Discussion

Chapter 22

Eye Movement Desensitization and Reprocessing

Anka Roberto and Ashley Swinson

LEARNING OBJECTIVES

By the end of this chapter, you should be able to:

•understand the origination of eye movement desensitization and reprocessing (EMDR);

•explore theoretical constructs leading to the formation of the eight- phased EMDR protocol;

•understand the context of the use of EMDR and its efficacy in healing posttraumatic stress disorder, anxiety, substance use disorders, and other symptoms associated with trauma-related disorders;

•explore evidence that supports the use of EMDR with clients of all ages; and

•apply tenets of EMDR to clinical cases.

INTRODUCTION

In the vast research regarding traumatic stress, there are several universal themes that stand out due to the exposure to such experiences. The human brain is designed to adapt to experience by perceiving and learning, so as one encounters the world, one’s brain will develop core beliefs systems that shape thoughts, feelings, behaviors, and decision-making. These core beliefs are built upon three developmental concepts: personal power, personal safety, and personal responsibility.

Current research supports the claim that unprocessed traumatic memories contribute to psychopathology. The unprocessed portions of traumatic memories that reside in the hippocampus, and are connected to the limbic system, impact the neurophysiology of the brain causing biophysical changes in brain structure and brain function (Shapiro et al., 2007; Wheeler, 2014; Van Der Kolk, 2015). These biophysical changes appear on functional magnetic resonance imagining (fMRI) studies like a traumatic brain injury (Fosha et al., 2009).

It has been estimated that one in four children experience abuse, and 60% of men and 51% of women in the United States have experienced at least one traumatic event (Richardson, 2018). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association [APA], 2013) defines traumatic experience as, “exposure to actual or threatened death, serious injury, or sexual violence” (p. 271). It goes on to explain that we can experience trauma in four different ways:

1.directly experiencing a personal trauma;

2.directly witnessing a trauma that occurs to someone else;

3.indirect exposure of a traumatic experience when a close family member, friend, or associate has direct experience (e.g., a loved one is in a severe car accident); or

4.vicarious exposure through the repeated or extreme exposure to aversive details due to professional responsibilities (e.g., child abuse investigators; Pai et al., 2019).

In addition to these life-threatening and violent experiences (referred to as big “T” traumas), research also indicates that the less intense but adverse experiences (referred to as little “t” traumas) can be as equally impactful on the brain (Barbash, 2019). See Table 22.1.

According to global organizations such as the Substance Abuse and Mental Health Services Administration (SAMHSA; 2016), adverse childhood experiences (ACEs) are defined as stressful life or traumatic events that happen to children ages 0 to 18. ACEs include the following experiences for children ages 0 to 18: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, intimate partner violence, living with a mother who was treated violently, substance misuse within the household, household mental illness, parental separation or divorce, and having a parent who has been incarcerated (Anda et al., 2006). In the 1990s, the Centers for Disease Control and Prevention led an investigation on the epidemic of childhood trauma and its correlation with adulthood disease, what is now known as the Adverse Childhood Experiences Study (Felitti et al., 1998). These adverse experiences consisted of big “T” and little “t” traumatic events. This research drastically shaped our understanding of how traumatic experiences affect overall lifelong wellness. While it is possible for someone to develop posttraumatic stress disorder (PTSD) in response to being exposed to traumatic experiences, there are many more negative consequences. ACEs and their impact on the developing brain and body are multidimensional, with long-lasting effects causing chronic disease into adulthood such as heart disease, diabetes, cancers, autoimmune disease, mental health disorders, higher suicide rates, and earlier mortality by 10 years (Felitti et al., 1998). Nationally, economic hardship and divorce or separation of a parent or guardian are the most common ACEs. Close to half of children in the United States have experienced at least one ACE and one in 10 children experienced three or more ACEs in their lifetime, which puts them at higher risk of long-term negative effects (Murphey & Bartlett, 2019; Redford & Pritzker, 2016).

The symptoms stemming from adverse and/or traumatic experiences span the mental, behavioral, and medical health spectra. Thus, treatment protocols addressing these symptoms should prioritize the relationship between the brain, body, and experience, while considering one’s past, present, and future; eye movement desensitization and reprocessing (EMDR) therapy does just that. This leading, innovative approach in resolving symptoms of PTSD as well as anxiety disorders, cognitive disturbances, addictions, and life stressors has been deemed by many clinicians and researchers the gold standard of treatment when used according to its protocol and treatment regimens (Adler-Tapia & Settele 2009, 2010; Bisson et al., 2007). EMDR has been noted to be more beneficial than cognitive-behavioral therapy in a meta-analysis for patients with prominent intrusion or arousal symptoms (Chen et al., 2015).

TABLE 22.1 BIG T AND LITTLE t

Types of Big “T” traumas Types of Little “t” Traumas

•Exposure to gun violence

•Car or plane accidents

•Directly experiencing or witnessing physical violence or sexual abuse

•Natural disasters

•Losing a child

•War/combat

•Severe neglect as a child

•Severe, life-threatening medical events

•Chronic or traumatic grief (loss by suicide)

•Family or marital distress including chronic conflict, infidelity, and divorce

•Bullying

•Postpartum issues

•Financial stress

•Feeling unloved or unimportant

•Providing extensive caregiving

•Mental illness or addiction in the family

•Chronic medical issues

HISTORICAL DEVELOPMENT

In 1987, Dr. Francine Shapiro stumbled across the relationship between bilateral stimulation (BLS; left to right lateral eye movement) and the reduction of internal stress. During her infamous “walk in the park,” she found that her uncomfortable thoughts about a stressful, disturbing situation had dissipated by the end of her walk. Dr. Shapiro had previously battled cancer for 10 years, so she was particularly intrigued by the mind-body connection, and she quickly noticed that during this walk, her eyes were tracking back-and-forth across the landscape while she ruminated on her stress. So, she repeated this activity: consciously thinking about a bothersome thought while rapidly moving her eyes back and forth, and she concluded that each time she repeated this, the negative feelings she held about her stress improved. She hypothesized that traumatic memories, which are composed of negative thoughts and affect, could be improved with the use of BLS, hence an outpouring of breakthrough research that resulted in a rigorous, evidence-based treatment protocol for PTSD: EMDR therapy (Shapiro, 2012).

Much like other studies on PTSD at that time, the initial subjects for EMDR research consisted of combat veterans. Following the Vietnam War, PTSD had become a substantiated mental health illness in the late 1970s, and as a difficult condition to treat, the most successful treatment modalities remained in question. The emergence of EMDR and its effectiveness in symptom remission, hallmarked by the efficiency of its delivery, set this therapy apart from other therapeutic interventions. And, unlike other treatment modalities that have undergone several revisions throughout the years, the rigid methodology of EMDR has been mostly unchanged since 1990 (Shapiro, 2001).

