
being held by someone who could be described as
nation of the EMDR provided to the 28 clients from
an “executive decision maker,” effectively someone
this disaster who received EMDR (Blore, 1997), 423
who had to have the confidence to make unilateral
traumatic memories were treated, with 20 memo-
decisions when needed—someone with a strongly
ries (i.e., 4.7% of the total) categorized as “anony-
acquired internal locus of control, which in turn pre-
mous traumatic memories” (Blore, 1997, p. 93), that
dicts resistance to influence from others (Crowne &
is, targets were not described as per normal Phase 3
Liverant, 1963).
requirements (F. Shapiro, 2001). Blore (1997) origi-
Thompson (1981) has also argued that aversive
nally attributed the reticence to disclose material
situations produce attempts to reassert control. So,
as interactions between guilt and the inherently
finally, there seemed to be a reason for the nondisclo-
“macho” status of the coal industry in the United
sure and whether coal miner, mine’s rescue worker,
Kingdom at the time (p. 93). The method adopted
or ship’s captain, the explanation that seemed to fit
to conduct EMDR was the standard EMDR protocol
was that the individual’s training ran counter to the
but with the following two key changes:
subsequent reality of the traumatic situation. To
s 4ARGET IMAGES WERE LABELLED h! v h" v h# v AND SO minimize the cognitive dissonance generated by this
forth rather than identified as per normal Phase 3 situation, the individual client had reasserted control
requirements. by withholding information.
s !LTHOUGH NOT CLEAR FROM THE ORIGINAL PAPER NO It was noted from 2003 onward that U.K. train
attempt was made to identify a negative (NC) or crew, particularly train drivers (in the United States,
positive cognition (PC). train drivers are known as train engineers), were also
It was also reported that reluctant to describe the details of some traumatic
memories. The A, B, C strategy, described earlier,
s ONE IMAGE LABELLED h$ v RESULTED IN A SPONTANE- was used again. The obvious question was could
ous PC of “I’m convinced I did the best I could,” train crew be placed in the category of “executive
and yet, decision makers”? At a subsequent audit in 2004 (see
s THE SAME COAL MINER REMAINED UNPREPARED TO also Blore, 2005) in a 1-year period, it was found that
describe the original image content after successful 21 train drivers had been treated with EMDR (out of
completion of EMDR. 62 staff from the same train operating company dur-
It is also worth noting that there was a suspicion that ing the same period). Although the choice of targets
guilt was ultimately responsible for nondisclosure was entirely made by the train drivers themselves,

