EMDR-Web.org

EMDR is an integrated psychotherapeutic approach to treatment of PTSD, and other trauma related events. There are multimodal, and multiphasic elements of the methodology. The eight phases of EMDR are:

Phase One – Client Preparation and History Taking

Phase Two – Client Preparation

Phase Three  - Assessment

Phase Four –  Desensitization

Phase Five – Installation

Phase Six – The Body Scan

Phase Seven – Closure

Phase Eight – Re-evaluation

In her 2001 textbook paper Dr. Shapiro defines “Adaptive Information Processing” “Specifically there appears to be a neurological balance in a distinct physiological system that allows information to be processed to an adaptive resolution” … meaning that “the connections to appropriate associations are made and that experience is used constructively…” (Shapiro 2001, p. 30). “When someone experiences a severe psychological trauma, it appears that an imbalance may occur in the nervous system, caused perhaps by changes in neurotransmitters, adrenaline, and so forth. Due to this imbalance, the information processing system is unable to function optimally and information acquired at the time of the event, including images, sounds, affect and physical sensationsis maintained neurologically in its disturbing state” (pg 31.)

I use the term “state dependent” in an equivalent way. My reasoning is as follows. When a person is not able to successfully digest an experience, it appears to be left in the developmental state from when it comes. This developmental state, when activated, may cause the person to act unwisely. Many times when a criticism of a person is that they are acting immaturely, I say that they are activated implicitly into thoughts, feelings and behaviors of the developmental epoch from when the trauma(s) originated. This is a linear explanation of many complex non-linear events, but it is a starting point from which to discuss the rationale and method of EMDR.

Furthermore, Dr. Shapiro states that EMDR seems to “catalyze” the brain’s activity in an accelerated form to promote healing through using the procedural steps outline along with dual attention stimulation.

EMDR has eight phases to it; we do not move toward active trauma work until a comprehensive evaluation and education are given to the client in phases one and two.

Phase One – Client History Taking.

Let’s say that a 45 year old man may come to treatment because of a mixture of anxiety and depression because of work place stresses. During phase one much attention is paid to the presenting problem, and any possible antecedents to it.  Much of the time, even  a single present day incident may have multiple traumas attached to it. The “presenting problem”, or “current day precipitant “(in EMDR terms) may contain many painful old unresolved memories attached to it. In this example the therapist may uncover many ACOA issues with this man’s father.

The preferable practice in EMDR is to work on the oldest traumas (linked to the presenting problem) first, before resolving the presenting problems (psychoanalytic thinking). The job of the clinician during phase one is to get:

1. all the descriptors of the current day precipitant; i.e. the picture; the core negative beliefs;
2. the positive attributes a person believes about themselves, (and also glean the positive attributes that the person has, but is not aware of.) It would be wise to then ask the client what they would like to believe about themselves, and how true they believe that positive cognition to be

I’m saying this as though it were step one, step two, etc. It certainly isn’t. It may take a session or two, or three to get a good enough sense of all significant issues a client needs to impart about the present day referent before getting older, relevant information (client centered). This is the interpersonal nature of the work. However, there is a reason that it’s important to get the rest of this information (core negative beliefs, positive attributes)- (cognitive) up front. In this way we are acting in concert with the standard method, which seeks gaining certain information that we will use to help the client heal. When we move into active trauma work (ATW) this information will speed the process of healing. The clinician will feel the client’s pain, and the client will not only have expressed it, he or she will have felt heard. Then when we start with the oldest or worst memory we’ll have an approximate affective “map of the territory”

It is important to note that Dr Shapiro goes from the present day referent, and links them to the oldest memories associated with it.. The rationale is that to initially ignore the past is to risk having come up as a form resistance, which in EMDR language is called “feeder memories.” Theses memories may sometimes halt the process and act as though they were unconscious resistances.

An important initial diagnostic question during phase one work, while taking a history is the determination about what type of initial work is needed; resourcing, or active trauma processing. Remember the consensual model of trauma treatment (Courtous, Herman) states that stability is the first goal. Without stability no trauma work should be begun. The careful clinician always keeps that rule in mind.

A major criterion for selecting a potential candidate for Active Trauma Work (ATW) in EMDR is their ability to tolerate high degrees of affective release. Safety factors must be evaluated at the start of a consultation for EMDR. Therefore, in history taking, the careful clinician assesses a client’s history for evidence of having the demonstrated ability of dealing with these high levels adequately; i.e., grieving to closure the death of a grandparent, or using criticism in a constructive way. We take into account the presenting problem, the old problems this is connected to, positive and negative belief systems, genetics, medical, family history, history of substance abuse in the client and the family, and the client’s demonstrated history and ability to deal with life’s vicissitudes. Safety in Phase One means being thorough!

