This manual equips clinicians with comprehensible instructions on the correct delivery of the Integral Eye Movement Technique (IEMT) in psychological trauma and the correct use of Mirror Visual Feedback (MVF) in treating phantom limb pain. Nothing contained here is intended to replace conventional treatment services and applications nor to portray the methodology as superior to other methodologies.

Integral Eye Movement Therapy (IEMT) is a psychotherapeutic approach designed to alleviate emotional distress and identity-based issues through specific eye movement techniques. It focuses on reducing the emotional intensity of memories and imprints that influence current emotional well-being. The therapy is particularly geared towards addressing patterns that perpetuate problems, effectively helping clients reframe their emotional experiences and identities. IEMT's techniques involve observing and altering eye movements to reprocess traumatic or intense emotional memories, thereby promoting psychological healing and behavioural change.

Mirror Visual Feedback (MVF) is a therapeutic technique utilized in treating phantom limb pain, where patients use a mirror to create the illusion of the presence of their amputated limb. This visual feedback helps the brain reconcile the discrepancy between the perceived and actual physical body, reducing pain and discomfort associated with phantom sensations. MVF is effective in retraining the brain and can significantly alleviate pain by modifying neural pathways related to the missing limb's sensory and motor signals.

Advisory Board

• Role: Guides and advises the Trainer and Director for the Project.

Andrew T. Austin - Trainer and Director for The Project

• Role: Responsible for the overall direction and training within the project. Acts as the primary liaison between the Advisory Board and the Core Training Group.

Core Training Group (Association Members)

• Composition: Includes both Clinical and Non-Clinical Association Members.

• Role: Receives training from the Director and is responsible for cascading the knowledge and training to the NGOs, charities, and clinicians in the field.

NGOs, Charities, and Clinicians Working in The Field

• Role: Apply the training to deliver treatment and services to the patients under the project's scope.

Patients

• Role: The recipients of the medical treatments and services provided by the trained staff of NGOs, charities, and clinicians.

This structured layout ensures that guidance and training flow effectively from the top-level Advisory Board down to the patients, optimizing the quality and consistency of medical care provided.

==== Module 1: Introduction to Eye Movements ====
  * Eye Movement Fundamentals
  * Practical Exercise: Directing Eye Movements

During Integral Eye Movement Therapy (IEMT) training sessions, participants engage in a role-playing exercise designed to simulate and practice therapy techniques. The exercise involves participants pairing up, with one person playing the role of the therapist and the other as the client.

Objective The goal is to practice eye movement techniques central to IEMT, ensuring participants are prepared to guide clients through these movements effectively.

Procedure Participants instruct each other to move their eyes in specific patterns: six times left, six times right, and six times along each diagonal direction. It's crucial for the client to continually think of a specific memory, particularly one that invokes a strong emotional response, ensuring simultaneous engagement in eye movement and memory recall.

Role Reversal After practicing one round, participants switch roles. This role reversal allows each person to experience and understand the therapy's challenges and nuances from both the practitioner's and the client's perspectives.

Follow-Up Questions After the exercise, the practitioner inquires if the client can revert the memory to its original state. If the client struggles, they are encouraged to “try harder.” This interaction is designed to challenge the client's ability to dissociate from the problem memory, addressing one of the patterns of chronicity in therapy.

Kinesthetic Reduction and Dissociation The session emphasizes reducing the kinesthetic feelings associated with memories. The aim is to decrease the emotional intensity tied to the memory, making it feel more distant and less vivid. This process is indicative of a dissociative shift, helping clients view the memory as a detached, historical event rather than a relived experience.

Patterns of Chronicity The exercise addresses chronic patterns where clients continuously test for evidence of their problems while ignoring any improvements. This pattern is often reinforced in clinical settings, where the focus remains on negative outcomes despite significant progress.

Learning Outcome This introductory exercise is designed to lay a practical foundation for managing basic eye movement techniques in therapeutic settings. It also helps participants become sensitive to the emotional aspects of therapy. The session prepares them for more advanced topics in the training, including a deeper exploration of trauma and its kinesthetic manifestations.

