Eye Movement Desensitisation and Reprocessing Therapy
The following is a revised version of an article that was written for the Australian Psychological Society (APS) in 2014. It was requested of Sigmund Burzynski, co-authored and largely written by me (Dr Darra J Murphy), with input from Dr Francine Shapiro. The original is available to APS members (only) on the Evidence- based and Quality Information for Psychologists (EQIP) website. You can read the revised article here, or download it as a PDF file by clicking on the button.
What is EMDR therapy?
EMDR therapy is an integrative approach to psychotherapy, based on a range of physiological and psychological principles, which incorporates eye movements and other forms of bilateral physical stimulation into a set of standard psychological procedures (Shapiro, 2001). The clinical efficacy of EMDR therapy in the treatment of post-traumatic stress disorder (PTSD) has been empirically validated (Bisson, 2007).
There are over 30 randomised controlled trials that demonstrate the clinical efficacy of EMDR therapy in the treatment of trauma. As stated, its efficacy in the treatment of Post Traumatic Stress Disorder (PTSD) is well-established (cf. below - International Treatment Guidelines), evidence is accumulating for its efficacy across a broad range of trauma-related psychopathology and its potential clinical application is now considered to be even broader still (Shapiro, 2014a).
Dr Francine Shapiro, a clinical psychologist in the USA, is the originator and developer of EMDR therapy. She first discovered the effects of eye movements in 1987 and EMDR therapy was introduced to the world in 1989, with the publication of a randomized controlled trial evaluating its effects with trauma victims (Shapiro, 1989). What began as Eye Movement Desensitisation (EMD) rapidly developed into a highly structured and phased approach to psychotherapy, with an emphasis on adverse life experiences and the manner in which they are encoded in memory (Shapiro, 1995).
In Shapiro’s Adaptive Information Processing (AIP) model, psychopathology is viewed primarily as a disorder of memory (Shapiro, 2001). The view that the memories of adverse life experiences (including but not limited to 'traumatic'
memories) are at the heart of psychopathology has been empirically validated (Felitti et al. 1998, Heim et al. 2004, Mol et al. 2005, Afifi et al. 2012). EMDR therapy demonstrates that these memories can be identified and processed to an adaptive resolution far more easily and quickly than has hitherto been recognised.
The aim and the outcome of EMDR therapy is to replace the 'perpetual re-experiencing' of traumatic events with a “learning experience” that becomes a source of resilience. Divested thus of their affective load, traumatic memories are reconsolidated (contextualised) as semantic memory and become part of a client’s life story (narrative). Desensitisation and adaptive resolution are experienced as outcomes of this reprocessing and re-consolidation.
One theory of mechanism is that attention to the key elements of a disturbing memory, along with bilateral physical stimulation (particularly eye movements), stimulates the orienting response (Stickgold, 2002). This appears to facilitate the rapid reprocessing of information, such as may occur naturally during the Rapid Eye Movement (REM) phase of sleep. More than 20 randomised trials and a recent meta-analysis (Lee et al, 2013) have demonstrated positive effects of the eye movements.
Recent developments in neuroscience have also highlighted the importance of ‘Resting State Networks’ (Menon, 2012 & 2015, Chamberlin, 2015). Distinctly different patterns of activation of widely distributed neural networks are associated with different degrees and forms of autonomic arousal. These correlate with recent developments in our understanding of stress responses and ‘polyvagal theory’ (Porges, 2001). These responses include:
- the ‘startle-freeze’ response (a heightening of the orienting response that alerts us to threat);
- the ‘fight-flight’ response (which represents our attempts to deal with a serious threat);
- the ‘fright-faint’ response (when the former have proved ineffective.
Essentially, stressful life experiences ‘calibrate’ the stress responses and may inhibit activation of the physiological pathways that are necessary to ‘re-calibrate’ them and return us to a resting state.
In Shapiro’s conceptual framework, all human beings are physiologically geared towards healing and the restoration of homeostasis (i.e. a steady state). The role of the therapist is therefore to facilitate a psychological process which already has a physiological basis (Shapiro, 2001).