A major risk in dealing with traumatized clients is the possibility for dissociation. In order to assess for this, Carlson and Putman’s Dissociative Experience Scale (DES) is administered. It is a 28-question instrument that covers most factors in dissociation, and weighs out the client’s potential. Once these client factors have been evaluated by the clinician and differential diagnoses are made the entire clinical picture has been addressed. Dysfunctional behaviors, and symptoms that need addressing will be determined. Evaluation will also take factors of personality variables, and current life situations and stressors into account before proceeding to phase two.

Phase Two – Client Preparation

The second phase of EMDR is Client Preparation.  During this phase attention is paid to evaluating and discussing with your client your conclusions as whether the client is ready for ATW or needs an elongated period of preparation (read-stabilization) work; and why. We are preparing the client for the more active phases to follow. I always check my conclusions about whether to start active trauma work, or whether to do more resourcing, next to the wishes and ideas of my client.  It is at this time that an explanation of EMDR is given to the client at their

level of understanding. When we proceed to ATW,specific instructions about how to use the

desensitization phase are given as well:

“Sometimes the picture may change sometimes it may not”

“Sometimes the thoughts may change, sometimes they may not” “Sometimes the sensations or feelings in your body may change,  sometimes they may not”

“Just notice what comes up, (free association); what is most important is that you just let it happen, and we will talk about it between sets”.

When we determine that an elongated preparation phase is needed we instruct our client in a process called Resource Development and Installation, or (R/D/I)

On of the most important activities of this phase is developing a Safe Place image. This entails eliciting from the client a safe place. Not every client who comes through our doors has one. Surprise! Do not pass go; Do Not proceed to phase three. This will be a “rule out”- meaning that if the client cannot bring up a state of mind where they can feel safe, then an elongated period of preparation is usually required. Going through a nine step protocol demonstrates the ability of the client to move from a calm peaceful scene, to one that is mildly disturbing, and then back to the calm scene. This is one of the best diagnostic procedures for insuring greater degrees of client success, because it demonstrates the client’s ability to shift from a calm state to an emotionally charged one, and then back again to a calm one. During the Safe Place procedure , in every step, the clinician is informed diagnostically about the client’s ability to create a feeling of safety and a demonstrated minimal ability for being able to have dual attention (a necessary precondition for active trauma work);

Stress management techniques; metaphors for dual processing (meaning being present in the consultation room and in the trauma simultaneously), and a stop signal (to let the client know that they are in control) are additional measures to ensure client safety and adherence to the protocol when starting ATW. During this phase, the chairs of the therapist and client are set in the proper positions to prepare for processing, and the different forms of bilateral stimulation are tried out.  During this stage, I also assess for secondary gain issues, and develop strategies with my client if they exist, to counteract the possibility of this issue blocking the treatment process.

The term, bilateral stimulation means to induce an alternating rhythm, of either eye movements by the therapist using his/her fingers sweeping back and forth across the face, with the head held still; or having the client listen to alternating beeps, or rhythms with headphones on each ear, or by the therapist tapping alternately on a part of the body that is not sensitive to the trauma, (usually the back of the hands). (cognitive/behavioral). While this process of bilateral stimulation is described here, most of its usage will be done in phases four and five.

A “set” of bilateral stimulation is defined as a series of eye movements, or sounds, or tapping of at least 24 times before stopping to inquire, ” what comes up for you now,” As long as there is movement in the process the clinician continues by saying, “go with that” and a new set is begun. The client is instructed that there is no verbal reflection or interpretation as long as the memory is processing. (client centered)

Phase Three – Assessment

The third phase of EMDR is the assessment phase, and contains elements of imaginal exposure (cognitive/behavioral). Here the word assessment is used to denote a procedure for setting up a protocol for processing a traumatic memory. An assessment protocol is defined as having the following characteristics:

Picture (P): (Usually the most disturbing part of the picture)

Negative Cognition (NC): (Negative self referencing belief)

Positive Cognition (PC): (hoped for belief)

Validity of Cognition Scale (VOC) – (rating of how valid that positive cognition is)

Emotions (E)- (triggered by linking the picture and the negative cognition)

Subjective Units of Distress Scale (SUDS) – a rating of how distressed the client is, in this moment when the picture of the original event and the negative self referencing belief are joined together)

Body (B) – and where that felt distress is, in the body.

