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The Flashforward Procedure
Robin Logie and Ad de Jongh
Introduction
The standard Three-Pronged Protocol for Eye Movement Desensitization and Reprocessing (EMDR) Therapy guides the overall treatment of the client (Shapiro, 2001). It consists of a “three-pronged” (past, present, and future) approach in which initially past events, then present issues, and finally anticipated future situations are targeted in therapy. The generic divisions of the targets are defined as follows:
- Past: The past experiences that have set the groundwork for the pathology are fully processed.
- Present: Some triggers can still remain active, even though the original traumas have apparently been processed. These triggers may be fed by some residual informa- tion from earlier events that have not been completely processed, or may be due to second-order conditioning.
- Future : In the third prong of EMDR Therapy, called the “Future Template,” treatment helps the client to visualize successfully managing an anticipated future event.
The Flashforward Procedure
The Flashforward Procedure has appeared to be an effective application of EMDR Therapy to deal with the second prong (“present”) of the three-pronged approach. It is a procedure to address clients’ irrational fears and anticipatory anxiety responses that persist after the core memories of past events have been fully processed. Even though the client’s focus is on the future, the fears are experienced in the present, triggered by negative, irrational thoughts with a catastrophic content. To this end, these are considered to be current fears, suitable for processing in the second prong. It has been shown that employing eye movements, and related working memory tasks, typically results in an amelioration of the emotionality and vividness of memories, not only for resolving unprocessed memories underlying posttraumatic stress disorder (PTSD), but also for those memories playing a crucial role in the development and main- tenance of other mental conditions (de Jongh, Ernst, Marques, & Hornsveld, 2013). It is also important to note that EMDR Therapy has not only been found to be efficacious in the processing of mental representations of distressing events that happened in the past, but also of potential mental representations in the future. Two subsequent analogue stud- ies have shown that mental representations about potential future catastrophes can be processed in the same way as past events (Engelhard et al., 2011; Engelhard, van Uijen, &
USE OF SPECIFIC PROCEDURES IN THE TREATMENT OF ANXIETY DISORDERS
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van den Hout, 2010). This has opened new opportunities for the treatment of a wide range of mental conditions in which mental imagery regarding the future plays a pivotal role (see later). Further details regarding the theoretical and research background of the Flash- forward Procedure are described in a paper by these authors (Logie & de Jongh, 2014).
Uses for the Flashforward Procedure
In most cases, the Flashforward Procedure should only be employed once all past traumatic events, relating to the current symptoms in question, have been fully resolved utilizing the Standard EMDR Protocol in the usual way. When it appears that the client still experiences anticipatory fear of confrontations with certain objects or situations, this should alert the therapist, first, to the possibility of unexplored past traumatic events that remain to be processed. Once all memories of relevant past events have been fully resolved, or it is not possible to identify any past events that appear to be at the root of or meaningfully relevant to the current symptoms, it would then be appropriate to use the Flashforward Procedure. There are other times when the use of the Flashforward Procedure could be indicated:
1. Disruptive feared event : Use of the Flashforward Procedure might be indicated when a future feared event is so disruptive to normal life that the client is either not sufficiently motivated to consider past events or is incapable of doing so. 2. Client skepticism : EMDR Therapy aimed at targeting clients’ expected doom sce- nario or fl ashforward might be indicated if it is necessary to convince skeptical clients of the benefits of EMDR Therapy by fi rst demonstrating it with some current issue with which they are preoccupied, and they are initially unwilling to accept that looking at past events may be the key to unlocking their problems. 3. Unable to identify past trauma : It may not be possible, with certain clients, to iden- tify any past trauma or negative experience that appears to be at the root of their current symptoms. 4. Flashforward as only EMDR Therapy target : In some cases (e.g., simple conditioned fears) targeting solely the irrational fear(s) and/or anticipatory anxiety response(s) by using the Flashforward Procedure is sufficiently potent to effectively alleviate the client’s symptoms.
Psychological Conditions Appropriate for Use of the Flashforward Procedure
Besides the aforementioned experimental studies, to date there are no clinical data from well-controlled studies about the effectiveness of focusing on individuals’ flashforwards. Yet, the fear of future catastrophe is a key component in several psychological conditions. The following list gives the major examples, though it is certainly not exhaustive:
- Obsessive-compulsive disorder (OCD) : This disorder relates to preoccupation with, and avoidance of, future events that the client deems to be catastrophic (e.g., being contaminated, house in flames). In one of their case studies, Böhm and Voderholzer (2010) describe using EMDR to target and successfully process a future scenario in which a female client with OCD believed that she will be punished in hell.
