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An Introduction to EMDR

Dr Liz Royle

MA, MBACP(Accred), EMDR Europe Approved Consultant

Cath Kerr

MSc, MBACP(Snr Accred), EMDR Europe Approved Consultant

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• An introduction to the development, goals and evidence

base of EMDR

• The Adaptive Information Processing model
• An overview of the 8 phase protocol
• Integrating existing therapeutic skills into EMDR practice
• The clients and conditions most suitable for EMDR
• Question and answer session.

Overview of session

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While we’re together …

• This is a SAFE PLACE
• No turf wars – all stances are valid
• Anonymity for casework
• Confidentiality for participants
• Mobile phones off or on silent if necessary
• Respecting other peoples opinions and experience
• Honesty
• Participation in the process
• Ask for what you need
• Take care of yourself.

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EMDR will save the world!

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What are your impressions, questions or thoughts about EMDR? Is there anything in particular you would like to get from today?

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So just what is EMDR?

EMDR is an evidence-based psychotherapy for Post- Traumatic Stress Disorder (PTSD) EMDR addresses the experiences that contribute to clinical conditions and those needed to bring the client to a robust state of psychological health (Shapiro, 2007) Successful outcomes and positive research are also well- documented in the literature for EMDR treatment of

• ther trauma-related mental health disorders and

somatic symptoms.

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The “discovery” of EMDR

A chance discovery by clinical psychologist Dr Francine Shapiro in May 1987 Eye Movement Desensitisation Controlled study 1988-89 with 22 victims of rape, abuse and Vietnam combat trauma 1990 Continued refinement of protocols leading to Eye Movement Desensitisation and Reprocessing.

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Aim of EMDR for clients

EMDR targets past experiences, current triggers, and future potential challenges, in working towards:

• Alleviating presenting symptoms
• Decreasing or eliminating distress from the disturbing memory
• Relief from bodily disturbance
• Resolution of present and future anticipated triggers
• Improving view of the self.

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A 2007 survey of 38 randomised clinical trials established that EMDR and Trauma Focused Cognitive Behaviour Therapy (TFCBT) are the two most effective treatments for PTSD In the UK, EMDR is one of the two recommended treatments for PTSD in the guidelines of the National Institute of Clinical Excellence (NICE). Clinical trials and research http://www.emdria.org/displaycommon.cfm?an=1&s ubarticlenbr=2

The evidence base for EMDR

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Memory networks

• Memories are stored as sensory input with associated thoughts,

beliefs and feelings as well as body sensations

• Memories with similar information are linked by their channels
• f association and stored in memory networks
• Adaptive memory networks are the primary basis of our

learning, self-esteem, positive growth and adaptive resources and behaviours

• Maladaptive networks are the primary basis of pathology
• Memories are considered “dysfunctional” because they are

physiologically stored in a way that does not allow them to link to any positive/adaptive networks.

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Problems with dysfunctionally stored memories

Disturbing memories are dysfunctionally stored as they were perceived at the time of the event, with the associated emotions, physical sensations, thoughts and beliefs These can be readily triggered possibly because the individual is not able to differentiate between past and present The perceptions of current situations link into the networks

• f physically stored memories in order to be interpreted

If a memory network contains an unprocessed memory, the current perceptions are formed by the earlier unsettling emotions, thoughts, beliefs, and physical sensations of the past event.

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Adaptive v maladaptive

Christian, Remembers being praised by a teacher, feeling glow of pride, physically relaxed, “I’m capable” Julie, Remembers being criticised in front of class, feels fear and shame, tense, “I’m incapable” Current interpretations?

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Memory channels of association

Think of a current issue that is a minor disturbance e.g. public speaking, someone who irritates you, minor stress around a piece of work to be done Bring up the image Notice the negative belief that you hold about this situation Notice the emotion and where you feel it in your body

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The Adaptive Information Processing (AIP) model

When we experience a distressing event, over time, the information processing system unhooks the disturbing emotions, thoughts, physical sensations connected to an event, resulting in adaptive resolution, thus constructing functional memories and memory networks This physical information processing system, has a natural tendency to be guided towards wellbeing.

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The AIP model

During the phase of reprocessing the maladaptive / dysfunctional memory networks start to link with existing positive, adaptive and functional memory networks As a result of EMDR – activated Adaptive Information Processing, emotional and physical disturbance is

• desensitized. Furthermore, there is an emergence of insight

and positive changes in physical and emotional responses Consequently this culminates in integration, when the new learning becomes available in the current life situation.