The early focus of EMDR was on the immediate relief of distressful symptoms: consciously holding adverse thoughts while bilaterally stimulating the body to achieve desensitization of the nervous system. However, for symptom remission to remain successful, long-term research revealed that one’s deeply held core belief system needed to be reprocessed as well. In addition to a client being able to remember a traumatic memory without feeling distress, the client could also recall that memory and maintain a positive core belief about oneself, evidence of true adaptive resolution in the brain and body.

It was also determined that multiple methods of BLS were effective in the treatment protocol, like alternating tapping sensations on each hand or alternating sound in each ear, though it has been established that lateral eye movements are the most efficacious (Solomon, 2014).

EMDR research subjects have expanded since then to include the civilian/general population, and consistently, these studies reveal that EMDR is an equivalent or superior intervention to cognitive-behavioral therapies, exposure therapies, and the use of SSRIs to reduce symptoms of PTSD (Bisson et al., 2007). After treatment is completed, EMDR is also more effective at maintaining symptom remission at 6 and 12 months out (Shapiro, 2001). Remarkably, debunking what we have assumed to be true about therapeutic processing, EMDR does not require a trusting relationship between the client and the therapist to be effective, does not require in vivo homework, and does not require a person to divulge the details of their traumatic story in order to heal from it.

Not everyone is an appropriate candidate for EMDR therapy, and the setting in which a client is receiving this intervention can impact the treatment direction. It is the clinician’s responsibility to adequately assess a client’s readiness and integrative capacity in order to proceed. While some contraindications are cautionary, there are clinical concerns that restrict utilization of this approach entirely. A client’s ability to maintain dual awareness by holding focus of the past and remaining safe in the present is key for reprocessing to occur, so if a client has intrusive, dissociative symptoms that hinder stability and safety, or if there are acute symptoms such as life-threatening substance use, active suicidality, self-injury, or homicidal/assaultive behavior, then EMDR therapy would be postponed until the client can demonstrate personal safety. Moreover, medications that inhibit one’s ability to learn (e.g., benzodiazepines), high doses of psychotropics, and polypharmacy can hinder the effectiveness of EMDR, as a client needs to be able to access affect while they are reprocessing. Therefore, the clinician should closely coordinate the client’s care with primary providers, psychiatrists, or psychiatric mental health nurse practitioners who may be prescribing such medications to allow for treatment planning to safely adjust doses appropriately. Caution should also be given to those clients who have a history of epilepsy or eye problems as these issues can worsen with eye movement sets, and when eye movements cannot be used, the clinician can use alternate forms of BLS. In the event of legal matters that may require client testimony detailing specific events, the clinician should advise the client of the possibility that EMDR treatment may affect the client’s ability to access vivid details and emotions that pertain to the event. It should be considered that if a client has received any special kind of assistance, caretaking, or compensation for their emotional disability (e.g., disability check), EMDR may remit the symptoms that warranted this resource, which could pose new challenges for the client (e.g., loss of income; Shapiro, 2001).

Conversely, those clients who are stable and have high integrative capacity are great candidates for EMDR, which is evidenced by the ability to maintain dual awareness/co-consciousness, present a coherent narrative of the experiences, learn and utilize new information, and access positive memory networks. Regardless of the intensity and severity of symptoms, a client’s ability to tolerate an emotional disturbance while self-regulating to lower their level of arousal and shift emotional states can be predictive of EMDR success. It is also helpful for clients to have social supports available between EMDR sessions to assist with soothing and comfort along the way (Solomon, 2014).

Ultimately, the goal of EMDR is to eliminate the presenting symptoms of distress in clients in an accelerated manner. Meta-analyses and clinical trials (randomized and non-randomized studies) that compare EMDR to other cognitive-behavioral and exposure therapies, like trauma -focused cognitive behavioral therapy, are consistent that EMDR is a comparable or more effective approach yielding long-lasting results with fewer attrition rates (Wheeler, 2014). It has been noted that fewer EMDR therapy sessions are required to achieve these results, and upon completion of treatment, symptom remission is maintained at 6- and 12-month follow-ups (Solomon, 2014).

Given the success of utilizing EMDR for those with PTSD, the research has further explored this protocol with other mental, behavioral, and medical health challenges. The assumption is that pathological symptoms are the result of maladaptively stored information in the brain’s memory networks, so it has been hypothesized that other health-related challenges could benefit from EMDR as well. Specialty EMDR protocols have been developed for populations like those with addiction, grief, pain, phobias, recent traumatic events, and so forth. For instance, the Recent Traumatic Events Protocol (R-TEP) was created by Elan Shapiro to address an acute event that has recently occurred to prevent the development of serious posttraumatic symptoms, which can be uniquely utilized with individuals or groups (Tofani & Wheeler, 2019). In the same way, AJ Popky developed the Desensitizing Triggers and Urge Reprocessing (DeTUR) protocol for addictions, particularly addressing the intensity of an urge that a client experiences when they are exposed to a trigger and have a desire to use substances (Shapiro, 2005).

CENTRAL THEORETICAL CONSTRUCT: ADAPTIVE INFORMATION PROCESSING THEORY

From a developmental perspective, we know that the interplay between predispositions and life experiences shapes the way individuals evolve over time. At the core, people hold belief systems regarding the central themes of personal responsibility, personal power, and personal safety that create conscious and unconscious consequences, greatly impacting the way one experiences oneself and the world around oneself. Therapeutic interventions are designed to address these themes and the coinciding psychopathologies.

Regarding treatment modalities that directly address trauma-based symptoms and disorders, there are two main modes of processing: top-down and bottom-up. In top-down therapeutic processing, one’s perception is driven by the internal cognitions that relate to what the brain already knows. Narrative therapies are top-down processes, as the therapy heavily relies on the stored context of thoughts and expectations. On the other hand, in bottom-up processing, one’s perception is driven by new sensations that are coming in and becoming known to the brain with no surrounding context or meaning. Interoceptive awareness is a key component of bottom-up processing, particularly with EMDR therapy, as one’s experience of somatic sensation in the present moment can positively alter one’s internal perception of safety, power, and responsibility.

The adaptive information processing (AIP) model is the central, theoretical construct of EMDR. It is assumed that memory networks are the basis of human functioning in which belief systems, perceptions, emotions, attitudes, behaviors, and symptoms are formed and expressed. As one experiences the world, the brain integrates information by either assimilating or accommodating the information into memory networks, and depending on the nature of the experience, different brain centers are activated.

For those experiences that are characteristically adverse or traumatic, the amygdala of the hind brain, sometimes referred to as the trauma brain or emotional brain, becomes activated. This limbic brain center is responsible for our survival instincts, emotional perceptions, and the storage of this respective memory into the hippocampus preparing oneself for similar events in the future, particularly those events that trigger fear. Similarly, the hippocampus, also connected to the limbic system of the brain, helps regulate our emotions and is associated with the storage of long-term memory. Both organs work in tandem when integrating life experiences into memory networks, storing information as bodily sensations, cognitions, emotions, and beliefs in order to survive and adapt (Van Der Kolk, 2015).