96 Journal of EMDR Practice and Research, Volume 7, Number 2, 2013

Blore et al.
 OF THE TRAIN DRIVERS WERE RELUCTANT TO DESCRIBE THE s 0ROCESS AS PER NORMAL
CONTENT OF TARGETS IN DETAIL WHEREAS  TRAIN DRIVERS s $ISCLOSURE MAY NEVER OCCUR BUT 0#S FREQUENTLY DO
 REFUSED OUTRIGHT TO DESCRIBE TARGET IMAGERY EMERGE DURING DESENSITIZATION
/NCE AGAIN THERE WAS A SUGGESTION THAT A MACHO CUL- s %VEN with A 0# DONT ATTEMPT TO IDENTIFY AN .#
TURE AT WORK HAD CONTRIBUTED TO THIS BUT THIS TIME IT s 3EEK A 0# IN 0HASE  OR OFFER THE CHANCE TO REWORD A
WAS NOTED THAT LIKE THE SHIPS CAPTAIN THERE WAS ALSO 0# THAT AROSE IN THE DESENSITIZATION PHASE 0ROCESS
A STRONGLY HELD BELIEF CONCERNING hCONTROLv STEM- AS NORMAL
MING FROM TRAINING s "ODY SCAN AS PER STANDARD PROTOCOL
s #LOSURE AND REEVALUATION PHASES AS PER STANDARD
A New Protocol Emerges PROTOCOL
"LORE AND (OLMSHAW  HAVE REPORTED THAT CLI-
!S EXPERIENCE ACCRUED IT BECAME CLEAR THAT THE
ENTS WHO ARE UNABLE OR UNWILLING TO DESCRIBE TARGET
FOLLOWING WAS IMPORTANT
IMAGES WERE CONSISTENTLY ABLE AND WILLING TO NEGOTI-
s .OT TO DISMISS THE REFUSAL TO DESCRIBE IMAGERY AS ATE %-$2 TREATMENT BY USING THE "4 PROTOCOL FRE-
hSIMPLY AVOIDANCEv QUENTLY MOVING ON TO THE STANDARD PROTOCOL AT A LATER
s 4HAT ASSISTING CLIENTS TO NOT DISCLOSE IMAGERY IN STAGE IN TREATMENT
DETAIL DID NOT CONSTITUTE COLLUSION BUT GENERALLY LED
TO DISCLOSURE AND TO THE USE OF THE STANDARD PROTO- Case Vignettes: Blind to Therapist
COL AT A LATER POINT IN TREATMENT Protocol’s Different Uses
s 4HERE WAS A CONSISTENT DIFlCULTY IN OBTAINING .#S
AND THAT ATTEMPTS TO OBTAIN .#S RESULTED IN MORE 4O DATE THE CURRENT VERSION OF THE "4 PROTOCOL HAS
REFUSAL BEEN USED AMONG AT LEAST SIX CLINICAL PRESENTATIONS AS
s "ECAUSE IT WAS NOT POSSIBLE TO ASK CLIENTS FOR PRE- ILLUSTRATED BY THE FOLLOWING CASE VIGNETTES THE lRST
CISE FEEDBACK AT THE ENDS OF SETS OF EYE MOVEMENTS TWO OF WHICH ORIGINALLY APPEARED IN A POSTER PRESENTA-
THE ONLY QUESTION RELEVANT WAS WHETHER THERE WAS TION AND HAVE BEEN UPDATED HERE 4HE lNAL VIGNETTE IS
hCHANGE OR NO CHANGEv A VARIATION ON THE "4 PROTOCOL
s 4HIS REQUIRED A NEED TO COACH CLIENTS AS TO WHAT
hCHANGEv CONSISTED OF DURING 0HASE  PREPARATION Vignette 1: Reassertion of Control
OF %-$2 Among “Executive Decision Makers”
s 5SING THE ! " # STRATEGY WAS TOO CUMBERSOME (Blore & Holmshaw, 2009a)
AND LED TO CONFUSION AND PROCESSING STALLING
s 0#S FREQUENTLY AROSE SPONTANEOUSLY DURING 0HASE  )N  THE  YEAR OLD TRAIN DRIVER OF A TRAIN TRAVEL-
DESENSITIZATION LING AT  MPH  KPH WAS INVOLVED IN A FATAL IM-
PACT WITH A  YEAR OLD MAN WHO HAD JUMPED IN FRONT
!FTER VARIOUS MODIlCATIONS THE "4 PROTOCOL WAS OF THE TRAIN 3UBSEQUENT INTERNAL AND EXTERNAL INVES-
PUBLISHED "LORE  (OLMSHAW A AND BRIEmY TIGATIONS EXONERATED THE TRAIN DRIVER OF ANY BLAME !
CONSISTS OF THE FOLLOWING SUBSEQUENT CORONERS HEARING REVEALED THAT THE DE-
s )DENTIlCATION OF A RELUCTANCE OR REFUSAL TO DESCRIBE CEASED HAD BEEN DEPRESSED FOR MORE THAN A YEAR AND
EVENTS TARGETSˆPARTICULARLY IN ANY DETAILˆDURING AT THE TIME OF THE FATALITY HAD BEEN ATTENDING A PSYCHI-
ANY OF THE PRELIMINARY PHASES OF THE STANDARD ATRIC OUTPATIENT CLINIC 4HE TRAIN DRIVER WHO HAD BEEN
%-$2 PROTOCOL REFERRED FOR %-$2 WAS SUFFERING FROM POSTTRAUMATIC
s %XPLANATION THAT %-$2 TREATMENT WILL NOT SUFFER IF STRESS DISORDER 043$ !MERICAN 0SYCHIATRIC !SSOCIA-
MATERIAL CANNOT BE DISCLOSED TION ;!0!=  AND WAS VERY RELUCTANT TO DESCRIBE
s #OACHING THE CLIENT IN CHANGE PRIOR TO DESENSITIZA- THE hPERI IMPACTv MEMORIES OF THE INCIDENT 4HE TRAIN
TION SO THAT FEEDBACK AMONG BILATERAL STIMULATION DRIVER DESCRIBED HOWˆDESPITE EVERY REASSURANCE
",3 SETS ONLY REQUIRES THE CLIENT TO PROVIDE FEED- FROM HIS EMPLOYERS THE "RITISH 4RANSPORT 0OLICE AND
BACK IF CHANGE IS OCCURRING OR NOT THE #ORONERˆHE STILL FELT ENTIRELY RESPONSIBLE FOR THE
s 'IVE THE UNDISCLOSED TARGET IMAGE A CUE WORD FATALITY )T WAS ESTABLISHED AT THE %-$2 ASSESSMENT
THIS REPLACED THE EARLIER LETTERING SYSTEM  THAT THE LEVEL OF PERCEIVED RESPONSIBILITY WAS CLOSELY
s )N 0HASE  DO NOT ATTEMPT TO OBTAIN AN .# OR 0# ASSOCIATED WITH BEING TRAINED TO always BE IN CONTROL OF
OR THEREFORE A VALIDITY OF COGNITION RATING THE TRAIN BEING DRIVEN )N EFFECT THE SUICIDE hPROVEDv
s #OMMENCE lRST SET OF ",3 BY SAYING hNOTICEv TO THE DRIVER THAT HE WAS NOT IN CONTROL !S STATED
CUE WORD EMOTION AND LOCATION  PREVIOUSLY 4HOMPSON  HAS SHOWN THAT IN THESE