==== Module 2: IEMT Kinaesthetic Pattern ====
  * Understanding Kinaesthetic Pattern Questions
  * Techniques for Professional Delivery

In the context of post-traumatic stress disorder (PTSD), practitioners must be versed in both the diagnostic criteria and therapeutic modalities. The “lynchpin” concept is integral to understanding and addressing PTSD, particularly within the framework of Integral Eye Movement Therapy (IEMT).

The lynchpin, a central tenet in IEMT, refers to a pre-trauma personality characteristic that was previously inconspicuous but has become a key causative factor in the individual's PTSD following a traumatic event. This once innocuous trait now serves as a catalyst, triggering intense and distressing flashback experiences when the individual encounters similar contexts or experiences that involve this trait.

It is essential to discern true PTSD, which aligns with the DSM-5 criteria, from conditions that may superficially resemble it but do not fulfil the formal diagnostic requirements. This distinction underscores the need for precise clinical evaluation and avoids conflating self-diagnosed PTSD with that which is clinically established.

In therapeutic practice, patients often desire to return to their pre-trauma selves and seek empathy from others, sometimes through public awareness efforts. The lynchpin concept facilitates a deeper understanding of the patient's experience by focusing on the internal changes they have undergone rather than external circumstances.

During the IEMT training, practitioners learn to identify and address the lynchpin using targeted eye movement techniques to mitigate its influence on the patient's current experiences. A reported shift in emotional response, perspective, or a sense of psychological progress often accompanies this process.

Furthermore, the training delves into the “living dead metaphor,” which encapsulates the feeling of being emotionally detached or numb, as if one were merely existing rather than truly living. The metaphor provides a framework for practitioners to explore and modify the patient's trauma narrative, potentially reducing its emotional impact.

Medical professionals receiving this training will be equipped to not only identify the lynchpin in PTSD patients but also to employ IEMT strategies effectively to alleviate the profound effects it has on their lives. This includes adjusting the “edit points” of traumatic memories to disrupt their recurrent and debilitating nature.

• Definition of the lynchpin in relation to PTSD.
• The significance of distinguishing between a normal personality trait and its transformation post-trauma.
• Overview of the lynchpin's role in maintaining PTSD symptoms.

• Differentiating between 'self' (internal factors) and 'other' (external factors beyond the patient's control).
• Dividing the patient's experience into segments: before the event, during the event, and after the event. This is not performed directly on the client's experience but rather through the use of hypothetical or real examples that illustrate the process.

• Isolating the specific moment or trait behaviour that the patient fixates on via story examples.
• Recognizing how this previously normal trait has become a source of distress and a trigger for flashbacks.
• Understanding the patient's tendency to cyclically attempt to correct this trait in the hope of negating the traumatic event.

• Providing detailed narratives that exemplify the lynchpin identification (as shown in the provided stories below).
• Highlighting the pivotal moment or behaviour that becomes the lynchpin for the patient's PTSD.

• Initiating Integral Eye Movement Techniques to address the identified lynchpin.
• Guiding the patient through recognizing and reframing the lynchpin to reduce its hold over their current life.

• Encouraging patients to articulate their experiences post-intervention.
• Observing any shifts in emotional response or behavioural changes.
• Repeat the process where necessary to ensure the lynchpin's influence is diminished.

• Discussing how the lynchpin influences the patient's identity across various contexts.
• Addressing the need for understanding from others and the frustration when it is not met.
• Explaining how the lynchpin can infiltrate multiple aspects of the patient’s life due to its association with their identity.

• Summarizing the importance of identifying the lynchpin in the therapeutic process.
• Emphasizing the role of the practitioner in facilitating a recontextualization of the lynchpin to promote healing and recovery.

I'm uncertain of the extent to which I can assist you. While I'm able to work with you, the exact benefits remain to be seen as the possibilities are numerous. The initial step is to gain an understanding of your situation, which is evidently quite severe. My intent is to guide you through a specific evaluation to see if it resonates with your experiences. This is crucial for my comprehension of your case.