When these limbic centers of the hind brain become activated by events that heighten negative affect and arousal, the frontal lobe of the brain shuts down, hindering the executive control of our brain and limiting our ability to adapt in a healthy way. The frontal lobe is responsible for the information processing system that exercises judgment, reasoning, and decision-making. When this brain center is inhibited, memory becomes dysfunctionally stored in the brain, and these maladaptively stored memories become the basis of our pathology (Solomon, 2014).

The AIP model is a three-pronged protocol, in which the past, present, and future experiences are attended to. Regarding the diagnosis of PTSD, the past is considered to be the present, and true healing of the illness cannot be achieved with properly addressing the way in which the past experiences are stored in the brain. AIP asserts that in order to achieve an appropriate and ecological resolution of symptoms, you need to access the maladaptively stored memories and simultaneously activate the information processing system in the frontal lobe through BLS in order to move the information into adaptive resolution. BLS keeps the frontal lobe engaged even when the hind brain is turned on, so that the limbic system can become desensitized and memories can be reprocessed differently, resulting in true resolution (Solomon, 2014).

PHASES OF EYE MOVEMENT DESENSITIZATION AND REPROCESSING

Phase 1: History Taking/Treatment Planning Phase

This phase involves a few steps to ensure the emotional safety of the client, which in turn, allows for the practitioner and the client to establish rapport. This is a time of exploration in a neutral, safe environment for the client through assessing history, exploring coping strategies, and treatment planning of future memories to be reprocessed. Focus will be given to the assessment of the client’s stability, current life situations, and barriers to reprocessing. Further assessment will include using the Dissociative Experiences Scale (DES; see Exhibit 22.1) to rule out dissociation, screening for safe use of EMDR, and identifying small t’s and big T’s to use for treatment planning of reprocessing sessions (Shapiro, 2001).

There are two key qualifiers when assessing a client’s trauma history: touchstone experiences and worst experiences. The AIP model presumes that traumatic memories are stored based on the level of intensity and impact of the event. Therefore, those traumatic experiences that either occurred earliest in a client’s life (“touchstone” experiences) or are considered the worst experience of a client’s life should be identified as target memories in the treatment plan. Sometimes, it can be difficult for a client to identify touchstone experiences, so the floatback technique is suggested. When a client is preoccupied with a present-day stressor, the provider can direct the client to identify the concurrent cognitions, emotionality, and somatic responses that relate to that stressor. Then, the provider will prompt the client to float back in time to identify an experience earlier in their life that felt the same, “As you notice how this stressor makes you feel in your body and the core Negative Cognition (NC) that corresponds with that discomfort, float back in your mind as far as you can go to see if there is an earlier experience in your life that feels the same.” This earlier experience, possibly a touchstone memory, could be an identified target for reprocessing.

EXHIBIT 22.1 Dissociative Experiences Scale—II

Instructions: This questionnaire asks about experiences that you may have in your daily life. We are interested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to you when you are not under the influence of alcohol or drugs. To answer the questions, please determine to what degree each experience described in the question applies to you, and circle the number to show what percentage of the time you have the experience.

For example: 0% (Never) 10 20 30 40 50 60 70 80 90 100% (Always)

There are 28 questions. These questions have been designed for adults. Adolescents should use a different version.

Disclaimer: This self-assessment tool is not a substitute for clinical diagnosis or advice.

1. Some people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don’t remember what has happened during all or part of the trip. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

2. Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was said. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

3. Some people have the experience of finding themselves in a place and have no idea how they got there. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

4. Some people have the experience of finding themselves dressed in clothes that they don’t remember putting on. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

5. Some people have the experience of finding new things among their belongings that they do not remember buying. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

6. Some people sometimes find that they are approached by people that they do not know, who call them by another name or insist that they have met them before. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

7. Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something and they actually see themselves as if they were looking at another person. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

8. Some people are told that they sometimes do not recognize friends of family members. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

9. Some people find that they have no memory of some important events in their lives (e.g., a wedding or graduation). Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

10. Some people have the experience of being accused of lying when they do not think that they have lied. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

11. Some people have the experience of looking in a mirror and not recognizing themselves. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

12. Some people have the experience of feeling that other people, objects, and the world around them are not real. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

13. Some people have the experience of feeling that their body does not seem to belong to them. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

14. Some people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

15. Some people have the experience of not being sure whether things that they remember happening really did happen or whether they just dreamed them. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

16. Some people have the experience of being in a familiar place but finding it strange and unfamiliar. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

17. Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of other events happening around them. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

18. Some people find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

19. Some people find that they sometimes are able to ignore pain. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

20. Some people find that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

21. Some people sometimes find that when they are alone they talk out loud to themselves. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

22. Some people find that in one situation they may act so differently compared with another situation that they feel almost as if they were two different people. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

23. Some people sometimes find that in certain situations they are able to do things with amazing ease and spontaneity that would usually be difficult for them (e.g., sports, work, social situations). Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

24. Some people sometimes find that they cannot remember whether they have done something or have just thought about doing that thing (e.g., not knowing whether they have just mailed a letter or have just thought about mailing it). Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

25. Some people find evidence that they have done things that they do not remember doing. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

26. Some people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember doing. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

27. Some people sometimes find that they hear voices inside their head that tell them to do things or that comment on things that they are doing. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

28. Some people sometimes feel as if they are looking at the world through a fog, so that people and objects appear far away or unclear. Circle the number to show what percentage of the time this happens to you.

0% 10 20 30 40 50 60 70 80 90 100%

Total:DES Score:

Total divided by 28)

Scoring the Dissociative Experiences Scale—II

The average of all the answers is the DES score, giving a maximum of 100. The questions are scored by dropping the zero on the percentage of each answer, for example, 30% = 3 and 80% = 8; these numbers are then added up to give a total. The total is multiplied by 10 and then divided by 28 (the number of questions) to calculate the average score.

Dissociative Experiences Scale Scores

High and low DES scores and high levels of dissociation are indicated by scores of 30 or more; scores under 30 indicate low levels (Carlson & Putnam, 1993, p. 22). Successful treatment of a dissociative disorder should reduce the DES score when compared to the result before treatment began (Carlson & Putnam, 1993, p. 23). Very high scores do not necessarily mean a more severe dissociative disorder is present; this is because the scale measures both normal and pathological dissociation (Carlson & Putnam, 1993, p. 18).

Dissociative Identity Disorder and the Dissociative Experiences Scale

Only 1% of people with dissociative identity disorder have been found to have a DES score below 30. A very high number of people who score above 30 have been shown to have posttraumatic stress disorder or a dissociative disorder other than dissociative identity disorder (Carlson & Putnam, 1993).

