EMDR in a Nutshell
In a nutshell, EMDR is different from other therapies because it helps the brain process information that we just can't seem to stop thinking about, being triggered or disturbed by, or have feelings of shame, depression, or anxiety for which we cannot find a source. It just may be that EMDR helps the brain manually reproduce what happens in the Rapid Eye Movement (REM) sleep phase. During REM sleep our eyes are moving all over and our brains are processing and storing information as memories. (For more on EMDR research, click HERE.)
EMDR therapy assists the brain in resuming its natural healing process and is designed to help the brain resolve unprocessed memories resulting from negative life events or traumas. For many clients, EMDR therapy can be completed in fewer sessions than other psychotherapies. EMDR therapy does not require talking in detail about distressing events.
(For video on EMDR click here.)
EMDR is an evidence based treatment for anxiety and trauma. Evidence-based treatments (EBT) are those in which studies have been conducted, replicated, and extensive research has been documented as successful
How does EMDR therapy work?
EMDR is a method of helping the central nervous system to process information in our brains, and somewhat, in our bodies. EMDR is not the same as brainwashing, hypnosis, voo-doo, or magic. You don't have to believe that EMDR works, for it to work. EMDR is not the merely the power of suggestion. EMDR works through our central nervous system using other parts of our central nervous system to process information. Our bodies naturally recover from illness or injury by means of our Immune System. Our minds have a similar system. It is called the Adaptive Information Processing System (AIP). Let's just call it our processing system. It is an immune system, of sorts, for the psychological aspects of ourselves. It works to heal our distressing thoughts, feelings, and sensations. We all have both "immune systems" and they are part of our Central Nervous System. EMDR helps our processing system process experiences that we react to with high arousal state; an intense level of fear, anxiety, etc. High levels of fear and anxiety are indicators that our fight or flight system is on.
When we experience an adverse life event or trauma our fight, flight, or freeze system kicks in to make us acutely aware of and heightens our ability to detect and fight with, flee from, or become immobile while in danger;. The only job of the fight, flight, or freeze system is to help us survive. Physiologically, the Central Nervous System is unable to process emotion when the fight, flight, or freeze system is activated. Our central nervous system cannot simultaneously use the fight, flight, or freeze system and the information/emotion processing system. It's just not possible. Think about it, if you are on a savannah with a hungry tiger salivating at you and you are hearing a low growl from the tiger, you are in fight, flight, or freeze mode - survival mode. Is there any part of you that would want to process how you feel about the salivating tiger? Doubtful, all parts of you want to to survive! As a result, the body and mind shift all energy and attention to survival and the fight, flight, or freeze system gets activated. So we either fight the tiger, flee from the tiger, or freeze not being able to think or move while the tiger salivates.
Think of of a time when you were shocked, experienced an unwelcomed surprise, were seriously frightened or stressed. How did you react? Did you jump? Did you startle? Did you feel fear? Anxiety? Both? Did you feel unsafe, dizzy, or like you wanted to run away, or maybe you felt frozen and couldn't think? These are all stress responses. If you experienced any of those reactions, that is because your fight or flight system was turned on. It automatically turns on when we perceive a threat and results in a stress response. Stress responses are instinctive. Have you ever tried not to startle when you were shocked, experienced an unwelcomed surprise, were seriously frightened or stressed? It is very difficult to suppress a stress response, exactly because they are instinctive. Instincts help us survive.
Arousal can be low level, like how we feel in the morning when we are barely awake or higher level, like when we feel sharply alert, awake, and attentive are tuned into our environment. When we perceive a threat, our fight or flight system is activated and we are in high arousal. High arousal prevents our processing system from processing and storing such information in a healthy way. It's like trying to put a big ole' piece of rock-hard-stale bread through a food processor to make bread crumbs. It ain't going through; it's not gonna process. We ain't gettin' any bread crumbs. The bread is just stuck. Same idea - our psychological processing system can not process information with high arousal. It' like the big ole' piece of rock-hard-stale bread; it ain't getting processed or organized for storage. High arousal jams the processing system. So information with a high level of arousal, is not processed nor stored in a useful way.