=== Story 1: A Case of PTSD === Consider this scenario: a man suffering from PTSD. (Here, you would show or draw the timeline diagram). Picture this as a timeline. Your current position is here, and the traumatic event is there. (Break down the timeline into sections: before, during, and after the event). Here's what happened before the event, the event itself, and what's happening now.

Above the line is 'self'—his experiences, decisions, and actions. Below the line is 'other'—aspects he has no control over, such as other people and the environment.

This individual was returning home from a party and was attacked. It was a case of senseless violence; he was simply in the wrong place at the wrong time.

We examine his actions before the incident—leaving the party, deciding to walk home against his friends' advice to take a taxi, thinking it necessary to sober up for an early shift the next day.

We speculate on the perpetrators—likely indulging in drugs and alcohol, habitual offenders, and generally problematic individuals.

Their lives intersected disastrously at the event. The details of their cruelty are clear—they cornered him, mocked, and assaulted him.

Post-event, what he couldn't control was the media attention, family reactions, and hospital gossip—all of which he overheard in an open ward.

Afterward, he withdrew from social life, turned to alcohol and drugs, and lived in isolation for a decade.

The critical revelation is what he fixates on—it's not the event itself, but the moment he pleaded for his life that haunts him.

=== Story 2: The Beirut Port Explosion === Another example involves a man who worked at the Beirut port. On vacation with his girlfriend, he agreed to extend the trip at her request. His friend covered his shift, which fell on the day of the catastrophic explosion. The friend perished, and the man, now jobless, descended into isolation and depression.

He didn't flashback to the phone call or losing his job but to the moment he agreed to stay with his girlfriend because it made her happy.

These individuals relentlessly scrutinize their actions. What was once a normal behavior becomes the focus of their rumination, as though changing that trait could have averted the catastrophe.

This relentless self-interrogation about a normal behavior or trait is what exacerbates their PTSD. It infiltrates their identity, affecting multiple life contexts, making them believe that this very aspect of who they are caused the traumatic event.

The common thread in PTSD is the attempt to retroactively alter the past or revert to their pre-trauma selves, hoping to change the outcome and seeking understanding from others. Unfortunately, while the focus is often on the aftermath, the internal struggle to amend a perceived fault goes unnoticed. This pattern is crucial to identify as it forms the basis of the therapeutic intervention.

Pain is a complex sensory and emotional experience that plays a critical role in protecting the body from harm. Understanding the pathways through which pain signals are transmitted to the brain is essential for clinicians managing trauma and combat injuries.

Pain signals are initiated by nociceptors, specialized sensory receptors that detect damage or potential damage to tissues. These signals are primarily of two types:

• Nociceptive Pain: This occurs when nociceptors are stimulated due to injury to bodily tissues. It is the pain that arises from physical damage such as cuts, fractures, burns, or inflammation.
• Neuropathic Pain: This type of pain is a result of damage to the nervous system itself, which can alter pain perception. It might be experienced as a burning, shooting, or stabbing sensation.

The process of pain signal transmission involves several steps:

• Transduction: The conversion of traumatic or chemical stimuli into electrical signals at the site of damage.
• Transmission: The pain signal is carried from the nociceptors through peripheral nerves to the dorsal horn of the spinal cord.
• Modulation: At the spinal cord, neurotransmitters can either amplify or dampen the pain signal.
• Perception: The brain interprets these signals as pain, influenced by both physical and psychological factors.

Understanding different types of pain is crucial for effective management, especially in a setting involving war trauma and combat injuries.

• Acute Pain: Immediate pain resulting from injury, lasting less than six months. It serves as a warning mechanism.
• Chronic Pain: Persistent pain that lasts longer than six months and can continue even after the injury has healed.
• Burn Pain: Typically acute and intensely painful due to nerve damage. Requires immediate pain relief and long-term management.
• Crush Injuries: Can result in both nociceptive and neuropathic pain. Initial severe pain may transition to chronic pain syndromes if nerves are damaged.
• Visceral Pain: Originates from internal organs; often difficult to localize. Typical in blunt force trauma to the abdomen.
• Somatic Pain: Arises from skin, muscles, bones, and joints. More localized; caused by direct trauma.
• Referred Pain: Pain felt in a part of the body other than its actual source, important for diagnosis.
• Phantom Limb Pain: Occurs after amputation where pain is felt as though it comes from the amputated limb.
• Psychological Pain: Emotional distress that exacerbates physical pain symptoms, requiring holistic care.
• Inflammatory Pain: Signifies tissue damage and inflammation, sustained by biochemical substances.