Clinical Uses of the Dissociative Experiences Scale

If a person scores in the high range (above 30), then the DES questions can be used as the basis for a clinical interview, with the clinician asking the client to describe examples of the experiences they have had for any questions about experiences that occur 20% of the time or more. Alternatively, the Dissociative Disorders Interview Schedule or Structured Clinical Interview for Dissociative Disorders-Revised can be used to reach a diagnosis (Carlson & Putnam, 1993).

Average DES Scores in research

General adult population 5.4

Anxiety disorders 7.0

Affective disorders 9.35

Eating disorders 15.8

Late adolescence 16.6

Schizophrenia 15.4

Borderline personality disorder 19.2

Posttraumatic stress disorder 31

Dissociative disorder not otherwise specified (OSDD) 36

Dissociative identity disorder (MPD) 48

Note: The Dissociative Experiences Scale-II is included in Appendix.

MPD, multiple personality disorder; OSDD, other specified dissociative disorder.

Source: Carlson, E. B. & Putnam, F. W. (1993). An update on the Dissociative Experience Scale. Dissociation 6(1), 16-27.

EXHIBIT 22.2 Subjective Unit of Disturbance (SUD) Scale.

EXHIBIT 22.3 Validity of Cognition (VOC) Scale.

Phase 2: Preparation Phase

During this phase, the practitioner gathers informed consent from the client and family (if applicable) and educates the client and/or family on the use of EMDR. Considerable attention is given toward resource identification, in which the practitioner and the client explore coping resources that will optimize the client’s stabilization throughout treatment. Examples include teaching meditation techniques, breathing exercises, relaxation exercises, establishing a Safe Place or Calm Place resource, and creating a Container that holds negative, intrusive thoughts and feelings about oneself. Specific EMDR resources, such as the Safe Place, Calm Place, and Container, involve the use of slow BLS, and these particular internal resources can be used during the additional phases of treatment to elicit self-soothing.

Facilitating the Resource of a Calm/Happy Place: The provider facilitates a mindfulness exercise in which the client is asked to close their eyes and create a real or imagined picture in their mind that allows them to feel the most happy, relaxed, or calm. If the client is not comfortable closing their eyes, they are asked to simply focus on the floor to help decrease outside distractions or stimuli. With a focus on the five senses, the provider asks the client to verbalize aloud what they notice as they visualize their happy/calm place in sight, smell, touch, sound, taste, and finally, the emotional somatic relationship of how they feel this place in their body. Lastly, the client is encouraged to establish a cue word that captures the experience in its entirety, essentially giving the happy/calm place a name that gets paired with the pleasurable cognitive, emotional, and somatic experience. The use of resourcing is two-fold: (a) the provider can encourage the client to access this calm/happy place at the end of each EMDR reprocessing session to successfully close down the session by connecting their somatic sense of self to a feeling or emotion of calm/happy, and (b) the client can independently self-direct use of this resource outside of therapy sessions to cope and soothe when distressed.

Facilitation of the Resource of a Container: The provider guides the client in a mindfulness exercise to create an imaginary container that can be made up of any substance, can be any color, and can be as large or as small as it needs to be. This container should be able to hold any negative beliefs, images, or memories that may intrude during sessions. The container must have a lid or a top and must be able to be locked. The provider then guides the client to explain verbally what the container looks like and the approximate size of the container. The client then is instructed to open the lid and place all memories, beliefs, and thoughts into the container. When all is in the container, the client is asked to close it and lock it, and then place the container somewhere safe where they can access if need be, but far enough away so that it doesn’t bother them. The provider asks the client where the container is stored. The container resource can be utilized at the end of each EMDR reprocessing session, and before use of the calm/happy place resource. This ensures that the client safely contains all that has been spoken about or reprocessed in session so that the session content is outside of one’s thoughts. If working with a child or an adolescent, a physical container may be useful to create and can be made from plastic blocks, cardboard, a metal can, or any other material to allow for the child to engage developmentally while using concrete thinking.

Phase 3: Assessment Phase of Eye Movement Desensitization and Reprocessing

As the provider begins the treatment planning process, this phase consists of the identification of target memories or experiences in present and past life events that cause emotional disturbance to the client. Identification of negative cognitions (NCs) and desired positive cognitions (PCs) is also established. NCs represent a negative, critical, or judgmental thought or feeling of oneself associated with a target memory, whereas a PC represents how the client would like to think and feel about themselves. When thinking of the target, the client is asked to measure their NC by indicating the level of disturbance it brings to them on a scale of 0 to 10; this is called the Subjective Unit of Disturbance (SUD; see Exhibit 22.2). The client may report that they have a SUD level of 0 if the target causes no distress to them when thinking about the target, or they may report a SUD level of 10 if the target causes them a very high level of disturbance, like panic symptoms or a hypervigilant reaction. When a client has successfully desensitized a target, the goal is to have a reported SUD of 0. The PC is measured by a Validity of Cognition (VOC) score on a scale of 1 to 7, 1 being not true at all and 7 being the most or very true (Exhibit 22.3). The VOC represents how true the PC feels to the person in the current place and time or in the here and now. When a client has successfully reprocessed a target and installed a PC, the goal is to have a reported VOC of 7.

Phase 4: Desensitization Phase

The goal of the desensitization phase is to reprocess memories that have been stored maladaptively so that they become adaptively resolved memories. This allows the client to be freed of symptoms associated with a trauma response such as anxiety, dissociation, and the triggering of the fight, flight, or freeze reactions. An example of this would be a client who smells smoke and is automatically triggered into symptoms of panic or emotional paralysis, in which the pre-frontal cortex inhibits their ability to reason and make decisions to establish a safety plan to respond to the smoke in an adaptive way. This client may have been in a house fire and has not processed the event adaptively. EMDR reprocessing allows the amygdala to let go of the association of the core NC and feeling held in the body when the smell of fire takes place. Due to AIP, resolution of this event would then allow the client to not have a panic response to the smell of smoke in the future.

Interestingly, this similarly occurs during dream cycles. The brain naturally reprocesses life events during rapid eye movement (REM) sleep. EMDR replicates this methodology at an accelerated rate during the reprocessing phase via BLS. Bilateral stimulation is accessed by allowing the client to follow the providers fingers from left to right, watching a light on a light bar from left to right, using tappers that vibrate in ones left and right hand alternatively, or listening to tones via a headset from left to right. Some clients have a hard time tracking with eye movement due to visual disturbances, migraines, or head trauma and prefer to reprocess via BLS with eyes closed and using tactile and auditory BLS via tappers or tones. As the client is asked to focus on the negative thought and belief of oneself (NC), the memory is targeted, BLS is applied, and reprocessing occurs continuously to allow the SUD to decrease.

The time period of desensitization varies from client to client as compounded traumas and complex cases can be more complicated to resolve. Many times, memory networks that are associated with a traumatic or disturbing event stem from early childhood with many roads that lead back to the original negative thought, belief, and body sensation.