Journal of EMDR Practice and Research, Volume 7, Number 2, 2013 97

Blind to Therapist EMDR Protocol
circumstances, clients will attempt to reassert control, change and abreactions. Eventually, “lamp post”
and it is likely that it is precisely what happened dur- became less upsetting and resulted in the feedback,
ing EMDR history taking. “He’s left,” which was the only clue to the image
EMDR was conducted using the B2T protocol. The content. The client identified a PC (albeit negatively
undisclosed target was given the cue word “27.” The worded): “I’m okay, I know it’s not my fault”; and
first few BLS sets were characterized by abreactions, later admitted to having believed that the abuse was
but the client did not use the safe place previously her fault for several decades (in effect disclosing the
installed. After several sets of eye movements, the NC after completion of Phase 4 and identifying the
train driver announced quite spontaneously he had PC). Treatment of the current trigger (hearing about
applied the emergency brakes and the train had come her niece’s abuse) then proceeded smoothly as per
to a halt almost half a mile down the track. He then the standard protocol. The client was discharged de-
described the various “safety-of-the-line” procedures scribing herself as better than she had been in years.
he had enacted, finally declaring there was nothing The client, who had not sought any further psycho-
else he could have done. On returning to 27, he de- logical treatment, was described 4 years after EMDR
scribed the details of what had happened and was as “flourishing.”
able to provide normal feedback from that point in-
cluding revealing the 27 related to a milepost he had Vignette 3: Minimizing Potential for
seen immediately prior to the impact. EMDR subse- Vicarious Traumatization
quently proceeded along the standard protocol and
was completed in five sessions. The train driver was A 36-year-old male involved in a serious and disfig-
asymptomatic on discharge. He was subsequently uring injury at work was referred for EMDR. The
assessed independently for a return to safety critical injuries were mostly concealed from view and had
work and returned to driving trains. Eight years af- healed well over a period of 2 years. The EMDR ther-
ter discharge, with no further treatment interventions apist who, coincidentally, had a close relative who
in the interim, it was noted that he was still driving had sustained an identical injury at work 10 years
trains without any problems. previously and had trained originally as a nurse, re-
vealed in supervision that she had been very upset
by the client’s history. She reported in supervision
Vignette 2: Shame and Embarrassment
that she had been having intrusive images of both
(Blore & Holmshaw, 2009a)
her relative’s injuries and one particular lecture slide
A 54-year-old female survivor of childhood sexual of a similar severe injury that had been projected
abuse experienced between the age of 7 and 11 years onto a large lecture theater screen during her nurse
had sought help for complex PTSD symptoms in the training. It was agreed during supervision to use the
past with little success. She had been referred this B2T protocol, with the intention of minimizing the
time for EMDR, having her memories reignited by potential for further distressing imagery. In addition,
discovering that one of her nieces had been sexually the therapist was advised to seek EMDR for her own
abused. At assessment, the client revealed she was memories (cf. F. Shapiro, 2001, p. 132, relating to the
troubled by one specific memory. Apparently, the suggestion that the clinician self-administers EMDR
perpetrator, now deceased many years previously, after sessions).
had never been confronted by what had happened Having coached the client into the nature of change
and, indeed, no one knew the precise details of what as per normal use of the B2T protocol and identifying
had occurred other than the client herself. At assess- two targets, one allocated the cue word “paper” and a
ment, the client was found to be suffering from both second given the cue word “instructions,” treatment
PTSD and chronic depression and explained that she proceeded relatively smoothly until a point of recur-
could not discuss the image because it was “too dis- rent “no change” occurred during feedback. Given
gusting for anyone to hear.” Therefore, not only did that basic strategies for unblocking processing did
the client not wish to discuss the particular image not appear to work, and that it was not possible to
but also did not wish to traumatize others. EMDR use a cognitive interweave, a visual interweave was
was conducted using the B2T protocol. The undis- used in which the client was asked to provide a second
closed target was given the cue word “lamp post.” image and place it alongside the target memory. The
The first few sets of eye movements were charac- second image was to represent a “resolution” of the
terized by little or no change followed by rapid target image—in other words, an adaptive outcome.