This protocol will now be explained in more detail.

At this time appropriate target memories are identified.  The client then

describes the picture that represents the worst part of the memory; the

negative belief they currently hold about themselves relating to this memory; what they would rather believe about themselves, and how true they think this positive believe it is  – remember, this is a wished for belief and not one currently held.  The Validity of Cognition rating scale is used, from 1 to 7, with one being totally false, and seven being totally true (Shapiro 1995). We do not expect that this rating will be high; the purposes of the (PC) and (VOC) are to point ourselves in the direction the client initially wants to go. A secondary purpose is to assure the client that they are more than their “pathology”.

Next to client is asked to link the picture with the negative belief and notice what emotions arise spontaneously.  There then asked to rate the severity of the distress on a scale from 0 to 10 with 0 being no distress, and 10 being the most severe distress. (This comes from Wolpe’s SUDS scale, or “subjective units of distress “).  Last, the client is asked where they notice the distress in their body.

An example of an assessment of a target memory may be as follows:

Memory- the 45 year old man who cannot stand up for himself to his boss describes this old memory;  “when I was a child my father would get drunk every night and would break furniture and beat my mother,my brothers, and myself.

Picture-Seeing my father punch my brother in the face and knowing that I’m next.

Negative Cognition-” I’m powerless to defend myself”

Positive Cognition-” I can stand up for myself”

VOC-3

Emotion-Fear and helplessness

SUDS-8

Body-Tightening of the chest; butterflies in the stomach

At this moment the assessment phase ends and the most active phase,

desensitization, begins.

Phase Four – Desensitization

During the desensitization phase (behavioral and psychoanalytic), the client is instructed to just notice whatever comes up into their consciousness while being stimulated bilaterally through the use of eye movements, alternating sounds, or alternating tapping.  These actions seem to activate the client’s inherent information processing system. These instructions to just notice whatever comes up are exactly similar to the analytic instructions to the client regarding free association. (See Stickgold, 2002 for a fuller explanation of the action of EMDR.)

When time has been taken to go through a client’s history, to properly prepare them, and to assess appropriate targets, this fourth phase can powerfully release dysfunctional stored emotion, and enhance the brain’s ability to appropriately reprocess old memories so that they are fully resolved and lessons about living can be gained.

In the desensitization phase, one might see the 45 year old man to

re-experience his feelings, and during successive sets of stimulation break down crying, and then reach a state of calm; or, one might see this man simply start to experience the memory in lesser and lesser stressfulness, until he felt completely released. There could be many other variations of

reactions as well. (The next step might then be to set up an assessment target of the current; complaint-not being able to stand up his boss, and desensitize that memory, etc.)

Phase Five – Installation

Once the desensitization phase is completed the installation phase begins. This phase is so named because the emphasis here is to install and strengthen the positive cognition (PC) (cognitive) that the client has chosen to replace the negative (and now fully desensitized) cognition with.  The clinician checks to see if the positive cognition still fits, and ascertains how true it feels to the client on a scale from 1-7 where one is totally false and seven is totally true.   The client then holds the once painful picture along side of the positive cognition and more sets of bilateral stimulation are applied, until the positive cognition is fully a 7. If the PC does not strengthen to a seven within a few sets, there may be an indication that more parts of a trauma need to be worked on, and the clinician and client must search for what is preventing this from happening. Questions like, “what prevents this cognition from being completely true?” may elicit “blocking beliefs” that may need then to be the source of the next target, before returning to complete the installation phase.

In the installation phase with this 45 tear old client, the picture of the father hitting the brother would be paired with the positive cognition, “I can stand up for myself “. One would expect that the VOC would now be a 6 or a 7, and after a few sets, completely a 7.