Effective pain management must be tailored to the type of pain and its underlying cause. This involves:

• Immediate and adequate analgesia for acute pain.
• Monitoring and treatment adjustments to prevent the transition from acute to chronic pain.
• Rehabilitation strategies to address physical and psychological aspects of pain perception and management.

In many, but not all, instances, chronic pain can be reduced by the application of the IEMT K-Pattern to the pain experience. The session frame set for the client mustn't lead them to expect effective analgesia or anaesthesia regarding their pain experience. The practitioner must avoid the temptation to enquire if the pain is reduced or even how it compares to before the session

There are some dimensions to consider:

1. The pain that is remembered
2. The pain that is current
3. The pain that is anticipated

In addition, the practitioner needs to consider the response to the pain, which may be adaptive or maladaptive. Pain leads to suffering, and in some instances, alleviating the pain does not necessarily change the experience of suffering, depending on how the person has adapted to it. Alcohol and drug use, self-harm, social withdrawal, self-pity, etc, may continue long after pain has been alleviated.

An example of the K-Pattern as applied to pain will look like this:

• “On a score out of ten, with ten being as strong as it can be, how strong is the pain now” (or, “as you remember it”/“anticipate it to be?”)
• “And, how familiar is this pain?”
• “And when is the first time you can remember experiencing this feeling of pain? It may not be the first time you have ever experienced it, but it is the first time you can remember now.”
• “And how vivid is this memory?”

Then, the client is instructed on eye movements while mentally holding on to that memory.

==== Part 1: Pre-Assessment ====
  * Comprehensive Assessment Protocols

==== Part 2: Assessing the Phantom ====
  * Techniques for Effective Assessment
  * Distinguishing Between Pain Sources

==== Part 3: Stages of the Treatment Session ====
  * Detailed Steps from Patient Expectation through to Reunion with Limb Image

The patient progresses through eight observable stages when using the mirror box. These are:

• Stage 1: Patient expectations and anticipation
• Stage 2: Focus of attention
• Stage 3: Reaction and Abreaction
• Stage 4: Emotional reunion with limb image
• Stage 5: Abreactional states
• Stage 6: Fascination and Exploration
• Stage 7: Fatigue
• Stage 8: Telescoping phenomena

Stage 1. Patient expectations and anticipation

The patient unfamiliar with MVF use will likely have their preconceptions of what will follow in terms of the experience and the clinical outcome. It should be noted that patients with the most amount of distress and the most to gain may be apprehensive and fearful that the method will be ineffective, and clinicians should note that the greater the distress, then the greater the level of disappointment and added distress will be in the event of MVF proving to be ineffective.

Clinicians should seek to ascertain and neutralise the patient's expectations, regardless of their beliefs and expectations. The attitude to foster is that of, “We are finding out what is possible with this process” rather than, “This is a treatment for your condition.” Discussion of outcomes should also be avoided other than to offer that “outcomes are largely irrelevant at this stage, as we are simply exploring what is possible.”

For the client who is sceptical and dismissive of the MVF approach, especially if they have tried it previously without positive effect, a neutral approach of “let's find out what happens when we change a few things around” is best rather than engaging in disagreement with the patient.

Clinicians should use a “pace, pace, pace and lead” approach, which begins by agreeing with the patient and leading them towards a more neutral stance.

Stage 2: Focus of attention

The patient is directed to create a convincing illusion by carefully adjusting the position and attitude of the limb reflected in the mirror. They are told to take as much time as needed. It will be noticed that the majority of patients find themselves quickly absorbed into the processes, and it is at this juncture, the clinician is best able to remain silent and out of view of the patient. Once patients focus on the illusion, they explore it and spontaneously create movements with their limbs.