Studies have shown an increase in hippocampal volume as a result of reprocessing and the successful reintegration of positive emotions associated with new memories that can be stored after the negative memories are resolved (Cozolino, 2010). The provider will recognize that when a target has resulted in a SUD of 0, the target is then considered to be reprocessed, and desensitization of that target is complete. Clients who have successfully reprocessed adverse events that cause disturbances in function and emotionality report having healthier relationships, a release of negative thoughts of oneself, and overall PCs with an absence of anxiety related symptoms (Adler-Tapia & Settle, 2009, 2010; Shapiro, 2012).

Phase 5: Installation Phase

The goal in this phase is to successfully install the client’s desired PC while it is being paired with the identified target. First, the provider will assess the original PC to see if it is still valid and fitting for the target that was desensitized in Phase 4. The PC is measured by assessing the VOC, with a goal of reaching a 7 on a scale of 1 to 7. The truer the PC, the closer the client is to a VOC of 7. The provider in this phase installs the PC with the use of BLS at the same rate and rhythm used during the desensitization phase. In many instances, this pacing of BLS will also allow for unresolved data to emerge. As previously mentioned, there are lots of intricacies when reprocessing memory networks, especially when working with complex cases, so even installing a core PC can trigger unresolved material. Ultimately, this phase is considered complete when the original PC associated with a target has a VOC of 7.

Phase 6: Body Scan

This phase consists of scanning the body to identify any residual somatic responses or feelings a client may have lingering that are associated with a target, a NC, or a memory. If the client notices any negative bodily sensations, the provider conducts BLS similar to Phase 4 to facilitate continued reprocessing to further “clean up” the disturbance. This ensures that NCs and affect associated with targets have been fully resolved and ensures that the body is not holding onto any negative reactions toward a target. If necessary, BLS is also used after desensitization to install PCs to maintain a VOC of 7 as mentioned in Phase 5.

Phase 7: Closure Phase

This phase occurs at the end of each EMDR session, whether the client has completed all phases or is working from phase to phase. It is essential that the provider allows for the client to leave each session feeling grounded and safe. This is where the Container resource and Happy/Calm Place are used, in that order, for the client to safely reintegrate into their world outside of the EMDR session. Additionally, it is important in this phase to teach the client how to mitigate flooding and to use positive coping strategies in between sessions. The provider may ask the client to journal in between sessions, practice self-directed cueing of their EMDR resources, and even use slow integration of BLS, such as the Butterfly Hug, as they venture into the world.

Providers often use a combination of mindfulness strategies to allow the client to feel the most grounded as they continue to contain negative thoughts, beliefs, and emotions associated with what was discussed in session. Many times, there will be sessions that need to close in the middle of reprocessing, and these moments in particular require that providers understand how to safely and adequately close down the session. It should be noted that the brain continues reprocessing for up to 72 hours after an EMDR session, so a safety and coping plan should be clearly established if the client’s distress worsens, and the client needs immediate support (Shapiro, 2001).

Phase 8: Re-evaluation

Re-evaluation happens at the start of each new EMDR session (see Exhibit 22.4). At the beginning of every EMDR session, the provider assesses the SUD associated with the identified target and NC, as well as the VOC of the desired PC, allowing for the provider to evaluate the progress between sessions. Because the brain continues reprocessing after an EMDR session, resolution of symptoms may occur outside of the office space (Shapiro, 2001). Conversely, if the client reports any distress, either with a SUD score greater than 0 or a VOC score less than 7, the provider will proceed with Phases 4 through 6 to achieve successful resolution. This phase continues throughout the entire EMDR process in-between sessions to allow all targets to be completely addressed. Resolution of symptoms may occur outside of the office space (Shapiro, 2001). Conversely, if the client reports any distress, either with a SUD score greater than 0 or a VOC score less than 7, the provider will proceed with Phases 4 through 6 to achieve This phase continues throughout the EMDR process in-between session, which allows all targets to be addressed; resolution of symptoms may occur outside of the office space (Shapiro, 2001).

EYE MOVEMENT DESENSITIZATION AND REPROCESSING PHASES

EXHIBIT 22.4 Eye Movement Desensitization and Reprocessing Treatment Plan.

Presenting issues (symptoms, relationship stressors, etc.)

Treatment goals:

1.

2.

3.

4.

Pick on presenting issues to start with here:

When did this problem begin? (triggering event)

What are your symptoms related to this event?

Have there been any changes in symptoms (frequency, intensity, duration, or new triggers)?

What is your negative belief about yourself when you think of this problem? (Negative Cognition or NC)

*If unable to determine a NC, any other symptom cluster, a dominant emotion or bodily sensation?

What you would like to believe about yourself? (Positive Cognition or PC)

First time you felt this way/thought this way about yourself?

Pick on presenting issues to start with here:

When did this problem begin? (triggering event)

What are your symptoms related to this event?

Have there been any changes in symptoms (frequency, intensity, duration, or new triggers)?

What is your negative belief about yourself when you think of this problem? (Negative Cognition or NC)

*If unable to determine a NC, any other symptom cluster, a dominant emotion or bodily sensation?

What you would like to believe about yourself? (Positive Cognition or PC)

First time you felt this way/thought this way about yourself?

Float back/affect scan to any other earlier times you felt this way?

Most intense:

Touch stone memory (first time)

Most recent:

Other minor incidents:

Source: Adapted from Leeds, A. M. (2013). Basic training in EMDR. Sonoma Psychotherapy Training Institute.

APPLICATION FOR SPECIAL POPULATIONS

Children

The use of EMDR with children has been deemed as a successful approach to help children overcome trauma symptoms from a variety of causes, including medical conditions and adverse childhood events (Diehle et al., 2015; Rodenburg et al., 2009). The basic tenets of implementing the use of EMDR with children is to provide a sense of safety and parental/caregiver involvement, if they are in fact a resource to the child. If the parent/caregiver is part of the trauma, it is important to establish therapeutic rapport with the child by allowing for Phase 2 of the EMDR protocol to be optimized. EMDR with children requires specialized training for providers who have received levels 1 and 2 training with specialized consultation hours. While the Phases 1 to 8 are still the same, the VOC, SUD, NC, and PC are obtained using developmentally appropriate language and using various contexts to identifying targets. Typically, children do well as Phase 2 is developed and children’s environments are made more stable and predictable. Play therapy and sand tray therapy are mediums for reprocessing of targets and can allow for accessing of memories, feelings, and thoughts for children. In addition, children have been known to reprocess faster and with more ease than adults given that their environment is stable, and they have at least one stable caregiver of support (Adler-Tapia & Settle, 2012). The case study that follows shows just how the eight phases of EMDR were used with a child with great success.