The Adaptive Information Processing (AIP) model
The AIP model forms the basis of understanding developmental and clinical phenomena, guides case conceptualisation and treatment planning and predicts positive outcomes. The model holds that:
- disturbing memories are stored physiologically, in 'state-specific form', as they were experienced and perceived at the time of the adverse life experience / event;
- without processing and integration into wider memory networks, dysfunction may occur when the memories of disturbing events are triggered and the encoded emotions, beliefs and physical sensations emerge along with their associated patterns of autonomic arousal;
- excluding situations caused by inadequate information or organic deficits, unprocessed (or incompletely processed) memories are the basis of psycho-pathology.
Normally, information is processed into memory from weak episodic form, through stable (strong) episodic form into semantic (explicit) or procedural (implicit) form (Stickgold, 2002). Disruptions of information processing arise as a consequence of the nature and level of the disturbances that occur at the time an adverse life experience is first encoded in memory. Precisely because of the real or perceived threat, such experiences are invariably associated with a high level of autonomic arousal (sympathetic hyper-arousal, or parasympathetic hypo-arousal, or a mixture of both). Encoded at the outset in such state-specific form, as stable (strong) episodic memory, these memories may persist as such in relative isolation and resist integration (Bergmann, 2010).
In the AIP model therefore, the incompletely processed memories of adverse life experiences result in disorders of cognition (thinking), emotion (feeling) and behaving (acting) in the present. Perceptions of current situations link into networks of stored memories in order to be interpreted, so if a network contains an unprocessed memory, the current perceptions are informed by the emotions, sensations, thoughts/beliefs associated with the earlier event and "the past becomes present”. This is the basis of PTSD and may well be the basis of other categories of psychopathology (Shapiro, 2014a; Solomon & Shapiro, 2008).
From EMD to EMDR therapy
Perhaps the most common and persistent misunderstanding in relation to EMDR therapy is that it is merely a desensitisation technique involving the use of eye movements (EMD). This view is both out-dated and grossly inaccurate. The standard eight-phase protocol for EMDR therapy is a highly structured and phased approach to psychotherapy (methodology), based on a clear conceptual framework (model) and with an emerging clarity in relation to the underlying neurobiology of why it works as well as it does (mechanism). There is a growing literature in relation to all aspects of this integrative approach to therapy (Shapiro, 2014b).
Adaptive resolution (reprocessing) of 'traumatic' memories requires the forging of links between disturbing memories and more adaptive memory networks. EMDR therapy begins with history taking and assessment through the prism of the AIP model. This includes assessment of the client’s capacity for self-regulation, followed by whatever stabilisation may be required, before disturbing memories are identified and accessed for reprocessing.
EMDR therapy involves 8 distinct phases.
The Eight Phases of EMDR therapy (& their primary Purposes)
8. Re-evaluation (Assessment of processing effects and treatment direction)
Phase 1: History (Case conceptualisation)
This phase begins with the AIP model firmly in mind. Case conceptualisation involves history taking and psychometric assessment, with a focus on current issues and past events that may have increased the client’s vulnerability to stress. Unless the client indicates a problem that may be addressed through education, or a contemporary trauma, the therapist will explain the AIP model and the need to look for past experiential contributors to the presenting problem.
Particular attention is given to adverse life experiences in childhood (e.g. adoption, attachment security, illness, injury, family of origin issues, schooling, relationships etc;), alongside a careful assessment of the client’s current stressors (triggers) and resources (including their own capacity for self-regulation). Direct questioning and EMDR therapy techniques are used to trace current dysfunction to past experiences.
The overall aim is to gain a clear picture of the client’s clinical landscape, so that appropriate sequences of target memories can be identified and a treatment plan developed to respond comprehensively to the presenting problem. In the 'Standard Protocol' of EMDR therapy, past experiences are processed first, followed by present triggers and finally future templates are set to encourage in vivo activation of behavioural changes. In more complex cases, this may need to be adjusted, in order to maintain client stability in the present.