For the outside observer, it may well appear that not much is happening, and all they can see is a patient staring at a mirror reflection of their limb. However, a lot is going on and being processed for the patient who is absorbed into the experience. This must not be interrupted.

Stage 3: Reaction and Abreaction

Shock, surprise, disbelief, and indifference are commonly experienced and expressed at this stage. For the patient who is absorbed in their focus of attention and also expresses indifference, clinicians should be aware that this may be as much of a need to “save face” as it is genuine. The clinician must remain indifferent to the reaction set expressed by the patient and, as much as possible, remain silent.

Some patients express surprise and quickly disengage from the mirror. In one instance, the patient, visibly shaken from his brief interaction with the mirror, requested leave to go outside for a cigarette. The clinician just gave a silent nod, and the patient later returned and continued his interaction with the mirror of his own volition and without the clinician's direction.

Stage 4: Emotional reunion with limb image

This stage quickly follows the reaction and abreaction stage and is commonly marked by a verbal interaction between the patient and the mirror reflection. This stage is marked by the experience of moving from merely seeing a convincing illusion to reconnecting to a visual limb image. It should be noted that whilst most patients can visually describe their phantom limb, often in detail, their visual description is created from their proprioceptive experience of it; at this point of the MVF session, the patient is now reunited with an actual visual presentation of the limb that matches their proprioceptive experience.

Stage 5: Abreactional states

For many patients, abreactional states may appear to be relatively extreme, especially those with high levels of dysmorphic distress from the loss of the limb combined with other changes to visual appearance (i.e. facial disfigurement, scarring, loss of other body parts) and function (in war trauma, genital injury and genital loss is common with leg amputation resulting from blast injury. Injuries of this nature often result not only in amputation but also in additional issues such as colostomy and urostomy formation).

The emotions expressed by the patient at this stage are abreactions, which means they are experienced and expressed “release and relief” rather than a re-experience and recycling of them.

The abreactional phase may be brief and mild for most patients and pass quickly. Still, for patients caught in the Pain-Depression-Dysmorphic Distress Cycle with a background issue of active and concurrent PTSD, a cyclical effect may sometimes be observed with emotional release, followed by further “Focus of Attention” and “Reunion with the Limb Image” followed by further abreactional releases. In these situations, clinicians are advised to “just let the patient talk it out” and to offer minimal feedback.

Stage 6: Fascination and Exploration

The fascination and exploration phase is dominated by curiosity as the patient explores the MVF experience without complicating emotions. It has been observed that some patients will happily stay in this stage until either interrupted by external necessities—i.e., the end of session time or the clinician interrupting—or internal necessities, such as the need to use the bathroom or another cigarette. It is recommended that the patient be allowed at least 20 minutes to explore this stage. Many patients have expressed a desire at the end of the session to construct themselves a mirror box and return to this exploration as soon as possible.

Stage 7: Fatigue

Fatigue is commonly reported post-session, especially where there have been strong abreactional states. Vivid dreams and deep sleep are also commonly reported in the nights following the session.

Stage 8: Telescoping phenomena

Telescoping is the effect of the phantom limb shortening with repeated use of the mirror box. In the example of an upper limb phantom, the limb shortens from the shoulder end and not from the finger end. As the telescoping develops, the patient's phantom will be reduced to just a phantom hand coming out of the stump and, finally, just the fingertips. It is unusual for the phantom fingers to disappear completely.

Telescoping is usually not noticed until after several days of consecutive use of the mirror and often not until the clinician asks about it. Whilst telescoping might seem a little unusual to anyone else, but to the patient, it appears to be experienced as perfectly natural.

Patients whose phantom pain is primarily caused by phantom contractures who only use the mirror box occasionally in order to “release” the contracture may not experience any telescoping phenomena.

==== Part 4: Managing Complex Issues ====
  * Addressing the Pain-Depression-Dysmorphic Distress Complex

==== A: Recommended Resources ====
  * Books and Articles for Further Reading

==== B: Glossary of Terms ====
  * Definitions of Key Terms Used in the Manual

• Standards for Training Delivery
• Feedback and Continuous Improvement Processes