CASE STUDIES

Case Study 22.1: A CHILD

The following is an example of utilizing EMDR therapy with a 9-year-old boy who presented with anxiety and paranoia in the aftermath of a school shooting in which he was a survivor located in a neighboring classroom:

B was a nine-year-old at the time of treatment residing with a two-parent family and two younger siblings. B was in the first grade at the time of the school shooting where many of his friends and classmates did not survive. B presented with aggression, frustration, and an overwhelming feeling of sadness and avoidance of talking about the events that occurred. He presented to the office with both parents being concerned that he was not sleeping well, as well as having a hard time at home, was easily aggravated fighting with younger siblings, having a hard time focusing at school on school work, and having a hard time at Boy Scouts and baseball with his peers. He was known to run off the ball field throwing the bat when he missed a pitch and hide in his room when home with his family after an argument over a toy with younger siblings or when arguing over typical things with parents. His emotions as mom and dad reported, “were over the top,” and “he easily goes from 0 to 100 over little things.” He came for EMDR therapy after dropping out of trauma-focused cognitive-behavioral therapy (tf-CBT) as he couldn’t handle the journaling or story telling of the sessions. B was also not sleeping well and was having nightmares.

The clinician used sand tray and play therapy as a medium to assess, plan, and treat the events of the school shooting and other events that occurred in the home after the events of the shooting. The clinician met one-on-one with each parent, both parents together, the child alone, and then the child and one of the parents during Phases 3 to 8 at each subsequent session.

Phase 1 consisted of verbal story telling by each parent from their perspective individually and as a couple and individually with the child via play/sand tray therapy. Both parents jointly shared that their son was exposed to the sounds of the shooting in the school and was overexposed to media, conversations, and the politics of the community he resided in during the immediate aftermath of the shooting. B’s father was very involved in the community through his volunteer work and was very involved in the recovery efforts as well. B reportedly attended five funerals of victims that caused more symptomatology to present itself as per both mom and dad. In retrospect, both parents admitted his overexposure of the events caused more harm than the actual event itself. The provider educated the child and family on EMDR and how it works and used language that would allow for the child to understand how it works in the brain. An analogy that is used often is as follows:

If you hold your hand out, your thumb is your emotional brain and your other four fingers are the thinking part of the brain. When you fold your hand into a ball with the thumb as the center of your hand and the other fingers over the thumb closing your fist, your brain is in calm mode. When something makes you afraid or reminds your brain of the bad thing that happened, your thumb/emotional brain acts out and reacts by running or fighting and then freezing making all your other fingers/your thinking brain go offline. This is what happens when your brain becomes activated and your mixed-up thoughts take over your brain. Many kids say they get confused or become afraid and feel like it’s happening again. That’s because the negative thing that happened which caused your brain to react in an unhealthy way may feel like it’s happening again because we need to allow for the memory of that event not have so much power over the brain. EMDR helps the emotional brain or your thumb not have that reaction anymore. It helps to calm your brain by changing the power of the memory. Almost like when super-heroes use their superpower to fight the bad guy. EMDR is a super-power that you can use to fight the bad memories.

Phase 2 consisted of building a physical container with B in the office made of plastic building blocks. He built a huge fortress that had a hatch on the top of it that could only be opened using a secret code that the provider and client had the code to. B reinforced this fortress using a double layer of blocks at the foundation and at the roof of the fortress. B asked if he could pick a spot on the top shelf in the provider’s locked closet to store the fortress. During this phase, B also created his happy/calm place in the sand tray. His calm place was at the lake in his dad’s boat with his family. He created a lake surrounded by trees, a family, and used a toy boat to signify the family boat. During this phase, the provider installed his happy/calm place with slow BLS via tappers. B tolerated this phase well each session. During this phase, the provider also had whichever parent was present for the session partake in the happy/calm place exercise to allow for a positive resource to be identified for the parent as well. This phase was also spent on conversations with the client and parents on stop signals, allowing him to know he could have control over when he wanted to stop once we brought up the bad thing that happened.

Phase 3 consisted of showing the provider in the sand tray about the bad thing that happened. B did not want to use his words or talk about his feelings but was able to use plush emoji toys to clarify emotions associated with the bad thing that happened. B was able to show the provider that he was sad, confused, and angry at what happened that day. He was also able to show the provider with his hand how disturbing the event was to him. A SUD of 10 = arms opened all the way and 0 = hands together, and a VOC of 7 being arms opened all the way and hands closed together as 1. The targeted event was the day of the shooting and going to the funerals with an SUD of 10 for both with an NC of “I’m not safe” and a VOC of 2 for “I am safe.” The provider used NC and PC playing cards to identify NC and PC with B.

Phase 4 consisted of play/sand tray therapy that started with B building two sides to his sand tray, both sides with building block structures at each end with monsters on the left side and people on the right side. The people were surrounded by army soldiers and warriors with shield and swords. B was given a set of tappers that he put into the sides of his sneakers as he created the bad thing that happened. He was asked to notice what he felt in his body as the tappers tapped during the play session; he moved the figures into an attack mode where the good and bad guys fought each other with the bad guys killing the good guys after the first session. The provider stopped B after 30 sets of BLS, cueing him to pause, breathe, and continue. B continued the desensitization phase for four sessions as he continued to reprocess the events of the day by burying babies in the sand, figures that were chaotic all around the sand tray, monsters attacking the people, army men fighting the monsters with a final resolution in the last session of reprocessing when B took a dollhouse and placed it in the middle of the sand tray, put people in the house, placed a tractor outside with a father in it and two dogs. He stated, “it’s over” and placed a happy emoji and placed it in the middle of the house. B put both his hands together when the provider asked how hard the mixed-up thoughts were now (signifying a SUD of 0) and a 7 on the VOC scale when asked how true the statement of feeling safe was.

Phase 5 was initiated after the completion of the reprocessing event for B by using BLS to install the PC of feeling safe; during this session, the parents were holding B on their lap as they tapped B on his legs from left to right and rocking back and forth.

Phase 6 was initiated after the installation phase as the child was given a play magnifying glass to scan his body to detect any spots that were bugging him or felt funny when he thought of the bad thing that happened. B stated that his belly felt funny during his first pass through. The provider then allowed B to recreate the event in the sand tray again; this time there was a boy with a baby and some coins that were surrounding the baby. The tappers were given to him; he put them in his shoes and he continued to bury the baby, find the baby, bury the baby, find the baby, and then bury the money and placed the baby in the boy’s lap in the sand tray. He then stated that they were both in heaven and safe. BLS stopped here, and B was asked to rescan his body. He stated, “It went away and the funny feeling is better.” Phase 6 repeated itself for three more sessions as B continued to scan his body on his heart and in his head, and needing to reprocess for three more sessions. The first session was his dad yelling in the house about money, the second was sadness and missing his friends, and the third about his mom being in bed all day demonstrated with a dollhouse and play dolls with him taking care of his mom. This phase returned to Phase 4 of desensitization ending with a SUD of 0 at completion.

Phase 7 was utilized at the end of each session by allowing B to place all his thoughts, memories, and emoji feelings into his fortress. B physically leaned his head over into his fortress each session and asked the provider to help him lock it up with the code. B recreated his happy/calm place visualizing it many times and then actually going out on the lake with his family in-between sessions, which was very helpful.

