Case Four: workplace performance without a PTSD diagnosis
Elena, a fictional analyst, avoids presenting work that she knows well. Her goal is to give a concise monthly report without abandoning it to a colleague. Assessment identifies a recent presentation in which she lost her place and a remembered school presentation in which classmates laughed. She says the two scenes share the meaning, “If I make a mistake, I become the joke.” This is her connection, not an inferred hidden cause.
The clinician and Elena select the remembered classroom scene within an EMDR plan because it strongly activates the same shame and body response. During assessment, Elena identifies the moment of looking up at laughing faces, the self-belief “I am ridiculous,” sadness and fear, and heat in her face. Her preferred cognition is “I can handle a mistake.” It is a believable goal, not “Everyone will like me.”
The clinician follows processing with brief prompts and the procedures of their training rather than convincing Elena that classmates were wrong. When material shifts to anger and then sadness, the clinician follows what emerges. Installation, body scan, and closure are completed as appropriate to the session; incomplete work would be closed and revisited rather than forced to a resolution.
At reevaluation, Elena reports less shame when recalling the classroom but still feels a jolt when the slide deck opens. That present trigger becomes the next point of assessment. The future template includes opening the deck, finding her place, pausing when interrupted, and correcting a minor error. Elena then practices a short real presentation and tracks whether she continues when nervous rather than whether nerves disappear entirely.
Clinical focus: The treatment addresses disturbing experiences and current cues associated with performance, while preparation and rehearsal address the performance task itself. This illustrates a clinical application; it is not proof that the particular sequence has been validated for all workplace anxiety.
How to read the cases
The following cases are wholly fictional teaching examples, not disguised patient records, trial participants, or promises about outcomes. Each includes a working hypothesis, competing explanations, a provisional decision, and evidence that would change the plan. The numerical ratings a clinician might collect are deliberately not fabricated here. Their absence keeps attention on the reasoning rather than suggesting that a particular sequence reliably produces a particular score.
The formulations are not complete clinical assessments. In practice, a clinician would establish diagnosis, risk, competence, consent, and the appropriate treatment pathway before applying them. The cases show why “finding the target” sometimes leads to a memory, sometimes to further assessment, and sometimes to deciding not to process a memory at that point.
Case One Marcus and the alarm at the end of the shift
Returning to the fictional Marcus introduced in Chapter 20, this expanded formulation shows how the same candidate target fits within coordinated care.
Presenting problem and desired change. Marcus, 41, works in building maintenance. Eighteen months after a workplace assault, he reports intrusive recollections, nightmares, avoidance of one corridor, and marked alarm when doors close behind him. A competent assessment supports PTSD. He also has an assessed alcohol-use disorder. His priorities are to finish shifts without leaving early, sleep more reliably, and reduce the drinking that has begun to damage his relationship and work attendance.
Context and immediate assessment. The perpetrator no longer works at the site, and the employer has changed access arrangements. The clinician nevertheless checks whether any continuing threat remains. Marcus has reliable housing and wants his partner involved in limited aspects of planning, but not in the content of his trauma sessions. He is receiving addiction care. The team clarifies who assesses withdrawal risk, manages relevant medication, and responds to a deterioration in drinking or safety. No claim is made that psychotherapy alone makes alcohol withdrawal safe.
Recent episode. A closing alarm sounds at 6 p.m. Marcus sees an image of the attacker's hand on the door. His chest tightens, he thinks “I cannot get out,” and he leaves through a side exit. At home, alcohol reduces his immediate distress. Later, sleep is poor and he feels ashamed. He sometimes drinks on days without the alarm, including social occasions, which shows that the trauma cue is not the only maintaining factor.
Working formulation. A remembered moment of blocked escape appears to contribute to cue-triggered re-experiencing and avoidance. Drinking sometimes functions to dampen that response but also has other reinforcement and dependence-related features. The plan therefore does not equate PTSD improvement with recovery from alcohol-use disorder.
Competing explanations. The team considers panic processes, occupational stress, sleep disruption, and substance-related effects. The chest symptoms receive appropriate medical consideration. If episodes occur without trauma cues and are maintained by fear of bodily catastrophe, panic-specific assessment may become necessary. If the workplace remains objectively unsafe, environmental action takes priority over construing all alarm as a memory effect.
Assessment Script: “The door image seems central when the closing alarm sounds. Is that the moment you want to work on, or is there another part that matters more? On evenings when you drink without that image, what is happening? What would tell us the trauma work is helping even if the alcohol problem still needs its own care?”
Candidate target and rationale. Marcus selects the remembered moment when the attacker blocked the exit. The rationale is its direct relationship to the present alarm and work avoidance. It is not chosen because it is the worst event in his life. A childhood experience of being trapped is noted but not prioritized solely because it is earlier; Marcus does not currently experience it as part of the same problem.