When the information gets stored in a way that is not useful to us, it is referred to as "maladaptive" storage. Conversely, when information that is stored in a way that is useful to us, it is referred to as "adaptive" storage, and 2 things happen. First adaptive storage is organized so that similar memories are stored together and second, any information that is not useful is not stored. "What we don't use, we lose." There is no need to remember information that is not useful. Useful information is remembered to help us make future decisions. For example, if you get in a traffic jam and decide to take an alley-way, but then run into some nasty potholes, most likely the memory of the alley-way experience will be stored adaptively. That is, you will have learned not to go down that alley-way again. Your processing system adaptively stored the memory and the information is useful.
EMDR allows normal healing to resume because it helps the processing system (the psychological immune system) process information with high arousal in an adaptive way. The result experienced by the client, is the development of insight, the storage of useful information, and the disposal of information that is not useful, such as distress, disturbance, anxiety, fear, etc. that are associated with the adverse life event or trauma. Such information is not stored. It is lost, does not exist, and does not result in ongoing distress and anxiety for the client.
(Please read the blog entries on C-PTSI (injury))
Who can benefit from EMDR therapy?
EMDR therapy helps children and adults of all ages.
Therapists use EMDR therapy to address a wide range of challenges:
- Anxiety, panic attacks, and phobias
- Chronic Illness and medical issues
- Depression and bipolar disorders
- Dissociative disorders
- Eating disorders
- Grief and loss
- Performance anxiety
- Personality disorders
- PTSD and other trauma and stress-related issues
- Sexual assault
- Sleep disturbance
- Substance abuse and addiction
- Violence and abuse
Can EMDR therapy be done without a trained EMDR therapist?
EMDR therapy is a mental health intervention. As such, it should only be offered by properly trained and licensed mental health clinicians. There are risks and benefits to EMDR and EMDR trained therapists know what to do if a client becomes overwhelmed with emotion, lost in a flashback, remembers experiences that had been repressed, has a dissociative reaction, or is becomes disturbed for days or weeks or is plagued with negative thoughts that they cannot seem to stop. Please do not try EMDR on your own.
How did EMDR therapy start?
In the late 1980s, Francine Shapiro discovered a connection between eye movement and persistent upsetting memories. With this personal insight, she began what became a lifelong study and development of Eye Movement Desensitization and Reprocessing (EMDR) therapy.
Over the years, and in the face of initial skepticism, Dr. Shapiro’s work developed from a hypothesis to a formal therapy process. EMDR therapy has been demonstrated to be effective for treating trauma in randomized clinical trials, case studies, and millions of clinical hours treating trauma and trauma-related disorders across the globe. From the American Psychiatric Association, the U.S. Department of Veterans Affairs (USVA) and Department of Defense (USDOD), the United Kingdom’s National Institute for Health Care and Excellence (NICE), and the World Health Organization (WHO), multiple global organizations now recognize the effectiveness of EMDR therapy that Dr. Shapiro developed. Most recently, the public acceptance of EMDR therapy was illustrated when Prince Harry reported that he engaged in EMDR therapy to treat trauma from his childhood.
Dr. Shapiro encouraged the foundation of EMDRIA, which comprises more than 11,000 mental health professionals who use EMDR therapy in their clinical practice to treat many conditions that impact mental health. Dr. Shapiro died in 2019, but her legacy of trauma-informed mental health.
Experiencing EMDR Therapy
After the therapist and client agree that EMDR therapy is a good fit, the client will work through the eight phases of EMDR therapy with their therapist.
Attention will be given to a negative image, belief, emotion, and body sensation related to this event, and then to a positive belief that would indicate the issue was resolved.
A typical EMDR therapy session lasts from 60-90 minutes. EMDR therapy may be used within a standard talking therapy, as an adjunctive therapy with a separate therapist, or as a treatment all by itself.