Phase 8 was utilized at the beginning of each session as the provider assessed SUD and VOC using hand measurements as playing cards were displayed. B also simply picked up where his brain left off at the start of his sessions, knowing exactly what he needed to reprocess in the sand tray and asking for the tappers when he knew he needed to start using them. It became an unspoken language in the office allowing for B to have power over his mixed-up thoughts and the emotions that they had on his body and brain.

B successfully completed EMDR with the provider and was able to play baseball with his team, performed better at school, and was able to restore relationships with peers and siblings. He was sleeping through the night and his nightmares went away. B came back a few times after EMDR for a few tweaks here and there but overall did very well. See Table 22.2.

Case study 22.2: a MIDDLE-AGED ADULT

The following is an example of utilizing EMDR therapy with a middle-aged adult who presented with a single-incident trauma and reported no prior trauma history.

K is a 62-year-old Caucasian female who lives at home with her husband. They have been married for 30 years and have two adult children who live out of state. K is the youngest of five siblings, and her parents are deceased. She reports no significant mental health histories on either side of her family. K’s parents divorced when she was a young child, and her father remarried a “great woman.” K works full-time as an engineer, has a positive relationship with her colleagues, and enjoys her career.

TABLE 22.2 EYE MOVEMENT DESENSITIZATION AND REPROCESSING PHASES

Phase 1 Client history and treatment planning

-Assess trauma history

-Interviews

-Play therapy/sand tray therapy

Phase 2 Preparation phase

-Informed consent

-Resource development

-Evaluation of trauma and dissociation

-Establishing Safe/Calm Place and Container exercise

Phase 3 Assessment phase

-Identification of target (T)

-Selecting image (I)

-Negative cognition/positive cognition (NC/PC)

-Emotion triggered by the memory (E)

-Subjective Unit of Disturbance (SUD), 10-point scale where 0 = not disturbing at all and 10 = very disturbing

-Validity of Cognition (VOC) assessment, 7-point scale where 1 is completely false and 7 is completely true

-Identification of body sensations and location of disturbance in the body

Phase 4 Desensitization phase

-Holding image/creating image, identifying the negative cognition (NC) and body sensation

-Initiation of bilateral stimulation (BLS)

-Continue BLS until SUD = 0

Phase 5 Installation phase

-PC identification or new one

-Assessing validity of cognition (VOC) 7-point scale where 1 is completely false and 7 is completely true

-Continues until PC is installed via BLS with positive outcome

Phase 6 Body scan

-Original target (T) and PC, assess for discomfort in body

-BLS, if necessary, to get rid of disturbance or discomfort

Phase 7 Closure

-Safe Place, Happy/Calm Place

-Container Exercise

-Teach Butterfly Hug

Phase 8 Reevaluation

-Reevaluation between sessions

-Overview of all phases to evaluate progress

-Goal is SUD of 0 and VOC of 7 for all targets and PCs

Source: Adapted from Adler-Tapia, R., & Settle, C. (2009). Evidence of the efficacy of EMDR with children and adolescents in individual psychotherapy: A review of the research published in peer-reviewed journals. Journal of EMDR Practice and Research, 3(4), 232–247; Greenwald, R. (1999). Eye Movement Desensitization and Reprocessing (EMDR) in Child and Adolescent Psychotherapy. Book-mart Press, Inc.

K sought EMDR therapy to address her symptoms of PTSD following a traumatic car accident 2 months prior when she was on her way to work on a dark, rainy morning. The at-fault driver hit K’s driver-side door at a speed of 45 mph. K reports that she had been in a minor car accident several years before this event, but she did not experience heightened symptoms following that accident. She was currently challenged with frequent tearfulness, mood lability (mostly feeling depressed), general hyperarousal, preoccupation with the accident, hypervigilance and flashbacks while driving, frequent thoughts of mortality, difficulty concentrating, social withdrawal, and insomnia. She was medically evaluated by her general practitioner who referred her for physical therapy. No medications were administered.

The clinician utilized the standard EMDR protocol for an acute, single incident trauma and met with the client for weekly psychotherapy sessions at 60 minutes in duration. Sessions 1 to 3 entailed history-taking and preparation phases. K presented with a general understanding of this trauma-based approach and endorsed minimal symptoms prior to this event; therefore, she did not require significant preparation for the therapy. K was favorably responsive to BLS via eye movements in long, rapid sets, and she successfully completed two EMDR resources followed by self-directed cueing—Calm Place and Protective Figure. This indicated a high integrative capacity and readiness for reprocessing.

Sessions 3 to 8 consisted of memory reprocessing in which Phases 3 to 8 were implemented, with the exception of Phase 5, installation phase. The identified target for reprocessing was this recent car accident with a central NC: I am going to die, and a desired PC: I am alive. By Session 6 and in subsequent sessions, K was achieving a SUD score of 0 during Phase 4 (desensitization) in relation to the target memory and working through Phase 5 (installation of the PC). Phases 5 (installation) and 6 (body scan) were successfully completed in Session 8 in which K could think of her car accident without experiencing any cognitive, emotional, or somatic distress while simultaneously feeling the truth of her PC, “I am alive.”

During these 2 months of EMDR therapy, K’s endorsement of PTSD symptoms fully remitted in that she felt safe again while driving and in those uncomfortable moments, like being stuck in congested traffic, K’s distress was momentary and quick to subside. K continued therapy with this clinician at a monthly frequency to work through other psychosocial needs, and at months 4 and 7 (Sessions 10 and 13), Reevaluation of the initial target memory indicated some distress related to presently driving under similar circumstances to the car accident (foggy or rainy conditions at dawn). Similarly, at month 9 (Session 15), K was distressed by the possibility of having another car accident.

As previously discussed in this chapter, the AIP model is a three-pronged protocol in which past, present, and future experiences are addressed (Solomon, 2014). Phases 3 to 8 were also applied in these sessions to “clean up” the lingering and maladaptively stored information, desensitizing the distressing experience of current and future triggers and successfully installing the PC: I am alive. By Session 15, K’s PC evolved to also include the statements, “It will all work out, I can only do what I can do, I am doing the best I can.”

At 18 months since the onset of EMDR therapy, K reports no pathological symptoms related to the car accident or to driving. Any respective distress appears normative given the circumstances. K graduated from EMDR therapy, and it was agreed that she could return at any time for booster support.

Case Study 22.3: A GERIATRIC/OLDER ADULT

The following is an example of utilizing EMDR therapy with a geriatric adult who presented with health-related anxiety and an underlying trauma history:

L is a 79-year-old Caucasian female who cohabitates with her partner of 4 years. She was in a previous marriage and has two adult children from that marriage with whom she is close. L is the oldest of three and raised in a Roman Catholic home, attending private Catholic school for many years. As a teenager, she lost her father suddenly, which greatly impacted her family’s affluent status in the community as he was reputable physician. L is a retired psychotherapist and has spent many years in therapy herself addressing psychosocial needs.

