Eye Movement Desensitization and Reprocessing in the Treatment of Panic Disorder With Agoraphobia

Clinical Case Studies
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Eye Movement Desensitization and Reprocessing in the Treatment of Panic
Disorder With Agoraphobia
Isabel Fernandez and Elisa Faretta
2007; 6; 44
Clinical Case Studies
DOI: 10.1177/1534650105277220

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Clinical Case Studies
Volume 6 Number 1
February 2007 44-63
© 2007 Sage Publications
Eye Movement Desensitization
10.1177/1534650105277220
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hosted at
and Reprocessing in the
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Treatment of Panic Disorder
With Agoraphobia
Isabel Fernandez
Italian Association for Cognitive Behaviour Therapy
Elisa Faretta
H. Bernheim Italian Institute of Clinical Hypnosis and Psychotherapy
This article describes a comprehensive treatment of a case of panic disorder with agoraphobia.
A thorough history taking revealed that experiential contributors had a pivotal role in the
development of the condition. Therefore, eye movement desensitization and reprocessing
(EMDR) was used to address early traumatic events as well as the present stimuli that caused
disturbance and had maintained symptomatology for the past 12 years. Although the client’s
symptoms were resolved after 15 sessions, EMDR was also effective in addressing future
behaviors and resolving anticipatory anxiety. During EMDR processing, the client demonstrated
emotional and cognitive changes consistent with trauma resolution, insight, and personal
growth. The client gradually enacted functional new behaviors spontaneously as treatment
unfolded. The therapeutic process and the targets are described in detail.
Keywords:
panic disorder; agoraphobia; eye movement desensitization and reprocessing; trauma
1 Theoretical and Research Basis
Eye movement desensitization and reprocessing (EMDR) is an integrative psychother-
apy that has been extensively evaluated in its approach to trauma and posttraumatic stress
disorder (PTSD). In 1998, the American Psychological Association’s Division 12 Task
Force on Psychological Interventions designated EMDR, along with exposure therapy and
stress inoculation therapy, to be probably efficacious in the treatment of trauma (Chambless
et al., 1998). The International Society for Traumatic Stress Studies (Chemtob, Tolin, van
der Kolk, & Pitman, 2000), the Israeli National Council for Mental Health (Bleich, Kotler,
Kutz, & Shaley, 2002), and the Northern Ireland Department of Health (Clinical Resource
Efficiency Support Team, 2003) soon followed by also designating EMDR as an effective
form of treatment for PTSD and victims of terror. Most recently, the U.S. Departments of
Defense and Veterans Affairs (2004) and the American Psychiatric Association (2004) have
given EMDR the highest level of recommendation.
Authors’ Note: Correspondence regarding this article should be directed to Dr. Isabel Fernandez Via Paganini,
50 20030 Bovisio Masciago (MI) Italy; e-mail: isabelf@tin.it.
44
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Fernandez, Faretta / Panic Disorder and EMDR Treatment
45
Since its introduction in 1989, several controlled studies have compared EMDR with
other types of treatment for PTSD. The findings indicate that EMDR and cognitive behav-
ioral therapy (CBT), including exposure, appear to be equally effective, although EMDR
may involve fewer treatment sessions and requires no daily homework (Ironson, Freund,
Strauss, & Williams, 2002; Lee, Gavriel, Drummond, Richards, & Greenwald, 2002; Power
et al., 2002; Rothbaum, 2001; Taylor, Thordarson, Maxfield, Fedoroff, Lovell, & Ogrodniczuk,
2003; Vaughan et al., 1994). Civilian studies of single-trauma victims (Lee et al., 2002;
Marcus, Marquis, & Sakai, 1997; Rothbaum, 1997; Scheck, Schaeffer, & Gillette, 1998;
Wilson, Becker, & Tinker, 1995, 1997) indicate a 77% to 100% remission of PTSD after
three to six sessions of EMDR treatment.