98 Journal of EMDR Practice and Research, Volume 7, Number 2, 2013

Blore et al.
With the two images in place, BLS was restarted. down his face. Between sets, the therapist would
The feedback thereafter was “. . . ‘paper’ has receded signal an inquiry by raising her eyebrows, and initially,
into the background, but the new image has come the client would shrug his shoulders. As the process-
forward . . .”—in other words, change had now oc- ing continued, the client’s body language quickly
curred. Further processing revealed subjective units of began to signal a change and the distress on the cli-
disturbance (SUDs) ratings of 0 and a return to the ent’s face turned to one of interest until he nodded
standard protocol ensued by inquiring about a PC. and said, “Okay.” EMDR continued for another set,
Circumstances prevented the therapist from obtain- and then the interpreter was asked to return to the
ing treatment herself until after the discharge of the room. A short break in processing ensued in which
client she was treating. In subsequent supervision, the the client was able to have his feedback interpreted
therapist reported she had still been “manufacturing” into English. A new target was then chosen, and the
her own imagery during sessions, but that using the whole process with the translator leaving the room
B2T protocol had helped enormously by “not having to was repeated. The client was later able to complete
listen to detailed descriptions of the client’s imagery.” the standard protocol with the translator present dur-
At the time of writing, 18 months after treatment con- ing processing.
clusion, both client and EMDR therapist reported no A year following discharge, it was reported that
problems. the client had enlisted for college to learn English.
At the time of writing, he is well and adjusting to life
in England.
Vignette 4: Cultural Issues—Avoiding Distress
Being Witnessed by a Fellow Countryman
Vignette 5: Need for the Presence of a
A 32-year-old male Iranian, who spoke only Farsi,
Translator Versus Prevention of Information
was a single man who had been imprisoned without
“Leakage”
trial, tortured, and publicly flogged in Iran. The client
was treated in the United Kingdom with EMDR in A general medical practitioner referred a 37-year-old
the presence of a translator. The client reported hav- Libyan freedom fighter to an EMDR clinic for treat-
ing been in constant fear of execution and was taken ment of memories of repeated physical assaults. The
in front of a firing squad on more than one occasion. referral letter included a photocopy of a second let-
He was able to speak about all of these incidents but ter written in English by the client’s cousin explain-
identified an early childhood trauma that he chose ing need for “. . . great caution . . .” as information
not to describe. It transpired that he was reluctant to would in all certainty “. . . find its way to government
disclose the target because of the depth of emotion sources . . .” and the “. . . family would be in mor-
that describing the target generated. Crucially, the tal danger.” The therapist, on seeing the client and
client was unwilling for the interpreter to witness his explaining EMDR, offered—through the translator—
distress. to conduct treatment with the absolute minimum
After discussion in supervision, it was agreed to of information. This decision was made because it
use the B2T protocol and the overall situation was was assumed that identifying any memory content
managed as follows: The interpreter remained in the could have identified the client’s family back in Libya.
room during history taking, preparation, and assess- However, because of the need for translation, it was
ment phases. As per the B2T protocol, the client had not possible to ask the translator to leave the room
examples of change post-BLS sets explained, along (as in the previous scenario). A safe place resource
with the usual addressing of fears and setting expecta- was installed relatively easily, and explanations and
tions. During preparation, an arrangement was made examples of the types of changes that often occurred
to refer to targets by simple cue words and to use with EMDR was discussed—again without reference
basic sign language to indicate change or no change to memory content other than their associations with
following BLS. Once it was clear that preparatory “strong emotions.” Particular emphasis was placed
phases were completed, including the assessment of on the possibility of very small changes in memory
the relevant target, the interpreter was asked to leave post-BLS sets using a metaphor relating to the com-
the room with instructions that he would be called mon competition scenario of two images, ostensibly
back periodically. the same, and with the caption “spot 10 differences.”
During initial BLS sets, the client was clearly in Demonstrations of how EMDR would proceed then
touch with the target memory, with tears pouring followed.