At the suggestion of a friend, L sought therapy from this clinician to address pressing anxiety struggles. Her partner had been recently diagnosed with cancer, which was greatly affecting her personal sense of security and power. She was afraid most of the time, particularly of death, and often felt like a child. L disclosed a long history of traumatic loss, chronic resentment, and spiritual angst. Of her many years of therapy, she had never been introduced to EMDR. In the history-taking and preparation phases, L gained new awareness that her present anxieties were directly related to her central belief systems that stemmed from childhood: It’s my fault, I am going to die, God has betrayed me. She was willing and amenable to proceeding with EMDR.

Due to the chronicity of L’s symptoms, her present struggle to self-regulate, and her frequent experience of feeling childlike, this clinician spent the first five sessions over the course of a month in Phase 2 (Preparation) implementing a blend of EMDR resourcing and ego states therapy to mitigate L’s dissociative tendencies when distressed by fear. It was determined that L responded more favorably to BLS via tapping in slow, brief sets. L was able to successfully establish an internal meeting place for her Parts, so that she could practice and maintain full adult consciousness when distressed (Seubert, 2017).

In Session 6 during Phase 3 (Assessment), L and clinician utilized the floatback technique to identify an EMDR target memory. In the present, L was mostly challenged by her health-related fears and preoccupations and felt tremendous anxiety in her body, mostly in her gut. Her central NC related to this experience was “I am trapped and miserable and I can’t handle it,” and she was able to connect this present awareness to her early childhood experience of feeling trapped and anxiety ridden in Catholic school.

Phase 4 (desensitization) occurred through Sessions 6 to 8, and it was noted that L’s Catholic experience chained to an earlier traumatic childhood memory at age 3 in which L felt trapped in her crib that she had soiled, and when she called to her father for help, he did nothing to help her. This past target memory was successfully desensitized in Session 8, and as the clinician facilitated movement into Phase 5 (Installation) with a desired PC, “I am free and able to handle it,” L struggled to fully accept this a true belief. Her current health anxieties and her realistic fear of aging and mortality were hindering Phase 5. Phase 4 (desensitization) was then implemented again for three more sessions with an identified target of this present triggering experience as well as a future template of her worst-case scenario: her partner becoming incredibly ill and disabled resulting in L having to provide care for him through his death. Both the present trigger and future scenario were successfully desensitized in Session 11, and installation of “I am free and able to handle it” became a true PC throughout this entire target experience by Session 12 (spanning early childhood through future adulthood).

At 12 months since the onset of EMDR therapy, L’s partner was diagnosed with a fatal and disabling illness, “my worst-case trigger,” she claimed. L had a brief emergence of anxiety symptoms for a week that remitted after she reached out for social support. She and her partner were also engaged in couple’s therapy to work on life adjustments together. L and the clinician agreed that they would continue to utilize EMDR as needed.

CRITIQUES OF EYE MOVEMENT DESENSITIZATION AND REPROCESSING

Strengths

The original and standardized EMDR protocol has remained relatively the same since the 1990s, and substantial research affirms its efficacy, particularly regarding the remission of PTSD. The duration of symptom remission achieved through EMDR sets this modality apart from other treatment interventions, and unlike what is needed for narrative-processing therapies, EMDR does not require therapeutic rapport or trust to be effective.

EMDR has become a versatile intervention in that it can be applied across all ages and many clinical populations. It can stand alone as a primary modality and can also be administered as an adjunct intervention. For example, a client who is receiving cognitive-behavioral therapy for an eating disorder may disclose that they experienced an early childhood trauma that perpetuates the eating disorder symptomology. If the primary therapist does not specialize in trauma therapy, it could be beneficial for this client to be referred to an EMDR provider to specifically address the comorbid trauma symptoms as a separate, concurrent service.

Limitations

The original EMDR protocol is very manualized. Trainers even recommend that new EMDR practitioners utilize their workbook scripts in session with clients when they begin to facilitate this approach. This can be aversive to providers and even awkward for clients, but the goal in utilizing a scripted text is so that new practitioners will honor the integrity of the approach as this yields the most favorable outcomes.

It has been found that EMDR is more effective for adults who have developed PTSD as an adult, instead of for adults with PTSD who also report a history of chronic childhood abuse (73% cured at 8 months versus 25% cured at 8 months; Van Der Kolk, 2015).

Additionally, the research is consistent that eye movements are the most efficient modality for BLS, and this particular technique can require a provider to sit closely to the client so that the client’s eyes can track the provider’s fingers that are being waved in front of the client’s face. Clients with a history of sexual trauma may be particularly sensitive to someone being so physically close to them, so administering eye movements in this manner may not be ideal for the client. There are EMDR devices, such as light bars, that facilitate the same eye movement for the client, but these devices can be cost prohibitive.

Optimal reprocessing sessions require a duration of 90 or more minutes to successfully execute Phases 3 through 7, and typical outpatient psychotherapy settings hold sessions for up to 60 minutes. Moreover, reprocessing sessions can be cognitively and physically taxing on a client, so a client may need some time to rest after an intense session, which may not be conducive to their schedule.

In the 30 years of EMDR development, many training organizations have delineated from Shapiro’s training institute. Some of these trainers have used their creative liberties to expand on and revise the original protocol, which has created variability in the approach. When these organizations do not promote respective research to determine the effectiveness of their EMDR methodology, it can adversely impact client outcomes.

CONCLUSION

EMDR is an effective therapy with an emerging evidence base to support the use of this therapy with diverse populations. The intervention protocol consists of eight phases, which include a blend of coping resources and memory reprocessing until dysfunctionally stored memories move into adaptive resolution, ultimately freeing clients from distressful symptoms and pathology. The history of trauma has bearing on the number of EMDR processing sessions that are required. For example, adult clients with complex and/or early childhood traumatic experiences require more EMDR reprocessing sessions than those with single incident traumatic experiences. Clinical social workers trained in EMDR are able to apply this therapeutic model in diverse settings.

SUMMARY POINTS

•There are eight phases of treatment in the EMDR protocol, which include a blend of coping resources and memory reprocessing until dysfunctionally stored memories move into adaptive resolution, ultimately freeing clients from distressful symptoms and pathology,

•EMDR therapy is effective for individuals of all ages,

•the central construct of EMDR is the AIP theory in which past, present, and future experiences are attended to for true healing of the brain to occur,

•both the amygdala and hippocampus are directly and positively altered in the brain with the implementation of EMDR therapy,

•adult clients with complex and/or early childhood traumatic experiences require more EMDR reprocessing sessions than those with single incident traumatic experiences, and

•research supports that EMDR therapy is a comparable or superior protocol to cognitive therapies, exposure therapies, and psychopharmacological interventions for the treatment of PTSD.