Phase Six – The Body Scan

Phase 6 is the body scan.  The client is instructed to hold both the picture (or target event) and the positive cognition together while scanning their body from top to bottom mentally. The client is asked to identify any residual tensions left in the form of body sensation. These sensations are then targeted for successive sets (body centered).  Usually these sensations dissipate by themselves, but in some cases more dysfunctional stored information will be revealed.  Shapiro states:

“There appears to be a physical resonance to dysfunctional material which may be related to the way it is stored physiologically. Identifying residual physical sensation and targeting it in this sixth phase of EMDR treatment can help to resolve any remaining on processed information.   This is an important phase and can reveal areas of tension or resistance that were previously hidden.” (Shapiro 2001, pgs. 74-75)

There are also some cases where the client begins to feel positive sensations as well. These sensations should also be paid attention to and processed, as more positive affect and cognition may be continuing, even though the client was sure just a moment ago, that the VOC was clearly a seven. As Dr. Shapiro has stated in her trainings, “it’s just a subjective number; we don’t know how far the positive affect can be strengthened.” Take the case of this 45 year old man who now appropriately anticipates confronting his boss. During the body scan he may also remember that an older brother of his who had molested him during their childhood years owed him $2000, and he had been letting him off the hook for it for years, in spite of his wife’s rational urgings that they needed the money for their children, this may happen because the client is still in an accelerated state of information processing, and more material may surface.  We tell our clients that the processing may stay activated for up to 48 hours after the session is over, so it stands to reason that right after desensitization and installation, both phases that are active trauma phases with bilateral stimulation, that the client’s processing may stay accelerated. He may not even need to deal with the old abuse issue, as it may have been implicitly processed along with the cluster of abuse issues he was consciously working on. He may be left with a new and positive association that, “I can tell Isaac that he’s got to pay me the money, and have a PC that goes along with this insight. At this point the client opens his eyes, and a few short sets of bilateral stimulation are applied, thus strengthening his positive beliefs about himself.

Phase Seven-Closure

Phase 7 is the phase of closure.  It is important to stress that every client at the end of every EMDR session should leave the therapist’s office in a state of relative equilibrium. In addition, specific instructions about

journaling (behavioral) are given. If the session is incomplete, meaning that the target memory is not completely desensitized, other procedures are used to close down the session.  The most typical procedure is to use some form of guided imagery or stress management to calm down the clients nervous system.  The client is also instructed to watch for other negative memories, as their may being a domino effect occurring, since stimulating one negative memory may activate others. Journaling may help contain the painful associated affects.   If it does not, the client is instructed to contact the clinician for further instructions.

Phase Eight – Re-evaluation

The final phase is entitled reevaluation.  This phase takes place at the beginning of the following session.  The clinician has the client re-access previously processed targets; the clinician elicits from the client any the relevant associations, dreams, or other painful memories, in order to assess whether treatment effects have been maintained, or whether more work needs to be done. New targets should not be started upon, until all aspects of the current target have been reprocessed, and integrated fully into the client’s consciousness. Phase eight’s importance cannot be over rated. In order to evaluate whether treatment effects are holding, it is crucial to re-access the old material that was processed. We are after “trait” changes and not state changes.

Case example – a “trait change” would be the 45 year old client’s demonstrating his use of his assertiveness skills with his boss, and perhaps with his brother. A “State change” simply means that the mood of the client has shifted from the beginning and end of a session. When this “state of mind” diminishes it usually means that there are more associative channels of unprocessed traumatic information to be accessed and reprocessed. Trait changes occur when all, or most old channels have been released. This is a long lasting change, not subject to regression in the face of associational stress.

The Three Pronged Approach

The “Three Pronged Approach”, old trauma, current day referents, and the future template completes the work. Our 45 year old client now has reprocessed his old ACOA-abuse traumas (old painful memories), processed his current day fears of confronting his boss; and after learning assertiveness skills confronts his boss, and hs brother (future template). Research has shown that adherence to the entire EMDR process is crucial for the most robust and sustainable outcomes. (Maxfield and Hyer, 2002)

Win, lose or draw”, the importance of the future template is the actualizing of the reprocessed information into a more adaptive schema. The man’s self esteem has risen as a result of the work, and his demonstrated ability to function on a more adaptive level. The 15 month Wilson et. al. follow up study showed that treatment effects held in a great majority of cases (84%) (Wilson, et., al., 1997)

Bibliography

Maxfield, L. and Hyer, L.,(2002) “The Relationship between Efficacy and Methodology in Studies Investigating EMDR Treatment of PTSD”, J. of Clinical Psychology V. 58, No. 1 pgs. 23-41

Shapiro, F., (1995) (2001) Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures NY Guilford Press

Stickgold, R., “EMDR: A Putative Neurobiological Mechanism of Action”,  J. of Clinical Psychology V. 58, No. 1, pgs 61-76

Wilson, S.A., Becker, L.A., & Tinker, R-H. (1995). “Eye Movement Desensitization and   Reprocessing (EMDR) treatment for psychologically traumatized  individuals”. J. of Consulting and Clinical Psychology 6-3 928-937