Readiness and coordinated plan. PTSD treatment is considered alongside substance-use treatment rather than being withheld until an arbitrary period of abstinence has elapsed. This is consistent with guidance supporting access to trauma-focused PTSD therapy in people with co-occurring substance-use disorders. [32] The team establishes session-specific feasibility, a practical between-session plan, and communication boundaries with Marcus's consent. Intoxication or medically concerning withdrawal would change the immediate action, not create a permanent prohibition.
Past–present–future sequence. The past focus is the blocked exit. The present focus is the closing alarm and the corridor. The future aim is to finish a shift, notice the difference between a reminder and actual danger, use agreed coping and support, and travel home according to his care plan. A future rehearsal includes what he will do if distress remains high; it does not imagine guaranteed comfort.
Reevaluation and decision branch. In a hypothetical review, Marcus reports that the door image is less intrusive and that he finishes more shifts, but weekend drinking is unchanged. The appropriate inference is partial improvement in the hypothesized trauma pathway, not a completed recovery or a failed EMDR course. Addiction treatment continues. If work avoidance remains, the clinician examines its current function instead of automatically selecting another memory.
Consultation questions. Is the PTSD indication adequately established? Is the target linked to the specific impairment? Are medical and addiction responsibilities explicit? What evidence would distinguish residual PTSD from an independent alcohol-use process? Has the client been offered genuine treatment choices rather than a promise that processing will solve everything?
Case Two Imani and the question of whether the danger is over
Presenting problem and desired change. Imani, 35, asks for EMDR because she feels “obsessed” with whether her partner is lying. She describes repeated checking of messages, poor sleep, and distress after discovering an affair. Her initial goal is to stop feeling anxious so the relationship can return to normal. A private assessment reveals that her partner also threatens to disclose personal information, controls access to shared money, and monitors her travel.
Why the initial request is not the whole formulation. The word “obsessed” does not establish OCD, and betrayal does not automatically establish PTSD. The clinician assesses trauma exposure and symptom patterns without presuming either diagnosis. Some checking may be driven by intolerable uncertainty, some by repeated deception, and some by attempts to anticipate a controlling partner's behavior. Reducing all checking without understanding these functions could remove an improvised protective strategy while leaving the threat intact.
Immediate priorities. The clinician explores privacy, safe communication, access to money and support, and whether appointments or written records could increase risk. Imani is offered specialist domestic-abuse resources and practical options without pressure to leave on a timetable chosen by the therapist. WHO's guidance emphasizes autonomy, supportive first-line response, and safety in care for women experiencing violence. [29] Local legal and safeguarding responsibilities are checked separately.
Working formulation. Current coercion and uncertainty are major maintaining conditions. A remembered episode of discovering the affair is distressing, but processing it would not make the present relationship safe. Imani also recalls a former partner disappearing without explanation. This may be relevant to the intensity of abandonment fear; it does not explain away her current partner's behavior.
Assessment Script: “Some of what you describe may be an old alarm, and some may be information about what is happening now. What do you fear your partner would do if you disagreed or changed your plans? Is there a safe way for us to contact you? Would you like to consider support options before deciding whether memory work belongs in the plan?”
Candidate targets and the decision not to start. The affair discovery and the earlier disappearance are recorded as possible future topics, not an immediate processing queue. The clinician does not select “I am too needy” as the negative cognition simply because Imani uses that phrase after arguments. Its source and function need examination; it may repeat the partner's demeaning account. At this point, the active focus is safety, informed choice, support, and a clearer differential formulation.
What would justify reconsideration. Later memory-focused work might become appropriate if Imani wishes it, an appropriate indication and evidence discussion are established, and the delivery context is workable. Complete absence of every life stressor is not required. However, active danger must remain represented in the plan, and reducing alarm must never be used to imply that a threat has become acceptable.
Past–present–future map. Past: known episodes of betrayal or unexplained separation that remain distressing. Present: actual threats, monitoring, uncertainty, and checking. Future: recognizing options, contacting support safely, setting boundaries where feasible, and responding to uncertainty without abandoning self-protection. A future template would not require imagining reconciliation or trusting the current partner.
Future Planning Script: “Imagine a situation in which you notice pressure to agree to something you do not want. What would help you recognize your options? Which response is safe in that setting? If speaking directly would increase danger, what other route to support could you use?” The answer may involve postponing a conversation or seeking practical assistance rather than assertiveness in the moment.
Reevaluation and decision branch. In one hypothetical development, Imani gains access to independent advice and chooses a separation. Her anxiety initially increases because the transition brings genuine uncertainty. That increase is not proof that she chose wrongly or that processing should be accelerated. The plan updates the safety assessment and support needs. If, later, a remembered scene continues to drive impairment in a safer context, target selection can be revisited with a more accurate purpose.