Phase 2: Preparation (Stabilisation)
Adequate preparation involves the development of a safe and sound therapeutic relationship and may also require instruction in self-care and affect regulation. This is achieved through standard cognitive-behavioural approaches, as well as relaxation training, breathing and guided imagery techniques). Adaptive memory networks may need to be accessed and targeted for re-enforcement, before any attempt is made to reprocess and reconsolidate disturbing memories.
Preparation therefore involves adequate stabilisation (testing and strengthening the client’s capacity for self-regulation), as well as instruction in the AIP model and the methodology of EMDR therapy, before disturbing memories are identified and accessed for reprocessing (EMDR treatment). Clients may have multiple adverse life experiences, beginning at an early age and extending over long periods of time.
Although the memories of early adverse life experiences are often easily accessed, such memories may be 'forgotten' (repressed, dissociated) in complex cases and may only emerge as the processing of what is remembered proceeds. A prolonged period of preparation may be required in such cases, with a clear focus on maintaining client stability in the present. The need for psychotropic medication may also need to be considered in this phase.
Phase 3: Assessment (target memory assessment)
Having identified or generated client resources, to consolidate or improve their capacity for self-regulation in the present, the primary goal in this phase is to identify the key elements of a memory which has been selected for processing. The memory targeted for processing may be any adverse event or life experience, with regard to the 'standard protocol'.
Primary aspects of an individual target memory (T) include an image (I), cognitions (C), emotions (E) and sensations (S), often referred to under the acronym TICES. These elements are identified in a standardised manner, designed to contain the affect that is invariably triggered by recalling such memories. An image is first sought which represents the worst part (or moment) of the memory. Next, a 'negative' cognition (NC) is sought to express the irrational meaning ascribed to the event and the disturbing affect associated with it.
This is then mitigated by seeking a desired 'positive' cognition (PC) to oppose to the NC. A 'validity of cognition (VoC) scale is then used to assess the current strength of the PC with the image in mind (1=completely false and 7=completely true). Clients are then asked to identify the emotions experienced, when the image and the NC are held in mind and to rate the level of disturbance they feel on a 'subjective units of disturbance' scale (SUD). In this way, baseline measurements are established before any attempt is made to reprocess a target memory.
It should be noted here that 'negative' refers to inaccurate, irrational or exaggerated (false) conclusions about the self and not simply to those which are pessimistic, whilst positive refers to 'accurate, rational (true) conclusions and not simply those which are optimistic. In complex cases, new targets may emerge as processing proceeds and further excursions back into the preparation phase may be required.
Phase 4: Desensitisation (reprocessing and reconsolidation)
Having selected the target memory for reprocessing, the client is instructed to bring back the memory, to focus on the image, the NC and the sensations in their body. In this way, the memory is accessed and stimulated (activated). The therapist then instructs the client to “let whatever happens happen” and to “just notice” whatever comes up.
The therapist administers 'sets' of bi-lateral stimulation (BLS), usually eye movements, although auditory stimulation or taps may be used. At the end of each set, the client is asked to report on whatever they notice (images, thoughts, emotions, sensations). Based on their response and guided by standardised procedures, the therapist determines the next focus of attention, asks the client to focus on it and “let whatever happens happen” during the next set of BLS.
Shapiro has written that: “The instruction to 'let whatever happens happen' and to 'just notice' the trauma and attendant disturbance, were initially included in order to reduce demand characteristics. … This cultivation of a stabilised observer stance in EMDR is inherent in a variety of Eastern meditative practices (Kabat-Zinn, 1990; Krystal et al. in press) and appears similar to the 'mindfulness' of dialectical behaviour therapy (Linehan, 1993) and the 'radical acceptance' of acceptance and commitment therapy (Hayes, Wilson & Strosahl, 1999).” (Shapiro, 2001).
What is most frequently observed during this phase is the forging of associative links between the memory of the stressful life experience and more adaptive memory networks, as new thoughts, insights, emotions and memories spontaneously emerge. Standardised procedures are used to guide the clients’ focus through various aspects of the memory network, until the affect associated with the memory is completely dissipated ('metabolised').