Overview of Experiencing EMDR Therapy
After the therapist and client agree that EMDR therapy is a good fit, the beginning sessions will involve discussing what the client wants to work on and improving the client's ability to manage distress.
When ready for the next phases of EMDR therapy, the client will be asked to focus on a specific event. Attention will be given to a negative image, belief, emotion, and body feeling related to this event, and then to a positive belief that would indicate the issue was resolved.
While the client focuses on the upsetting event, the therapist will begin sets of side-to-side eye movements, sounds, or taps. The client will be guided to notice what comes to mind after each set. They may experience shifts in insight or changes in images, feelings, or beliefs regarding the event.
The client has full control to stop the therapist at any point if needed. The sets of eye movements, sounds, or taps are repeated until the event becomes less disturbing.
EMDR therapy may be used within a standard talking therapy, as an adjunctive therapy with a separate therapist, or as a treatment all by itself.
How Long Does EMDR Therapy Take?
A typical EMDR therapy session lasts from 60-90 minutes. It could take one or several sessions to process one traumatic experience.
The goal of EMDR therapy is to process completely the traumatic experiences that are causing problems and to include new ones that are needed for full health. The amount of time it will take to complete EMDR treatment for traumatic experiences will depend upon the history of the client. Complete treatment of a single EMDR trauma target involves a three-pronged protocol to alleviate the symptoms and address the complete clinical picture. The three prongs include:
- past memories
- present disturbance
- future actions
Although EMDR therapy may produce results more rapidly than other forms of therapy, speed is not the goal of therapy and it is important to remember that every client has different needs. For instance, one client may take weeks to establish sufficient feelings of trust (Phase 2), while another may proceed quickly through the first six phases of treatment only to reveal something even more important that needs treatment.
"Processing" in EMDR Therapy
"Processing" does not mean talking about a traumatic experience. "Processing" means setting up a learning state that will allow experiences that are causing problems to be "digested" and stored appropriately in your brain. That means that what is useful to you from an experience will be learned, and stored with appropriate emotions in your brain, and be able to guide you in positive ways in the future.
The inappropriate emotions, beliefs, and body sensations will be discarded. Negative emotions, feelings and behaviors are generally caused by unresolved earlier experiences that are pushing you in the wrong directions. The goal of EMDR therapy is to leave you with the emotions, understanding, and perspectives that will lead to healthy and useful behaviors and interactions.
Eight Phases of EMDR Therapy Treatment
There are eight phases to EMDR therapy: initial history discovery and treatment planning, preparation, assessment, desensitization, installation, body scan, closure, and then reevaluation.
Phase 1: History and Treatment Planning
This phase generally takes 1-2 sessions at the beginning of therapy, and can continue throughout the therapy, especially if new problems are revealed. In the first phase of EMDR treatment, the therapist takes a thorough history of the client and develops a treatment plan. This phase will include a discussion of the specific problem that has brought him or her into therapy, the behaviors and symptoms stemming from that problem. With this information, the therapist will develop a treatment plan that defines the specific targets on which to use EMDR:
- the event(s) from the past that created the problem
- the present situations that cause distress
- the key skills or behaviors the client needs to learn for his future well-being
One of the unusual features of EMDR is that the person seeking treatment does not have to discuss any of his or her disturbing memories in detail. So while some individuals are comfortable, and even prefer, giving specifics, other people may present more of a general picture or outline. When the therapist asks, for example, "What event do you remember that made you feel worthless and useless?" the person may say, "It was something my brother did to me." That is all the information the therapist needs to identify and target the event with EMDR.
Phase 2: Preparation
For most clients this phase will take between 1-4 sessions. For others, with a very traumatized background, or with certain diagnoses, a longer time may be necessary. In this phase, the therapist will teach you some specific techniques so you can rapidly deal with any emotional disturbance that may arise. If you can do that, you are generally able to proceed to the next phase.