Although clearly efficacious in its approach to trauma, published case histories also pro-
vide support for the use of EMDR in the treatment of a variety of disorders, including those
related to anxiety, such as phobia and panic disorder (De Jongh & Ten Broeke, 1998;
De Jongh, Ten Broeke, & Renssen, 1999; Goldstein & Feske, 1994; Nadler, 1996; Shapiro
& Forrest, 1997). However, most of the controlled phobia research failed to use the EMDR
protocol in its entirety (see De Jongh et al., 1999; De Jongh, Van den Oord, & Ten Broeke,
2002; Shapiro, 1999), a factor that may explain the minimal to modest success of EMDR
reported in their findings. Studies using a greater length of treatment demonstrated positive
effects in the treatment of panic disorder (Feske & Goldstein, 1997), although not with
panic-disordered participants also experiencing agoraphobia (Goldstein, de Beurs,
Chambless, & Wilson, 2000). As a possible explanation for these findings, Goldstein noted
that “people with agoraphobia are more avoidant of intense affect, that they have highly dif-
fused fear networks, and that they have difficulty making accurate cause-effect attribution
for anxiety and fear responses” (Shapiro, 2001, p. 363). Thus, as the client is at risk of
becoming overwhelmed, thoroughly preparing the client to tolerate the intense affect that
often accompanies the processing phase of EMDR is an essential component of therapy.
Traditionally, treatments for panic disorder, with or without agoraphobia, have consisted
of pharmacological and CBT approaches, both of which are considered effective treatments
for this disorder (Sturpe & Weissman, 2002). However, there is some evidence to suggest
that use of benzodiazepines to alleviate panic symptoms as needed (as opposed to more
regular use), is related to poorer CBT outcomes (Westra, Stewart, & Conrad, 2002).
Interoceptive exposure and cognitive therapy alone appear to be equally effective in treat-
ing panic disorder without agoraphobia (Arntz, 2002), and panic-control treatment alone
and in vivo exposure both effectively reduce panic-related fears and agoraphobia (Craske
et al., 2002). Furthermore, the positive treatment effects associated with panic-control treat-
ment, with and without exposure, appear to positively affect other comorbid conditions
(Tsao, Mystkowski, Zucker, & Craske, 2002). Some therapies requiring minimal therapist
contact, such as various forms of bibliotherapy, computer-administered vicarious exposure,
problem-solving, palmtop computer-administered therapy, and some forms of CBT have
shown some promise in the treatment of panic symptoms, although clients with agoraphobia
appear to require more therapist-initiated exposure (see Newman, Erickson, Przeworski, &
Dzus, 2003, for a review).
Although CBT has been established as an efficacious form of treatment for panic disor-
ders, less is known about its effectiveness over time. Analyses of long-term outcomes (van
Balkom, de Beurs, Lange, & Van Dyck, 1999) indicated that the clinical effectiveness of
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46
Clinical Case Studies
various evidence-based treatments is limited, even when their efficacy had been demon-
strated in a controlled trial. The results further suggest that patients recover from a short
course of treatment but that the vast majority of patients need prolonged additional treat-
ment. As noted by Ost, Thulin, and Ramnerö (2004), “there is still much room for further
development of CBT methods for PDA [panic disorder with agoraphobia] because only
60% of the patients treated in RCTs [randomized controlled trials] published since 1990
have achieved a clinically significant improvement” (p. 1106).
Given these findings and the difficulty that many clients experience in undergoing direct
therapeutic exposure to their fear and body sensations, EMDR is emerging as a viable treat-
ment alternative. However, to understand how EMDR may be beneficial in the treatment of
panic disorders, with or without agoraphobia, an explanation of the theoretical framework
for EMDR, the adaptive information processing (AIP; Shapiro, 1995, 2001, 2002) model,
is necessary. In brief, the AIP model is based on the idea that the neurobiological system
naturally attempts to process current perceptions in a manner that promotes associations to
relevant stored information, to facilitate learning, and to relieve emotional distress. The
resulting transfer of information from implicit to explicit memory systems (Shapiro, 2001;
Stickgold, 2002) allows disturbing thoughts, emotions, and bodily sensations to be resolved
by facilitating access to the stored material and linking it with more adaptive information.
However, the intense affect and subsequent dissociation that accompany trauma may inter-
fere with this process, causing the information (e.g., images, thoughts, emotions, and sen-
sations) to be dysfunctionally stored within the memory network. Because the event is
isolated within the network, preventing associations with adaptive information, the unre-
solved material is easily triggered during similar encounters, often leading to intrusive
thoughts, emotions, and somatic responses. The consequent habitual response patterns can
manifest in characterological difficulties, psychopathology, and the avoidance behaviors
associated with phobias and panic disorders.