Stressful memories are thus 're-processed', physiologically, to an adaptive resolution. This is generally defined as a reduction in the SUD to 0 (i.e. no disturbance associated with the memory), unless it is deemed ecologically appropriate for this to be otherwise. Precisely how much affect is revealed and processed during this phase, in any particular therapy session, depends on the complexity of the client’s adverse life experiences.
Phase 5: Installation (Cognitive Enhancement)
Only when the disturbing affect associated with the Target Memory is fully metabolised (as defined above), does the therapist proceeds to this next phase. The goal in this phase is to strengthen the positive effects of the Positive Cognition (PC), by linking it to the original target memory. As the client will have come more fully into the present at this point, at least in relation to this particular experience, the therapist first checks the suitability of the original PC.
The client may choose to proceed with this or to choose another PC that is now more suitable (or 'attainable'). The therapist will continue to administer sets of bilateral stimulation until there is an increase in the Validity of Cognition (VoC) to 7 (completely true), when the memory and the chosen PC are held in mind.
Phase 6: Body Scan (Somatic assessment and processing)
Once satisfied that Phases 4 and 5 have been completed, the therapist will check again that there is no residual disturbance in the body. Asking the client to hold the memory and the PC in mind, the therapist instructs the client to scan from their head to their toes for any body sensations. Any residual disturbance requires the administration of further sets of BLS, until the disturbance has resolved. Pleasant body sensations may be enhanced with slow sets of BLS.
Phase 7: Closure (Re-stabilisation)
Typically, processing is considered to be complete when there is a reduction in the SUDS to 0 (no disturbance associated with the memory), an increase in the VoC to 7 (completely true, when the memory and the PC are held in mind) and a clear body scan (no disturbing body sensations). Anything less may require re-stabilisation at the end of a therapy session. The client will be instructed to use one or more of their stabilisation skills to settle themselves before leaving the room. Clients will also be instructed that processing may continue between sessions and to use a TICES log to note any disturbance, including additional (potential Target) memories that come up between sessions.
Phase 8: Re-evaluation (Assessment of processing effects and treatment direction)
Subsequent treatment sessions begin with a re-evaluation of any memory targeted in the previous session. An incompletely processed memory will require further re-processing (Phase 4-6). An assessment may also be made of the degree to which the processing has resulted in any 'generalisation effect' (i.e. resulted in the automatic processing of associated memories and a general improvement in well-being). A new target will then be selected for processing, or if all target memories have been processed, the therapist will proceed to install 'future templates'.
Overall, EMDR therapy involves a standard 'three-pronged' protocol for addressing dysfunction and involves targeting:
Past events, which act as experiential contributors to current dysfunctions;
Present situations, that trigger disturbances of mood, thinking or behaviour;
Future functioning, which may require education and the incorporation of new skills.
In complex cases (e.g. Dissociative Disorders), identifying the need for additional stabilisation is paramount, before any processing is attempted. This may be difficult at the outset of therapy, which is why completion of an approved training in EMDR therapy is a fundamental requirement for the safe practice of this highly effective and comprehensive approach to psychotherapy and why advanced training is required to deal with the most complex cases.
APPLICATIONS & EFFICACY
Post Traumatic Stress Disorder (PTSD)
EMDR therapy is widely recognised as having Level 1 evidence for its clinical efficacy in treating PTSD. It is currently recommended by (but not limited to):
International Treatment Guidelines (PTSD)
2000 International Society for Traumatic Stress Studies
2002 Israeli National Council for Mental Health
2003 Northern Ireland Department of Health
2004 American Psychiatric Association
2004 US Departments of Veteran Affairs & Defense
2005 UK National Institute of Clinical Excellence
2007 Australian National Health and Medical Research Council
2012 Australian Psychological Society
2013 World Health Organisation (WHO)
2014 German Federal Joint Committee (GB-A)
In its recognition of EMDR therapy for stress-related disorders, the WHO identified trauma-focused CBT and EMDR therapy as the only psychotherapies recommended for children, adolescents and adults with PTSD, statin:
Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.” (WHO, 2013)
This highlights the inherent safety of EMDR therapy, when a 'fidelity' to all 8 phases of the approach is practiced. With adequate preparation, EMDR therapy carries less risk of re-experiencing the trauma (due to less exposure) and all the therapeutic work is done within the affect-regulating presence of the therapist (no homework). For PTSD, research has indicated rapid treatment effects in numerous randomized trials.