Journal of EMDR Practice and Research, Volume 7, Number 2, 2013 99

Blind to Therapist EMDR Protocol
 The first target was given the cue word “street,” the contract to provide treatment excluded treating
and the client was reminded that when the eye move- preexisting problems, so the cause of the stammering
ments stopped, he only needed to nod his head to was not investigated. The first target image was duly
indicate change in apparent experiences of the mem- identified, and despite the very obvious problem with
ory, shake his head to indicate no change, or shrug stammering, Phase 4 commenced unremarkably.
for “uncertain.” The early BLS sets tended to result However, a few sets into processing the stammer-
in shakes of the head. However, the client was vis- ing deteriorated markedly to the point that feedback
ibly relaxing, suggesting change was happening. took so long that processing continually stalled. Even
This seeming contradiction resulted in breaking off mentioning “the target” seemed to make the problem
processing and restating the nature of change. This re- worse and eventually “(name of) location” was used
vealed that the client had thought change only applied as a cue word in its place. Various strategies thereafter
to the imagery. On restarting processing, feedback af- were tried to encourage brief feedback without suc-
ter BLS sets quickly turned to head nods. cess. Treatment was therefore stopped, the safe place
The client had several problems with “stuck exercise was used, and a discussion ensued so as to
processing.” The therapist reported using a visual establish what might facilitate feedback. It was agreed
interweave strategy, which involve “stretching the to use the feedback method adopted in the B2T pro-
images or otherwise intentionally manipulating tocol. Treatment was duly recommenced, but even
them in some way.” We have called this strategy stating that there was, or was not, change proved
“morphing.” The effect was immediate, and the pro- too difficult. In the end, the client was encouraged
cessing was restarted. to nod or shake his head to indicate change post-BLS
In due course, the translated feedback revealed that set. This immediately helped, and a sequence of BLS
the client had spontaneously considered the thought, ensued followed by nods/headshakes. It was less
“We’re safe,” which he insisted was more important obvious that a channel of association had been cleared
than “I’m safe.” After this, EMDR was then proceeded by processing and, with hindsight, several erroneous
more or less as per the standard protocol from that “returns to target” followed. Eventually, desensitiza-
point. tion was complete, and a PC was obtained. After a
To assist with the confidentialization process, it return to Phase 4, because of a second target emerg-
was necessary to make changes to the log of events ing, the process of choosing a cue word and adopting
between sessions. Initially, it was understood that nods and headshakes was repeated—this time much
anything written would be in Arabic and need trans- more smoothly.
lating, so instead of writing words down, he drew On completion of treatment, the computer tech-
what looked like cartoon images of a face with vary- nician was relaxed and able to speak more freely with
ing degrees of happiness or sadness, and thus not only a minimal stammer. It is likely that some of the
giving any information away that could potentially treatment effects were down to the subsequently
also be “leaked.” disclosed information that “previous therapists
The client describes himself as “happy” 1 year after have given up on me,” thus underlining that taking
treatment. The family finally left Libya 18 months a client-centered approach—as EMDR encourages
after the client’s EMDR was completed. us—can reap huge dividends in terms of relief of suf-
fering. The client returned to work promptly. That
was 2 years ago.
Vignette 6: Reducing Potential Stalling in
Processing: Client With Severe Stammer
Discussion
This case is different to the other vignettes in that
only a single component of the B2T protocol was These vignettes clearly illustrate the range of uses
used rather than the complete protocol. Treatment of the B2T protocol in what otherwise would have
commenced with the use of the standard protocol and been complex clinical presentations that might have
a fully identified image, NC and PC, but then changed otherwise ruled out using EMDR altogether. There
to the B2T protocol when it became apparent that is also a clear theme of “client centeredness” in the
providing feedback was hampering processing. flexibility of conducting EMDR among these clients
A 31-year-old computer technician who suffered using the B2T protocol. Although the intended rea-
with a long-standing stammering problem sought help sons for using the B2T protocol varied throughout the
for his memories of an assault at work. Unfortunately, six vignettes described and shown briefly in Table 1,

100 Journal of EMDR Practice and Research, Volume 7, Number 2, 2013

Blore et al.
 TABLE 1. Synopsis of B2T Protocol Components Used Among Six Case Vignettes
Vignette 2— Vignette 3—
Components of B2T Vignette 1— Shame and Vicarious Vignette 4— Vignette 5— Vignette 6—
Protocol Used Control Issues Embarrassment Traumatization Witnessing Emotion Leakage of Information Stammer

Therapist awareness of Yes—client hypo- Yes—client’s request Yes—therapist’s Yes—client “unable to Yes—warning Nondisclosure not
client reluctance to thesized to be reas- request describe childhood contained in an issue
disclose information serting “control” trauma” photocopied letter

Blind to Therapist EMDR Protocol

Explanation of Client’s training “Too disgusting for Therapist had similar Depth of emotion and Significant risk of Not applicable
reluctance anyone to hear” experiences cultural issues danger to family
B2T protocol intention To facilitate treatment To work within client’s To minimize poten- To preserve wish for To minimize risk of To minimize
while also permit- requested parameters tial for vicarious translator not to danger to family the possibility
ting cognitive traumatization witness emotional of stalled
distortions expression processing
Client taught nature of Yes Yes Yes Yes Yes—in considerable No
“change” in EMDR detail
Cue words for targets Yes—“27” Yes—“lamp post” Yes—“paper” and Yes—(not stated) Yes—street Not needed
“instructions”