Does the AIP model have a place among the models of fear acquisition? There is much
debate in the literature about whether fear is acquired through associative conditioning or
whether it is nonassociative (innate) by nature (Davey, 2002; Kleinknecht, 2002; Marks,
2002; McNally, 2002; Mineka & Ohman, 2002; Poulton & Menzies, 2002a, 2002b). Some
theorists believe that fear acquisition requires an aversive event that serves as an associa-
tive learning experience, although memory of the event may not be accessible within the
memory network (Kleinknecht, 2002; Mineka & Ohman, 2002). Other theorists support the
nonassociative model, which proposes that certain fears have been naturally selected
because of their ability to provide safety (e.g., fear of heights, water, strangers, etc.), and
are therefore innate in all humans (Poulton & Menzies, 2002a, 2002b). Because exposure
to the fear-provoking stimuli over time facilitates habituation, those with limited opportu-
nities of exposure are at risk of phobias (Poulton & Menzies, 2002a, 2002b). The AIP
model would emphasize that regardless of origin, the problem is essentially formed and
sustained by the inability of adaptive information to link with the network containing infor-
mation regarding the feared event.
Although proponents of the conditioning model might appreciate EMDR ability to
access and target an etiological conditioning event, it is also possible to address past, present,
and future symptoms in the absence of a known etiological event. Thus, EMDR has the
ability to address panic and phobia regardless of the method by which the symptoms, or
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Fernandez, Faretta / Panic Disorder and EMDR Treatment
47
fear, were acquired. Once the appropriate targets are chosen, the EMDR protocol addresses
all experiential components (images, thoughts, emotions, bodily sensations) to stimulate
the information processing system as explained by the AIP model.
2 Case Presentation
In the following case, EMDR was used to successfully address panic disorder with ago-
raphobia. Adriana presented for treatment at the age of 32, with a diagnosis of panic disor-
der with agoraphobia. Although her symptoms first appeared at the age of 20, by the time
of treatment, her panic attacks were occurring once or twice per month (with some episodes
occurring at night).
3 Presenting Complaints
Adriana was reporting a constant underlying tension, worry, and pervasive apprehension
for the next panic attack, which contributed to her agoraphobic avoidance. A daily activity
most affected by Adriana’s panic attacks was driving. Eight years previously, she had expe-
rienced an intense panic attack (the worst one) and had not been able to drive alone with-
out fear ever since. The panic attacks were unexpected and invariably occurred when she
was driving alone. Her symptoms included a feeling of choking (because of a disturbance
in her throat), tachycardia, sweating, feeling faint, tingling in her hands, leg tremors, visual
disturbances, and a fear of dying. Eventually, Adriana’s agoraphobia extended beyond her
fear of being alone in the car to include any place where it might be difficult to escape or
to receive help in case of a panic attack. These included being blocked in a traffic jam,
shopping, and riding elevators.
Over time, Adriana became afraid of being alone, even when in her own home.
Consequently, she actively avoided being alone (at home or outside) and performed all of
her daily activities with an accompanying person. Naturally, this significantly affected her
ability to function, in that it substantially limited her outings. Adriana was unable to go
shopping or to the supermarket and even postponed her wedding several times. Using the
subjective units of disturbance scale (SUD; Wolpe, 1958), where 0 reflects no disturbance
and 10 the highest imaginable, Adriana rated her anxiety-provoking situations to range
from being in a traffic jam with an accompanying person (SUD = 4) to driving to work
alone (SUD = 10).
4 History
During the first phase of EMDR treatment, a complete history is taken to identify perti-
nent information for a focused treatment plan. Past events related to the distress are inves-
tigated, as well as present situations triggering the disorder and behaviors or skills the client
requires. In Adriana’s case, it was discovered during this phase of treatment that there were
no other cases of panic disorders or mental problems in her family. However, her father had
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48
Clinical Case Studies
a car accident when Adriana was 10 years old and subsequently avoided driving for 2 years,
instead delegating this task to his wife. Adriana’s mother was described as an apprehensive
person, although without a diagnosable pathology.
When Adriana was a few months old, her parents took her to live with her grandparents
for practical reasons (they had to wake up early to go to work). They used to visit her after
work on their way home. The family was finally reunited after they purchased a home near
the grandparents when Adriana’s mother was pregnant with her brother. The birth of this
brother also involved a traumatic experience. The day he was born, Adriana (then 8 years
old) was trapped in the elevator, and her distress was intensified by the fact that her mother
was not there to help and comfort her.
Shortly after her brother’s birth, another traumatic event occurred. When Adriana was
9 years of age, some burglars entered the property, after presuming that nobody was home.