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The AIP model

EMDR procedures activate the target memory and stimulate the adaptive information processing system Reprocessing forges adaptive associations between networks

• f information stored in the brain. EMDR facilitates an

associative process that allows the relevant connections to be made The unprocessed components of memory (image, thoughts, sounds, emotions, physical sensations, and beliefs) transform during processing to an adaptive resolution. What is useful is stored, available to inform future experiences and what is no longer adaptive is discarded (for example, physical sensations, irrational beliefs).

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Before the trauma

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During the trauma

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After the trauma – maladaptive processing

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The three pronged approach of EMDR

There are different EMDR procedures for different diagnoses such as trauma, phobia, traumatic grief However all scripted EMDR protocols incorporate the three pronged elements of PAST, PRESENT & FUTURE.

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Case examples

Bill, PTSD: PAST: Armed bank raid PRESENT: sudden movements, shouts, large males, banks, uniforms, being at work FUTURE: the thought of returning to work, possibility of further robberies Carol, traumatic grief: PAST: police notification, attendance at hospital, funeral, telling children PRESENT: seeing clothes in wardrobe, avoiding memories, withdrawal from social contact FUTURE: attending events alone, future self-image, loneliness and ability to cope

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• EMDR is not just about eye movements
• A comprehensive approach with standardised principles,

protocols and procedures

• EMDR is a distinct eight stage, integrative, psychological

treatment that combines aspects of other psychological

• rientations.

The 8 phase protocol

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Phase one: History taking

• Checking client appropriateness for EMDR treatment
• Taking a full history, identifying the current problems and

past difficulties

• Checking general level of functioning including safety

factors, health and medication, and support systems

• Developing a treatment plan and identifying targets for

processing

• Exploring goals for the future and identifying new skills

that are needed.

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Introducing Emma

27 year old, professional woman, “date rape” 9 months ago No prior history of mental health problems, no medication 12 sessions CBT, 6 sessions counselling following attack – some symptom improvement but not as hoped for IES-R scores Avoidance = 16, Intrusion = 21, Hyperarousal = 24 NC I’m stupid, embarrassment and fear of being judged, blames self (this prevents her from reporting) Themes from lifeline and assessment reflect safety, shame, being deserving and blame

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Phase 1: Emma

Emma’s symptomatology: Poor concentration Sleep difficulties and nightmares Intrusive images during the day Hyper-arousal Avoidance behaviour (work, social activity) Lack of self-care

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Phase 1: Emma

Present triggers that stimulate the material: Being alone at home Smell of alcohol or cigarettes on someone’s breath Going out socially Getting dressed up and putting make-up on Being around men Questions about her medical leave Making simple mistakes such as forgetting to take her purse when shopping for food

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Phase 1: Emma

Early memories that may be responsible for setting the groundwork for the dysfunction: Parents’ divorce Maternal criticism Being “sent away” to live with aunt Childhood molestation by cousin’s friend Aunt’s reaction to molestation – rejection, blame, not being protected Starting new school Date rape

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Phase 1: Emma

Event Themes Parents’ divorce Safety and responsibility Being shouted at by mother Shame, responsibility Being sent away Rejection Childhood molestation by cousin’s friend Safety Shame Aunt’s reaction to molestation Blame, Rejection, Safety? Fear, Shame Starting new school Rejection, Fear “Date rape” Shame, Blame, Safety

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Phase two: preparation

• Building the therapeutic relationship
• Providing a clear explanation of EMDR theory and practicalities
• Addressing any fears and expectations
• Establishing a safe place and/or other positive memory networks
• Developing skills to manage emotional distress
• Testing eye movements or other form of DAS and the ability of

the client to maintain dual awareness between the past and present.

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Phase 2: Emma

Psycho-education provided The body’s arousal system, the panic diagram and dealing with hyperarousal Managing sleep disturbance Managing symptoms of re-experiencing Managing symptoms of avoidance and numbing Self-soothing Meditation and listening to music Grounding strategies and breathing techniques Safe place imagery Safe place enhanced and practised– sitting on the end of a jetty watching the sun set

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Phase three: Assessment

• The aspects of the memory are elicited
• A representative image, negative and positive thoughts

related to the memory

• Emotions and body sensations
• Baseline measures are taken to determine the client’s

response to desensitisation

• The memory is activated (along with more adaptive

networks).