- Specifi c phobias : The fear of future events is also clearly a major component in specific phobias (de Jongh, 2009; de Jongh & ten Broeke, 2007, 2009; de Jongh, ten Broeke, & Renssen, 1999; de Jongh, van den Oord, & ten Broeke, 2002). The use of EMDR Ther- apy in the treatment of phobias is supported by controlled research (e.g., Doering, Ohlmeier, de Jongh, Hofmann, & Bisping, 2013; Triscari, Faraci, D’Angelo, Urso, & Catalisano, 2011), and evidence suggests that the inclusion of the processing of feared future events could be helpful (Engelhard et al., 2010). Examples of phobias, and their possible target images, are:
- Dog phobia (e.g., being attacked by a dog)
- Dental and medical phobias (e.g., extreme pain, being powerless, “bleeding to death”)
- Social phobia (e.g., being rejected or other embarrassing situation)
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that describes the relationship with the target image as being intrusive and (too) over- whelming to cope with it by the client. Accordingly, it has often appeared most appropriate to suggest the NC “I am powerless” (against the image) and PC “I am in control/I can han- dle it (the intrusive image),” as standard cognitions.
Step 5: Validity of cognition (VOC), emotion, subjective units of disturbance (SUD), and location of body sensation
These are carried out according to the Standard EMDR Protocol.
Step 6: Phases 4 to 8 (desensitization, installation, body scan, closure, and reevaluation)
These are carried out according to the Standard EMDR Protocol
Cognitive interweaves are utilized in the usual way, and when they become necessary.
The Flashforward Script
Phase 1: Client History
Client history is taken according to the Standard EMDR Protocol.
Phase 2: Preparation
Preparation is done according to the Standard EMDR Protocol, together with an explanation of the Flashforward Procedure and how it will benefit the client. Say, “We have now dealt with all the events from your past that seem to have been feeding into your current problems and these are no longer distressing you. But, it seems that you are still left with some fear and dread of what might happen in the future, which has been left behind, even after all the past events have been dealt with. So, we are now going to focus on this present trigger of the future, and what it is that you are dreading, using the same procedure as we used for the past events.”
Phase 3: Determine the Flashforward
Step 1: Identify the catastrophic event Say, “We need to figure out what kind of image is in your head that makes you scared about a future confrontation with what you fear. What is the worst thing you could imagine happening? Basically we should look for your ulti- mate doom scenario.”
If necessary, the therapist asks additional questions, for example: Say, “What do you imagine might go wrong if you (state the concern, such as ‘Come across a dog,’ ‘Have a dental treatment,’ ‘Climb a tower,’ etc.) ?” Say, “If you had a terrible nightmare about (state the concern, such as ‘Driving your car to work on a busy road’), what would the most disturbing picture look like?”
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Step 2: Follow the event to its ultimate conclusion Say, “Why would this be so terrible for you?”
Say, “What would be the worst thing about that?”
Repeat as necessary until the client cannot identify anything worse.
Step 3: Make a detailed picture of the flashforward
Image
The therapist might then ask the client to make a still picture of this scene. Ask that the picture be as detailed as possible.
Say, “Exactly what would (the flashforward identified earlier) look like?”
Or say, “What can you see in that?”
If the client still has more than one picture, she is asked to contrast these images, for example, by saying the following:
Say, “If you were forced to choose, what would be most disturbing for you now: the picture of your dying, or the picture that represents the situation of being unable to care for your family?”
Negative Cognition
Say, “What words go best with that picture (state the flashfor- ward) that express your negative belief about yourself now ?” or “ When you think of (state the fl ashforward), what negative thought do you have about yourself now?” Note: The therapist can suggest, “I am powerless.”
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my fingers (or any other bilateral stimulation, BLS, you are using). Just let whatever happens, happen, and we will talk at the end of the set. Just tell me what comes up, and don’t discard anything as unimportant. Any new information that comes to mind is connected in some way. If you want to stop, just raise your hand.”
Then say, “Bring up the picture and the words (repeat the NC) and notice where you feel it in your body. Now follow my fingers with your eyes (or other BLS). ”
Even though the target is a future catastrophe, the client may spontaneously bring up the original trauma even though it had previously, apparently, been fully processed. If this occurs, the therapist should continue to allow the client to go with the past event because the flashforward may have elicited other channels connected to the trauma that had not previously been processed.