The family heard noises in the garden and saw some men wearing balaclavas. The men
immediately ran away. Adriana recalled her mother exclaiming, “Who knows what they
would have done to us had they entered and found us here!” Consequently, Adriana expe-
rienced nightmares for years and was afraid to remain home alone.
Prior to the onset of Adriana’s panic attacks, two particular events appeared significant,
in terms of the development of her panic disorder. The first, a cannabis intoxication,
appeared to precipitate the first anxiety attack. After smoking marijuana, Adriana experi-
enced intense perspiration, visual disturbances, and a strong feeling of anguish while dri-
ving her car. A month after this episode, she underwent an appendectomy. Another month
later, she suffered her first real panic attack while she was driving.
Adriana reported several unsuccessful psychotherapy cycles over the years. She had also
received pharmacological treatment because the onset of the disorder and the specific med-
ications had been changed several times. Pharmacological treatment did not appear to ame-
liorate her panic symptoms.
5 Assessment
Adriana recorded her panic symptoms in a weekly diary for the first 2 weeks to assess
her behavioral, physiological, cognitive, and emotional responses. She was asked to write
the date, the situation, the trigger, the intensity (from 0 to 10), the duration, who was with
her at the time of the attack, and the symptoms. The diary was also kept for 2 weeks at the
posttreatment and at the follow-up after 1 year. Recovery was tracked by monitoring the
following baseline symptoms:
Panic Attacks at a 7 to 8 SUD Level
Pervasive tension, worry, and fear three to four times a week before leaving the home
and before leaving the office with an intensity of SUD of about 5.
Physical symptoms were “need for air,” dizziness, heart rate acceleration, weakness at
the legs, and internal shaking. The trigger was the fear of fear.
Avoidance of situations that could provoke panic attacks (e.g., driving by herself, going
to the supermarket, staying at home alone, and so on).
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Fernandez, Faretta / Panic Disorder and EMDR Treatment
49
Adriana stated that because she always had an accompanying person in anxiety-provoking
situations, her diary was only partial and did not reflect all the symptoms caused by the
disorder.
In addition to the elimination of the panic attacks and the anticipatory anxiety, Adriana
articulated the treatment goals in four domains:
Behavioral
To be able to drive the car by herself (e.g., to work, to the supermarket, to the hairdresser) without
depending on someone else.
To be able to do pleasant things (e.g., window shopping, going out with a friend, and so on), enjoy-
ing them, and feeling free to do them.
Cognitive
To overcome and change the belief of not feeling well, to no longer perceive the car and her house
as a potential danger or threat.
To change the tendency of seeing and anticipating catastrophes.
Physiological
To eliminate and resolve accelerated heart rate, shaking, feeling of not being able to breathe, dizzi-
ness, and weakness at the legs.
To learn to relax to face these situations with no body disturbance.
Emotional
To learn to master her fear and manage her emotions (fear, tension, worry, blocks).
To overcome the feeling of tension in places where an accessible exit is not visible (e.g., tunnels,
movies, traffic jams, and so on).
6 Case Conceptualization
Many clinicians, regardless of their theoretical approach, believe that small and severe
traumas experienced in early childhood have a significant impact on the insurgence of psy-
chological distress. Raskin, Peeke, Dikman, and Pinker (1982) reviewed the antecedents of
anxiety disorders and found that 53% of the participants suffering from panic disorders had
experienced separation from their parents in childhood or adolescence, whether through
death, divorce, or other means. These findings also indicated that the impact of traumatic
life events depended on the age at which they occurred. Brown, Harris, and Eales (1993)
confirmed the impact of abandonment and separation on the development of panic disor-
ders, adding that exposure to unpredictable and uncontrollable stimuli in childhood may
also contribute to such symptoms. These results are consistent with the AIP theory
(Shapiro, 2001, 2002) described previously, in that these events may have created enough
distress to impair the information processing of the event, resulting in stored affects and
sensations that form the base of the pathology.
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Clinical Case Studies
Although most would acknowledge that the intensity of a traumatic event contributes to
the impact on the individual, the participants’s mental processing skills must also be con-
sidered. For instance, a harmless event for an adult may be traumatic for a child. According
to the AIP model, these events are considered small t trauma, although the events needed
to diagnose PTSD such as accidents and natural disasters are considered large T traumas
(see Shapiro, 2001, 2002). As mentioned previously, if the adult’s neurological structure is
still affected by traces of an insufficiently processed traumatic childhood experience, an
apparently neutral current event can be experienced by the participant as anguishing and
elicit an intense anxiety reaction.