One of the primary goals of the preparation phase is to establish a relationship of trust between the client and the therapist. While the person does not have to go into great detail about his disturbing memories, if the EMDR client does not trust his or her therapist, he or she may not accurately report what is felt and what changes he or she is (or isn't) experiencing during the eye movements. If the client just wants to please the therapist and says they feel better when they don't, no therapy in the world will resolve that client's trauma.
During the Preparation Phase, the therapist will explain the theory of EMDR, how it is done, and what the person can expect during and after treatment. Finally, the therapist will teach the client a variety of relaxation techniques for calming him or herself in the face of any emotional disturbance that may arise during or after a session.
In any form of therapy it is best to look at the therapist as a facilitator, or guide, who needs to hear of any hurt, need, or disappointments in order to help achieve the common goal. EMDR therapy is a great deal more than just eye movements, and the therapist needs to know when to employ any of the needed procedures to keep the processing going. Learning these tools is an important aid for anyone. The happiest people on the planet have ways of relaxing themselves and decompressing from life's inevitable, and often unsuspected, stress. One goal of EMDR therapy is to make sure that the client can take care of him or herself.
Phase 3: Assessment
In this phase, the client will be prompted to access each target in a controlled and standardized way so it can be effectively processed. Processing does not mean talking about it. (See the Reprocessing sections below.) The EMDR therapist identifies different parts of the target to be processed.
The first step is for the client to select a specific image or mental picture from the target event (which was identified during Phase One) that best represents the memory. Then he or she chooses a statement that expresses a negative self-belief associated with the event. Even if the client intellectually knows that the statement is false, it is important that he or she focus on it. These negative beliefs are actually verbalizations of the disturbing emotions that still exist. Common negative cognitions include statements such as "I am helpless," "I am worthless," "I am unlovable," "I am dirty," "I am bad," etc.
The client then picks a positive self-statement that he would rather believe. This statement should incorporate an internal sense of control such as "I am worthwhile/lovable/a good person/in control" or "I can succeed." Sometimes, when the primary emotion is fear, such as in the aftermath of a natural disaster, the negative cognition can be, "I am in danger" and the positive cognition can be, "I am safe now." "I am in danger" can be considered a negative cognition, because the fear is inappropriate -- it is locked in the nervous system, but the danger is actually past. The positive cognition should reflect what is actually appropriate in the present.
At this point, the therapist will ask the person to estimate how true a positive belief feels using the 1-to-7 Validity of Cognition (VOC) scale. "1" equals "completely false," and " 7" equals "completely true." It is important to give a score that reflects how the person "feels," not " thinks." We may logically "know" that something is wrong, but we are most driven by how it " feels."
Also, during the Assessment Phase, the person identifies the negative emotions (fear, anger) and physical sensations (tightness in the stomach, cold hands) he or she associates with the target. The client also rates the negative belief, but uses a different scale called the Subjective Units of Disturbance (SUD) scale. This scale rates the feeling from 0 (no disturbance) to 10 (worst) and is used to assess the disturbance that the client feels.
The goal of EMDR treatment, in the following phases, is for SUD scores of disturbance to decrease while the VOC scores of positive belief increase.
Reprocessing. For a single trauma reprocessing is generally accomplished within 3 sessions. If it takes longer, you should see some improvement within that amount of time. Phases One through Three lay the groundwork for the comprehensive treatment and reprocessing of the specific targeted events. Although the eye movements (or taps, or tones) are used during the following three phases, they are only one component of a complex therapy. The use of the step-by-step eight-phase approach allows the experienced, trained EMDR therapist to maximize the treatment effects for the client in a logical and standardized fashion. It also allows both the client and the therapist to monitor the progress during every treatment session.
Phase 4: Desensitization
This phase focuses on the client's disturbing emotions and sensations as they are measured by the SUDs rating. This phase deals with all of the person's responses (including other memories, insights and associations that may arise) as the targeted event changes and its disturbing elements are resolved. This phase gives the opportunity to identify and resolve similar events that may have occurred and are associated with the target. That way, a client can actually surpass his or her initial goals and heal beyond his or her expectations.