Consultation questions. Has the clinician privately assessed coercion? Is a memory explanation obscuring current conduct? Would any proposed couple intervention be safe and freely chosen? Are records and contact methods safe? Is success being defined by Imani's agency and functioning rather than the survival of the relationship?
Case Three Noor and the medical waiting room
Presenting problem and desired change. Noor, 26, is autistic and communicates fluently but needs time to process unexpected questions. After a frightening emergency procedure, Noor avoids medical appointments and experiences intrusive images of being held still. The initial referral describes “noncompliance.” Noor describes a different goal: “I want to get healthcare without feeling trapped, and I need staff to explain before touching me.” Assessment explores PTSD, the exact circumstances of the procedure, and current healthcare needs.
Access and environmental assessment. Bright lights, crowded rooms, unpredictable waiting, and rapid questioning are difficult even when no traumatic memory is present. The clinician distinguishes longstanding sensory needs from new trauma-related responses. Accommodations are not made conditional on successful therapy. Noor chooses written agendas, clear explanations, pauses before answering, and a non-touch form of the agreed intervention where clinically appropriate.
Recent episode. A nurse reaches toward Noor without warning. Noor experiences a sharp image of the emergency room, loses track of the question, and leaves. In a quieter appointment where each step is explained, anxiety is lower but the image still appears when equipment is placed nearby. This pattern suggests both a memory-linked process and continuing access barriers.
Working formulation. A known medical event may contribute to re-experiencing and avoidance. Sensory overload and lack of predictable consent procedures independently increase distress. Therapy should address the trauma-related component while the healthcare team improves accessibility. The objective is not to make Noor tolerate unnecessary touch or behave less autistically.
Assessment Script: “Which part is the memory coming back, and which part is difficult because of what the room or staff are doing now? You can answer in writing or take time. When you say you lose track, do you mean the question becomes hard to follow, you feel far away, or there is a period you cannot remember?”
Dissociation and competing explanations. Noor reports two episodes of feeling unreal but no established recurrent amnesia. The clinician does not infer a dissociative disorder from autistic shutdown or a single description. Further assessment considers panic, overload, fatigue, medication effects, and dissociative symptoms. If substantial unexplained gaps or loss of orientation emerge, specialist consultation is obtained before progressing with a memory-processing plan.
Candidate target and rationale. Noor identifies a remembered moment of being held still after saying “wait.” The current meaning is “My no does not count.” The target is not “hospitals” as a whole or a therapist-invented scene of earlier abuse. It fits because it recurs at present appointments and relates directly to Noor's desired ability to receive care with agency.
Evidence and consent. The clinician explains the evidence for EMDR in PTSD while acknowledging that evidence about specific autism adaptations is less developed. Therapist consensus on adaptations can inform accessibility but cannot guarantee efficacy. [37] Noor is offered alternatives and may decline EMDR without losing support for healthcare access.
Readiness and plan. Before proceeding, the clinician checks that Noor understands the task, can signal a pause in a usable way, and can remain sufficiently aware of the current setting. Apparent stillness is not assumed to mean comfort. The clinician also confirms a plan for upcoming medically necessary appointments so that therapy does not inadvertently delay essential care.
Past–present–future map. Past: the known restraint-related moment. Present: unannounced approaches, equipment, and waiting-room cues. Future: attending an appointment with written preferences, asking for an explanation, using a pause signal, and deciding with staff how to continue. The future scenario includes a staff member forgetting the plan and Noor using an agreed route for clarification or support; it does not assume a perfect healthcare system.
Reevaluation and decision branch. In a hypothetical review, Noor reports fewer intrusive images but still needs reduced sensory load and extra processing time. Those ongoing needs are not treatment failure. If the image improves while avoidance persists, the clinician assesses whether the remaining barrier is sensory, practical, relational, or trauma-related. If dissociation increases, the plan pauses for assessment rather than pushing harder through the same target.
Consultation questions. Are autism-related needs being mistaken for resistance or symptoms to eliminate? Is the target a known event rather than an inferred cause? Have trauma and environmental barriers been separately measured? What would establish that an adaptation preserves meaningful consent and participation? Is specialist input needed for unresolved diagnostic or dissociative questions?
The common reasoning across different decisions
These cases lead to different immediate actions because their formulations differ. Marcus may receive coordinated PTSD and substance-use treatment. Imani needs a plan that foregrounds current coercion before assuming memory processing is the next step. Noor may need both trauma treatment and enduring accessibility changes, with specialist input if assessment identifies additional complexity.
A coherent target is not the most emotionally dramatic detail in the history. It is a justified, collaborative treatment focus whose relationship to the person's goals can be examined. Consultation is most useful when the clinician brings that reasoning—including uncertainty—rather than only asking which memory should come first.