In addition to the role of events per se (abuse, accidents, separations, etc.), parental atti-
tudes must also be considered. Parental apprehension, strict parenting approaches, and rigidity
tend to influence children’s lives, thereby reducing their ability to explore independently
and to achieve self-confidence (Parker, 1981). Converting these parental attitudes into targets
through the identification of representative events will allow them to be processed through
the EMDR protocol.
The correlation between symptoms and previous negative or stressful experiences is par-
ticularly clear in panic disorders. In fact, with reference to the role of unpleasant events in
the etiology and maintenance of emotional disturbance, memory plays a mediating role
(Williams, 1996) between event and psychopathology. Therefore, working on negative and
damaging experiences is considered a key to accessing and changing dysfunctional knowl-
edge and behavior. Given EMDR’s proven effectiveness in this regard, one would expect it
to effectively address the traumatic etiological events related to panic disorders. However,
before using EMDR, therapists must take a thorough client history to identify and define
the experiences that have created a vulnerability to these symptoms. The first panic attack
is often the climax of a chain of stressful events, occurring once life circumstances are no
longer conducive to escaping into avoidance (Fava & Mangelli, 1999). Often panic attacks
occur during times of high stress, generated by problems at school or at work, loss of a
loved one, as well as after a surgery, an accident, or the birth of a child.
Because the feeling of powerlessness and loss of control typical of panic disorders con-
figure a cognitive and emotional schema often learned after experiencing disturbing events,
the great challenge in psychotherapy is to identify and to reconstruct other situations asso-
ciated with similar feelings of panic or distress (Fernandez, 2001). Moreover, the thera-
peutic goal is to identify the moment and the situation responsible for these dysfunctional
learning experiences. Often, this involves incidents of abuse, parental arguments, accidents,
and separations or losses.
Because these experiences have been dysfunctionally stored in the memory, information
is fragmented, stored as sensory impressions, and later experienced as anxiety and distress.
Evidence suggests that symptoms experienced during panic attacks (anxiety, extreme agi-
tation, exaggerated startle response, irrational thinking, and blocking beliefs, harrowing
emotions, eventual depersonalization and derealization experiences) become traumatic
experiences in their own right (McNally & Lukach, 1992). Therefore, it is necessary to
address the memories of particularly traumatic panic attacks, including the first, the worst,
the last, and a projected future event. EMDR is an integrative psychotherapy that uses an
8-phase treatment approach and standardized phobia protocol to address these issues
(Shapiro, 2001).
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Fernandez, Faretta / Panic Disorder and EMDR Treatment
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7 Course of Treatment and Assessment of Progress
Unlike CBT, which focuses primarily on exposure to situations and body sensations
through therapist-assisted exposure, the primary focus of EMDR treatment is in-session
processing of etiological events, triggers, and new behaviors. Targeting individual memo-
ries often leads to insights, and the revealing of other triggers and events for subsequent
processing. In all, 12 sessions of EMDR focused on processing of etiological memories and
triggers and 3 on development and enhancement of future behaviors. All in vivo exposure
was self-initiated by the client and done without therapist assistance.
The history-taking phase was conducted in the first three sessions. During the second phase
of EMDR treatment (client preparation), a therapeutic alliance is strengthened between the
client and the clinician, a task that is consistent with any psychotherapeutic process. The find-
ings of Goldstein et al. (2000; see also Shapiro, 2001) underscore the need to allocate ade-
quate time to establish a therapeutic alliance and prepare the client. Consequently, alliance
building and three sessions of psychoeducation on anxiety symptoms, including self-control
techniques, were conducted before reprocessing began. The EMDR process and effects were
explained to Adriana, and she was provided with a safe place exercise, which asked her to
bring up an image of a place that elicited a positive feeling of well-being (e.g., walking on her
bare feet on the green grass at her uncle’s farm, feeling the softness and the freshness of the
grass under her feet). While concentrating on this image, she felt lightness on her whole body
and associated it to the word nature. The image, emotions, and physical sensations were then
increased through simultaneous pairing with bilateral stimulation (see Shapiro, 2001). This
exercise is a very nonthreatening way to introduce EMDR to the client. Adriana would then
be able to use this exercise to regain her emotional calmness if disturbing material was
re-experienced during therapy or between sessions.