Journal of EMDR Practice and Research, Volume 7, Number 2, 2013

How client indicated Stated Stated Stated Nonverbal signals and Nonverbal signals Nonverbal signals
“change” after stated “Okay”
BLS set?
Interweaves used? No No “2-image strategy” No “Morphing” No
Emergence of PC or Yes—(effectively) Yes—(albeit worded Yes—“I am okay” Yes Yes—but in second Yes—“I can cope”
PC theme “I did the best I negatively) person (not first)
could”
Able to complete Yes Yes Yes Yes Yes Yes
standard protocol
thereafter?
Subsequent disclosure Yes—“27” was the No—apparent altruistic No Yes No—and modification Described
of target milepost number. motive to client log beforehand
Outcome/follow-up Still driving trains 8 4 years after EMDR 18 months after 12 months after treat- 12 months after Returned to work
years after EMDR described as discharge, both ment described as discharge, describes within a week
“flourishing” client and therapist “well” and adjusting self as “happy.” of discharge.
“no problems” to United Kingdom 18 months after Still at work
life; attending col- discharge, family left 2 years later
lege to study English Libya

101
Note. B2T ⫽ blind to therapist; EMDR ⫽ eye movement desensitization and reprocessing; BLS ⫽ bilateral stimulation.
THE OVERRIDING PRINCIPLE WAS THAT THE "4 PROTOCOL explains the intention behind using the B2T proto-
did not replace the standard EMDR protocol but col in each vignette.
FACILITATED IT s 'IVEN THAT THE THERAPIST WILL HAVE DIFlCULTY IN ESTAB-
/NE EXPLANATION FOR THE UNWILLINGNESS TO DESCRIBE LISHING WHETHER CHANGE POST ",3 SET HAS OCCURRED
IMAGERY COULD BE PUT DOWN TO LACK OF CONlDENCE TO DOES THE CLIENT UNDERSTAND WHAT CHANGE IS
PUT INTO WORDS AN INTERNAL EXPERIENCE OR IN OTHER 4HIS IS AN IMPORTANT PART OF THE "4 PROTO-
WORDS AVOIDANCE )NDEED IT IS HARD TO ARGUE THAT IT ISNT COL 4HE CLIENT NEEDS TO BE THE DECISION MAKER
AVOIDANCE BUT GIVEN %-$2S CLIENT CENTEREDNESS THE AND THEREFORE NEEDS TO KNOW WHAT CHANGE IS
onus is on the therapist to assist the client overcome BEFOREHAND 4HE ADVICE IS TO KEEP EXPLANATIONS
THE HYPOTHESIZED AVOIDANCE RATHER THAN MERELY DEFER STRAIGHTFORWARD AND INCLUDE ALL COMPONENTS
TREATMENT BECAUSE THE CLIENT ISNT hPSYCHOLOGICALLY OF THE TARGET INCLUDING REFERENCE TO hNEGATIVE
MINDEDv OR PREPARED TO lT THE PREEXISTING TREATMENT THOUGHTSv  FOR EXAMPLE h3OMETIMES CHANGES CAN
FORMAT BE QUITE OBVIOUS SUCH AS THE IMAGE MOVING AWAY
!NOTHER POSSIBLE INTERPRETATION IS THAT WITHHOLD- FROM YOU OR CHANGING ALTOGETHER OR THE SENSA-
ING CONTENT DETAIL IS MERELY COINCIDENTAL !GAIN THIS TION IN THE BODY MOVES OR THE EMOTION CHANGES
MAY BE SO ESPECIALLY BECAUSE NONE OF THE AFOREMEN- OR DISAPPEARS OR NEGATIVE THOUGHTS YOU MAY HAVE
TIONED VIGNETTES HAS BEEN SYSTEMATICALLY QUANTIlED ABOUT YOURSELF ALTER   v 4HE FOLLOWING METAPHOR
NEVERTHELESS THE ISSUE OF NEEDING TO HELP THE CLIENT IS USEFUL IF THERE IS A NEED TO EXPLAIN ABOUT SUBTLE