For instance, randomized trials have indicated that 84-90% of single-trauma victims no longer have PTSD within three 90-minute sessions (Rothbaum, 1997; Wilson, Becker & Tinker, 1995, 1997) and 100% of single-trauma victims and 77% of multiple trauma victims no longer have PTSD in a mean of 5.4 hours of treatment (Marcus et al., 1997, 2004). It should be noted, however, that loss of a PTSD diagnosis is relatively easy to achieve. However, a 'cure' (a more complete relief from distress) is also attainable with at least eight 90-minute sessions each of EMDR therapy (van der Kolk, 2008).
In addition to the randomised controlled trials that demonstrate the clinical efficacy of EMDR therapy in the treatment of stress-related disorders, there is a vast emerging literature in relation to its clinical applications. Many clients do not meet current diagnostic criteria for PTSD, but elements of what are currently defined as characteristics of PTSD are recognisable in a great many cases of psychological distress:
Whilst there is now a whole category of Trauma and Stressor-Related Disorders in the DSM-5 (which includes Acute Stress Disorder, Adjustment Disorders, Reactive Attachment Disorder, as well as PTSD), diagnosis is still largely based upon symptomatology rather than upon the aetiological significance of stress and adversity in generating psychopathology and its associated symptomatology (American Psychiatric Association, 2013).
SUMMARY & CONCLUSIONS
In summary, EMDR therapy is steadily gaining recognition as an effective approach to persistent disturbance and psychopathology related to adverse life experiences. Overall, the goals of EMDR therapy may be summarised as follows:
- maximum treatment effects whilst maintaining client safety;
- adaptive resolution of presenting problems;
- incorporation of new skills and behaviours;
- optimisation of client function (cognitive, emotional and somatic).
EMDR therapy recognises that information is stored physiologically in memory and retrieved along with associated patterns of response. As perceptions in the present link to existing memory networks, various components of incompletely processed memories are experienced physiologically (images, emotions, physical sensations, thoughts/beliefs). The information processing system, like other body systems, is inherently homeostatic and geared towards health unless somehow “blocked”.
As the processing is activated, disturbing (dysfunctionally-stored) memories are integrated and transformed into a learning experience, which can become the foundation of resilience (Shapiro, 2001). EMDR therapy reveals that it is possible to identify and divest disturbing memories of their affective load much more rapidly and completely that was hitherto recognised. Whilst underlying biological mechanisms are still under investigation, as with any other form of psychotherapy, research indicates that the bi-lateral physical stimulation (and most particularly eye movements) does indeed change brain function.
It appears to tax working memory and to stimulate the orienting response, so that episodic memories of distress are reconsolidated as semantic (narrative) memory and become part of a client’s life story. This appears to occur naturally to some degree during the rapid eye movement (REM) phase of sleep. This may explain why eye movements appear to be so powerful in stimulating the information processing that is so characteristic of EMDR therapy (Bergmann, 2010).
In this sense, EMDR therapy is consistent with bio-medicine and the physiological principles of regulation and homeostasis (i.e. that a small event can have a large impact, when the 'system' is unstable or vulnerable, as is the case for all of us in childhood). It should also be noted that it is already known that the impact of early stressful / adverse life experiences (ALEs) has an equivalent or greater negative effect than events which meet the current clinical criteria in the DSM-5 for the diagnosis of PTSD (Mol et al., 2005).
In conclusion, EMDR therapy is widely recognised for the treatment of PTSD and other trauma-related disorders (cf. Evaluated Clinical Applications). Most recently, Shapiro has drawn the attention of the medical profession to the importance of processing the impact of all adverse life experiences (Shapiro, 2014a), as these have significant implications for health in general and are highly amenable to treatment (cf. Research Overview).
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