As appropriate, the therapist should use cognitive interweaves if these become necessary. Note: EMDR focused on flashforwards usually goes smoothly and therapists rarely need to use cognitive interweaves.
Phase 5: Installation
Install the PC
Say, “As you think of the (state the fl ashforward), how true do the words (state the PC) feel, from 1 being completely false to 7 be- ing completely true?” 1 2 3 4 5 6 7 (completely false) (completely true) Say, “Think of the (state the flashforward) and hold it together with the words (repeat the PC). Go with that.”
Continue this procedure until the VoC is 7.
Phase 6: Body Scan
Say, “Please close your eyes. As you think of (state the flashfor- ward), say to yourself ‘I can deal with it.’ Then bring your attention to the different parts of your body, starting with your head and working down- ward. Any place you find any tension, tightness, or unusual sensation, tell me.”
If any sensation is reported, the therapist introduces BLS. If it is a positive or comfortable sensation, BLS is used to strengthen the positive feelings.
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If a sensation of discomfort is reported, this is reprocessed until the discomfort sub- sides. Finally, the VoC has to be checked. Say, “As you think of the incident, how do the words (restate the PC), feel from 1 being completely false to 7 being completely true?” 1 2 3 4 5 6 7 (completely false) (completely true)
Video Check
Say, “This time, I’d like you to imagine yourself stepping into the scene of a fu- ture confrontation with the object or a situation for which the future template was meant (e.g., making a trip on an airplane, meeting an unknown person, a dog, a dentist). Close your eyes and play a movie of this happening, from the beginning until the end. Imagine yourself coping with any challenges that come your way. Notice what you are seeing, thinking, feeling, and experienc- ing in your body. While playing this movie, let me know if you hit any blocks. If you do, just open your eyes and let me know. If you don’t hit any blocks, let me know when you have viewed the whole movie.”
If the client encounters a block and opens her eyes, this is a sign for the therapist to instruct the client as follows: Say, “Say to yourself ‘I can handle it’ and follow my fingers (or other form of BLS) .” If the client is able to play the movie from start to finish with a sense of confidence and satisfaction, the client is asked to play the movie once more from the beginning to the end, eye movements are introduced, and the PC “I can handle it” is installed. In a sense, this movie is installed as a future template. Say, “OK, play the movie one more time from beginning to end and say to your- self ‘I can handle it.’ Go with that.” Do this until the movie can be played without any blocks or significant disturbances.
Phase 7: Closure
Say, “Things may come up or they may not. If they do, great. Write it down and it can be a target for next time. You can use a log to write down triggers, images, thoughts, cognitions, emotions, and sensations; you can rate them on our 0 to 10 scale where 0 is no disturbance or neutral and 10 is the worst disturbance. Please write down the positive experiences, too.” “If you get any new fantasies, memories, dreams, or situations that disturb you, just take a good snapshot. It isn’t necessary to give a lot of detail. Just put down enough to remind you so we can target it next time. The same thing goes for any positive dreams or situations. If negative feelings do come up, try not to make them significant. Remember, it’s still just the old stuff. Just write it down for next time. Then use the tape or the Safe Place exercise to let go of as much of the disturbance as possible. Even if nothing comes up, make sure to use the tape every day and give me a call if you need to.”
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Doering, S., Ohlmeier, M.-C., de Jongh, A., Hofmann, A., & Bisping, V. (2013). Efficacy of a trauma-focused treatment approach for dental phobia: A randomized clinical trial. European Journal of Oral Sciences, 121 , 584–593. Engelhard, I., van den Hout, M., Dek, E., Giele, C., van der Wielen, J., Reijnen, M., & van Roij, B. (2011). Reducing vividness and emotional intensity of recurrent “flashforwards” by taxing working memory: An analogue study. Journal of Anxiety Disorders, 25 , 599–603. Engelhard, I., van Uijen, S., & van den Hout, M. (2010). The impact of taxing working memory on negative and positive memories. European Journal of Psychotraumatology, 1 , 5623. doi:10.3402/ejpt.v1i0. Logie, R., & de Jongh, A. (2014). The flashforward procedure: Confronting the catastrophe. Journal of EMDR Practice and Research, 8 , 25–32. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York, NY: Guilford Press. Triscari, M., Faraci, P., D’Angelo, V., Urso, V., & Catalisano, D. (2011). Two treatments for fear of flying compared: Cognitive behavioral therapy combined with systematic desensitization or eye movement desensitization and reprocessing (EMDR). Aviation Psychology and Applied Human Factors, 1 , 9–14.