OVERCOME THEIR PREDICAMENT REMAINS 4HERE IS IN- CHANGES THAT COULD BE EASILY DISMISSED h9OU MAY
TRIGUINGLY A THIRD POSSIBILITY HIGHLIGHTED BY THE SECOND WELL HAVE PLAYED THE COMPETITION IN MAGAZINES
VIGNETTE ALTRUISM !LTHOUGH SPACE DOES NOT PERMIT AN THAT SHOWS TWO PICTURES WHICH ARE SUPERlCIAL-
EXPLORATION OF THIS FACTOR THE SECOND VIGNETTE COULD LY THE SAME BUT WITH THE CAPTION @SPOT THE 
BE ILLUSTRATING A FORM OF hREVERSE CLIENT CENTEREDNESSv DIFFERENCESv
IN WHICH THE CLIENT IS CONSIDERING THEIR PROBLEM FROM s 7HAT TYPES OF hCUE WORDSv ARE NEEDED WITH THE
THE THERAPISTS PERSPECTIVE "4 PROTOCOL
7HICHEVER EXPLANATIONS ARE CORRECT CAUTION IS #UE WORDS ARE ALREADY USED TO TRIGGER THE USE
STILL WARRANTED WHEN USING THE "4 PROTOCOL 4HIS IS OF AN ENTIRE RESOURCE SUCH AS A SAFECALM PLACE
PARTICULARLY IMPORTANT BECAUSE A RELATIVE LACK OF INFOR- )N THE "4 PROTOCOL THE CUE WORDS NEED TO TRIG-
MATION MEANS THE BASIC QUESTIONˆh(OW DO ) KNOW GER THE ENTIRE TARGET MEMORY NOT JUST A VISUAL
MY CLIENT IS WELL ENOUGH PREPARED FOR %-$2vˆIS COMPONENT 0ROVIDED A CUE WORD TRIGGERS AN EN-
INEVITABLE YET NEEDS ANSWERING IN THE AFlRMATIVE TIRE MEMORY THEN THEY CAN CONSIST OF ANYTHING
)N SOME WAYS THE QUESTION CAN BE ALTERED TO hAM ) ALTHOUGH THEY NEED TO BE BRIEF AND PREFERABLY
PREPARED ENOUGH TO CONDUCT THE "4 PROTOCOLv GENERATED BY THE CLIENT SEE 4ABLE  FOR EXAMPLES 
!LTHOUGH THE EFFECTIVENESS OF THE "4 PROTOCOL HAS &ROM TRIAL AND ERROR IT IS CLEAR THAT USING SOME
YET TO BE FORMALLY QUANTIlED THERE IS SUFlCIENT CLINI- FORM OF LETTERING OR NUMBERING OF TARGETS MERELY
CAL EXPERIENCE TO BE ABLE TO ISSUE GUIDELINES ON HOW TO CAUSES CONFUSION SEE "LORE  UNLESS A LET-
MANAGE THE USE OF THE PROTOCOL 4HE FOLLOWING QUES- TER OR NUMBER IS MATERIAL TO THE TARGET ITSELF SEE
TIONS AND ANSWERS SUMMARIZE THE KEY CLINICAL POINTS 6IGNETTE  AS AN EXAMPLE 
TO CONSIDER SEE ALSO 4ABLE   s (OW WILL PROCESSING DIFFER TO THE USE OF THE STAN-
DARD PROTOCOL
s )S THE CLIENT INDICATING A RELUCTANCE TO DISCLOSE MATE- -ANAGING THIS ASPECT OF THE "4 PROTOCOL RE-
RIAL PARTICULARLY DETAILED INFORMATION )S THERE AN QUIRES PRACTICE ! COUPLE OF THE MOST COMMON
EXPLANATION FOR THE RELUCTANCE QUESTIONS ARE 7HERE IS THE END OF A CHANNEL OF AS-
)T IS PARTICULARLY NECESSARY TO MAKE A DISTINC- SOCIATION (OW CAN ) DISTINGUISH BETWEEN BLOCKED
TION AMONG hRELUCTANCE TO DISCLOSE v DISSOCIATION PROCESSING AND REACHING THE END OF A CHANNEL OF
AND AVOIDANCE BECAUSE OF ANXIETY OR LACK OF ASSOCIATION
preparation. 4HIS RELIES ON THE THERAPIST ESTABLISHING A lNELY
s 7HAT IS TRYING TO BE ACHIEVED BY USING THE "4 PRO- TUNED CONGRUENCY BETWEEN A STATED hYESNOv OR
TOCOL )N OTHER WORDS WHAT IS THE INTENTION NONVERBAL NODSHAKE OF HEAD AND THE REMAINDER
Consideration should be given to both client and OF NONVERBAL SIGNALS 7HERE THERE IS DOUBT A SEC-
THERAPISTS PERSPECTIVESˆSEE FOR COMPARISON THE OND BRIEF QUESTION IS OFTEN USEFUL ALONG THE LINES
DIFFERING PERSPECTIVES IN 6IGNETTES  AND  4ABLE  h)S WHAT YOU NOW GET BETTER WORSE OR NOT SUREv