During the first history-taking and preparation sessions, Adriana had gained awareness
of the issues or situations that contributed to this disorder and was able to identify the rel-
evant triggers. This information was key in formulating the treatment plan, which involved
a very specific method of addressing these issues. Allowing six sessions for history-taking
and preparation fostered a sense of coparticipation in Adriana and became central to the
psychoeducation, which set the stage for subsequent reprocessing. Explanations to Adriana
regarding the standard EMDR protocol (Shapiro, 2001) that targets etiological events that
are experiential contributors to the disorder, recent triggers, and future templates became
part of the psychoeducation process.
During the third phase of EMDR treatment (assessment), the client and the clinician
identify the target to be processed in that session and choose the image that represents the
worst part of the traumatic event, along with a statement that expresses a current negative
belief about herself (e.g., “I am in danger”). Then the therapist encourages the client to find
a related positive statement that she would like to believe instead (e.g., “I am safe now”).
The validity of cognition scale (VOC; 1 = feels completely false to 7 = feels completely
true; Shapiro, 1989, 2001) is used to obtain a rating of how true the positive statement feels.
The client also identifies the negative emotions (e.g., fear, anger) linked to the memory and
to the negative statement “I am in danger.” The intensity of these emotions is measured
using the SUD scale and the accompanying bodily sensations (e.g., tension, spasms) are
identified.
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Clinical Case Studies
To illustrate, it was decided to target Adriana’s first panic attack for EMDR treatment
because it was the most disturbing event in the history of her disorder. She viewed it as an
event that was influencing her ability to function daily. As she described it,
I was discharged from the hospital . . . . A few days later . . . I went out for some shopping . . . .
While I was driving near my house, I was suddenly caught by an incredible agitation. I felt I
couldn’t breathe, as if I had a cramp, but I could do nothing . . . everything was blocked . . . my
body tingled . . . my head was spinning. I was very scared of dying. Terror. I couldn’t
breathe . . . . I don’t know how, but I succeeded to return home, I laid on the couch, but these
feelings did not go away. On the contrary, they got worse.
For Adriana, the most anguishing memory in this case was the image related to being in the
car, still trying to breathe but unable to inhale air. She felt a pain in her chest, her heart
accelerated, and she felt “a terrible feeling of death.”
Adriana, guided by her therapist, linked the image of this scene, to a negative self-belief
“I cannot control the situation.” The positive statement, that is, what she would rather think
about herself (“I can handle the situation”) did not feel very true to Adriana (VOC = 2 of 7).
The emotion linked to this memory (SUD = 10 of 10) was terror, and the distress was
noticed in the arms, chest, and legs.
During the fourth phase of EMDR treatment (desensitization), eye movements or other
forms of bilateral stimulation are used while the client focuses on the image, negative cog-
nition, and bodily sensations. This enables the dual focus of attention, whereby the client
concentrates on her inner experience associated with the traumatic memory while also
attending to the external bilateral stimulation administered by the therapist. The therapist
guides the client through several sets of eye movements until the SUD level has decreased
to a value of 0 or 1 (e.g., when the reaction is appropriate to the present circumstances).
After each set of eye movements, the therapist asks the client, “What do you notice now?”
to facilitate the verbalization of any new associations that might emerge.
After 10 sets of eye movements, Adriana noted that her distress had substantially
reduced. The scene of the first panic attack had faded and other memories, associations, and
sensations began to emerge. The positive associations that emerged over time were increas-
ingly adaptive and provided evidence that Adriana was starting to distance herself emo-
tionally from the situation. This was evident by such statements as “looking at this scene
does not bother me” or “I can handle these situations.” After further sets of eye movements,
Adriana gradually produced several meaningful memories and associations. For instance,
she reported seeing herself handling that situation because she managed to reach home in
spite of her feelings. In fact she noted, “All things considered, I never lost control . . .”
During the next phase of treatment (installation), the positive belief is strengthened after
the client no longer feels the distress related to the targeted traumatic memory. This is
obtained in practice by associating the positive cognition (“I can handle these situations”)
with the traumatic experience and adding eye movements. Installation is considered com-
plete when the client considers her positive statements totally true (VOC = 7).
For Adriana, the positive statements included “I can trust my ability to manage emotions”
or “I can handle these situations.” The clinician instructed Adriana to mentally recall the
distressing event (first panic attack) and to associate it with the positive statement during
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