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Phase 3: Emma

Target memory Emma being shouted at by her mother Image Mother crying and shouting Negative cognition It’s my fault Positive cognition and VOC It’s not my fault VOC = 2 Emotions Fear, shame, guilt, sadness SUDS 8 / 10 Location of body sensations Nausea, feels heat rising up neck, flushed

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Phase four: desensitisation

• The eye movements (or other DAS) begin while the client

holds the memory in mind

• After each set of eye movements the therapist is given

brief feedback from the client

• Gradually the client becomes calmer and starts to recall

the event in a more adaptive way

• SUDS are used to measure the treatment effect.

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Phase five: installation

• The suitability of the positive cognition is established and

changed where necessary

• Using DAS, the PC is integrated with the targeted memory,

resulting in strengthening and enhancing associations to positive memory networks. This would only be done after desensitization is complete.

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Phase six: body scan

The therapist will assess adaptive resolution of the target by asking the client to hold the original memory, whilst considering the positive cognition, and checking their body for any tension or sensation. The therapist should then target any residual physical manifestation with Dual Attention Stimulus.

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Phase seven: closure

The client is fully debriefed and advised to keep a log as processing can continue for 48 hours If the session is incomplete, the client’s emotional state is stabilized and the client is reoriented to the present A closing relaxation exercise, e.g. safe place, guided imagery is often used.

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Phases 4 – 7: Emma

Desensitisation: Associated memories surface Release of emotion Somatic processing New insights into past event Adult perspective Negative affect reduced to 0 New belief “It wasn’t my fault” VoC 7 Relaxation, instructions and normalisation regarding further processing

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desensitisation video http://www.youtube.com/watch?v=KpRQvc W2kUM http://www.youtube.com/watch?v=bqbFIj5vw mA#t=111

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Phase eight: re-evaluation

Re-evaluation is the eight phase of EMDR. Re-evaluation is done at the beginning of each session following a desensitization session. It involves

• Re-evaluating the general level of function
• Reviewing the client’s journal
• Assessing the current state of the previously targeted

material

• Considering the subsequent targets and treatment plan.

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How EMDR integrates with existing skills

Accredited EMDR courses will only accept trainees with an established mental health / therapeutic background and therefore have the ability to

• Take an appropriate history
• Stabilise the client
• Build a therapeutic relationship
• Assess risk

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Challenges for the person-centred therapist

• Allowing each session to unfold from the client’s current

concerns and selecting a new target from the “issue of the week”

• Reprocessing on these targets is seldom “completed” in one

session

• Incompletely reprocessed targets remain unresolved and

continue to be a source of residual symptoms when the next “issue of the week” becomes the focus

• Avoided issues and avoided etiological experiences may

never be addressed in a comprehensive treatment plan.

Adapted from Andrew Leeds 2009

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Challenges for the CBT therapist

• May be more focused on their patients’ predominant

maladaptive beliefs than on developing a case conceptualization based on etiology

• May select targets based primarily on current stimuli that

give rise to current maladaptive beliefs

• May fail to pay attention to identifying and reprocessing

etiological events and experiences that are the sources of the onset and reinforcement of these beliefs

• This increases the risk of inefficient and incomplete

reprocessing due to unidentified etiological targets. Adapted from Andrew Leeds 2009

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Referring for EMDR

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Can you only use EMDR for PTSD?

• Depression
• Pain
• Complicated grief
• Eating disorders
• Oncology
• CFS
• BPD ….

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Cautions and contra-indications

Potential clients should be carefully screened by the psychotherapist including consideration of

• Dissociative Disorders
• Complex trauma
• Poor physical health, e.g. heart / respiratory problems

(inability to withstand heightened affect)

• Epilepsy
• Drug / alcohol abuse / suicidal ideation
• Eye disease / surgery / contact lenses
• Legal issues.

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EMDR is a complex and powerful therapy that should only be provided by properly trained clinicians There is a wealth of research on the effectiveness of EMDR BUT the results are based on the approach being delivered according to standardised principles, protocols and procedures Beware therapy that is “like EMDR”!

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Questions to ask of any potential therapist

• Was their training course approved by EMDR

Europe?

• Did they complete all levels? If not, do not refer

complex trauma

• Are they receiving ongoing supervision?
• Are they accredited by the EMDR UK & I

Association?

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EMDR and positive psychology

• Peak performance protocol
• Address any performance anxiety
• Enhance existing resources
• Install missing resources

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Thank you for listening! Any questions?

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For More Information

EMDR Association UK & Ireland www.emdrassociation.org.uk EMDR Europe www.emdr-europe.org EMDR International Association www.emdria.org

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