During desensitization, the therapist leads the person in sets of eye movements, sounds, or taps with appropriate shifts and changes of focus until his or her SUD-scale levels are reduced to zero (or 1 or 2 if this is more appropriate). Starting with the main target, the different associations to the memory are followed. For instance, a person may start with a horrific event and soon have other associations to it. The therapist will guide the client to a complete resolution of the target.
Examples of sessions and a three-session transcript of a complete treatment can be found in F. Shapiro & M.S. Forrest (2004) EMDR. New York: BasicBooks. http://www.perseusbooksgroup.com/perseus-cgi-bin/display/0-465-04301-1
Phase 5: Installation
The goal is to concentrate on and increase the strength of the positive belief that the client has identified to replace his or her original negative belief. For example, the client might begin with a mental image of being beaten up by his or her father and a negative belief of "I am powerless." During the Desensitization Phase that client will have reprocessed the terror of that childhood event and fully realized that as an adult he or she now has strength and choices that were not there when he or she was young.
During this fifth phase of treatment, that person's positive cognition, "I am now in control," will be strengthened and installed. How deeply the person believes that positive cognition is then measured using the Validity of Cognition (VOC) scale. The goal is for the person to accept the full truth of his or her positive self-statement at a level of 7 (completely true).
Fortunately, just as EMDR cannot make anyone shed appropriate negative feelings, it cannot make the person believe anything positive that is not appropriate either. So if the person is aware that he or she actually needs to learn some new skill, such as self-defense training, in order to be truly in control of the situation, the validity of that positive belief will rise only to the corresponding level, such as a 5 or 6 on the VOC scale.
Phase 6: Body Scan
After the positive cognition has been strengthened and installed, the therapist will ask the person to bring the original target event to mind and see if any residual tension is noticed in the body. If so, these physical sensations are then targeted for reprocessing.
Evaluations of thousands of EMDR sessions indicate that there is a physical response to unresolved thoughts. This finding has been supported by independent studies of memory indicating that when a person is negatively affected by trauma, information about the traumatic event is stored in body memory (motoric memory), rather than narrative memory, and retains the negative emotions and physical sensations of the original event. When that information is processed, however, it can then move to narrative (or verbalizable) memory and the body sensations and negative feelings associated with it disappear.
Therefore, an EMDR session is not considered successful until the client can bring up the original target without feeling any body tension. Positive self-beliefs are important, but they have to be believed on more than just an intellectual level.
Phase 7: Closure
Ends every treatment session. Closure ensures that the person leaves at the end of each session feeling better than at the beginning.
If the processing of the traumatic target event is not complete in a single session, the therapist will assist the client in using a variety of self-calming techniques in order to regain a sense of equilibrium. Throughout the EMDR session, the client has been in control (for instance, the client is instructed that it is okay to raise a hand in the "stop" gesture at anytime) and it is important that the client continue to feel in control outside the therapist's office.
He or she is also briefed on what to expect between sessions (some processing may continue, some new material may arise), how to use a journal to record these experiences, and what calming techniques could be used to self-soothe in the client's life outside of the therapy session.
Phase 8: Reevaluation
Opens every new session. The Reevaluation Phase guides the therapist through the treatment plans that are needed in order to deal with the client's problems. As with any form of good therapy, the Reevaluation Phase is vital in order to determine the success of the treatment over time. Although clients may feel relief almost immediately with EMDR, it is as important to complete the eight phases of treatment, as it is to complete an entire course of treatment with antibiotics.
The Role of Past, Present, and Future Templates
EMDR therapy is not complete until attention has been brought to the past memories that are contributing to the problem, the present situations that are disturbing, and what skills the client may need for the future.
Excerpts above from: F. Shapiro & M.S. Forrest (2004) EMDR: The Breakthrough Therapy for Anxiety, Stress and Trauma. New York: Basic Books. http://www.perseusbooksgroup.com/perseus-cgi-bin/display/0-465-04301-1