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Blore et al.
 Obviously, good preparation beforehand will facili- component to other presentations. To be able to
tate matters. manage these often delicate situations by facilitat-
s 7HAT INTERWEAVES ARE AVAILABLE TO UNBLOCK ing the clients’ wishes until they feel comfortable
processing? to disclose material—or not as in the case of
A second aspect of how processing may differ Vignette 2—surely promotes the therapeutic re-
is the use of interweaves. By intention, the target lationship in EMDR and EMDR’s credentials as a
memory content and the NC are not known, also, client-centered therapy. This alone warrants the
the content of any emerging material post-BLS investigation of the wider use of the B2T protocol;
is not known, so using standard cognitive inter- suffice to say, at present, rather than insisting that
weaves is virtually impossible. However, using shame and embarrassment issues are sidelined for
visual interweaves works very well, particularly the sake of compliance to a psychological model,
two strategies: there can be no reason to dismiss a client as “not
being psychologically minded” any longer.
“Two-image strategy”—see Vignette 3 for an
Vignette 6, despite only using part of the
example.
B2T protocol, highlights a very important cli-
“Image morphing”—see Vignette 5 for an
ent presentation, namely, aphasia—the inability
example.
to any degree to be able to express oneself (cf.
In addition, it is worth mentioning that basic Brookshire, 2003; Code, 2003; Code & Petheram,
strategies to unblock processing (F. Shapiro, 2011). The vignette is related to a client with a
2001) can also be used effectively such as chang- severe stammer, which on the aphasic spectrum is
ing direction, speed, modality of BLS, and so forth arguably not a severe aphasic problem. However,
because none of these require any disclosure of successful use of the B2T protocol begs the ques-
target content. tion, “To what extent can EMDR be usefully
s 7HAT HAPPENS IF A 0# DOES NOT EMERGE employed among clients with expressive prob-
In the six vignettes, a PC arose on each occa- lems of any degree?” The question is important
sion. On this basis, it does appear that PCs arise because of the prerequisite in any form of psy-
almost spontaneously as a general rule. There chotherapy to be able to communicate. It follows
have been some occasions when this has not oc- that profound clinical presentations of aphasia
curred, but either way, it has been possible to among clients are not currently amenable to talk-
establish an appropriate PC at the commence- ing therapies and because, logically, the greater
ment of Phase 5 (installation of PC). It therefore the problem with communication, the greater
does not appear to matter if a PC doesn’t emerge the difficulty in engaging with psychotherapy. A
spontaneously. protocol that at least addresses the issue of apha-
s #AN THE STANDARD PROTOCOL BE SUBSEQUENTLY sia is therefore significant. Aphasia of any cause
completed? often holds unspeakable trauma, psychological
Again, all six vignettes show that it was possi- pain, and feelings of loss, hopelessness, and de-
ble to dovetail the B2T protocol into the standard tachment. These are mental health issues like any
protocol. The only vignette to differ was the sixth, other and are deserving of attention. EMDR, via
which commenced with the standard protocol, the B2T protocol, appears to have a method of
used a component of the B2T protocol, and re- “opening up” this category of problematic presen-
turned to the standard protocol from Phase 5 tations, which previously would not even have
onward. been considered for therapy. Use of the B2T pro-
s 7HAT OTHER POTENTIAL USES FOR THE "4 PROTOCOL tocol, or modified version of it, possibly with the
may there be? aid of information technology, could therefore
It is unlikely that the six vignettes cited in this represent a significant step forward in the psycho-
article represent the total use of the B2T protocol. logical mental health welfare of all clients with
In this respect, Vignettes 2 and 6 are particularly profound difficulties in speaking, potentially, up
noteworthy. to and including “locked-in syndrome.”
Vignette 2, relates to managing shame-related s %VALUATION AND FURTHER RESEARCH
issues. Shame and its counterpart, embarrassment, Regarding B2T protocol research, all six vi-
are undoubtedly very common problems—if not gnettes cited have come from routine clinical
as primary presentations, then as a secondary experience. This account does not mean the

Journal of EMDR Practice and Research, Volume 7, Number 2, 2013 103

Blind to Therapist EMDR Protocol
 potential usefulness of the B2T protocol has been References
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Tedeschi, R. G., & Calhoun, L. G. (2004). A clinical Correspondence regarding this article should be directed to
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Joseph (Eds.), Positive psychology in practice (pp. 405–419). York, YO1 9RA, United Kingdom. E-mail: [Link]@
Hoboken, NJ: John Wiley & Sons. [Link]

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