Today we have a guest post from Jeremy Fox, LPC and EMDRIA-approved consultant. Jeremy takes an in-depth look at what EMDR therapy is and how it works, and dispels common EMDR myths.
With Prince Harry’s recent, recorded Eye Movement Desensitization and Reprocessing therapy session reaching international audiences, EMDR has entered public awareness and gained widespread interest.
This is for good reason: EMDR is recognized by the World Health Organization (WHO) as a first-choice treatment for Post-Traumatic Stress Disorder (PTSD), and the International Society for Traumatic Stress Studies (ISTSS) strongly recommends EMDR for the treatment of PTSD across children, adolescents, and adults (Castelnuovo, Fernandez, & Amann, 2019). With this information in mind, what is EMDR, how does it work, and how can it help you?
What is EMDR therapy?
EMDR owes its beginnings to a walk in a Los Tagos, CA park, when in 1987, psychologist Dr. Francine Shapiro discovered her eyes rapidly moving between trees, while thinking of a memory with negative emotions. She then immediately noticed a decline in the vividness of the emotional content. Shapiro began studying the connection between eye movements and memories, titling her new method EMD, or “Eye Movement Desensitization,” due to the desensitizing effect of eye movements on the negative emotions of traumatic memories (Hensley, 2015). EMD was renamed EMDR in 1991, due to the recognition of cognitive reprocessing effects. Where negative thoughts once accompanied the recollection of traumatic events, new statements, such as “I’m safe now,” or “I can protect myself,” could be installed alongside the previously frightening memory, removing physical tension and fright, and offering a sense of freedom and safety.
What happens during EMDR therapy?
With support from the WHO and ISTSS, EMDR is clearly a promising treatment method, but how does it work? EMDR therapy is based on Shapiro’s (2001) Adaptive Information Processing (AIP) model, which describes an innate neurobiological mechanism which consolidates new memories into pre-existing networks. In neuroscientific terms, the information processing system facilitates reconsolidation (re-storage) of traumatic memories into the appropriate past tense (Markus & Hornsveld, 2017). Traumatic events overwhelm the capacity of this information system, and memories are encoded in state-dependent form, with vivid emotions and sensations attached. EMDR is credited with re-activating adaptive information processing, so that the reliving symptoms of trauma, such as intrusive images, physical tension, rapid heart rate, and shortness of breath, are uncoupled from the memory of a distressing event, which can then be stored in semantic form.
It should be noted that only therapists instructed in EMDR from an EMDRIA-approved training may provide the therapy.
Phases of EMDR
The model proceeds across eight distinct phases, from treatment planning, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation. Traumatic memory reprocessing, which is what is often referenced by the term “EMDR,” does not even begin until phase four (desensitization). In phase 1, clients collaboratively explore their history of trauma with a therapist, creating a road map of the first or worst memory, a relevant present source of distress, and a future scenario or situation which might be challenging, and which the client will imagine themselves successfully navigating. EMDR follows a three-pronged approach, in which past, present, and future situations are all addressed via desensitization and reprocessing, within separate sessions.
In phase 2, clients are taught skills for containing emotional distress which may arise during EMDR treatment. Clients are often directed to construct a mental “container” for storing unsettling images or other sensory information, as well as an imaginary “calm place.” This caution and preparation allows for optimal client readiness and prevents a sense of overwhelm from accessing memories without adequate tools. For example, if residual negative sensations remain, after a session of phase 4 desensitization, clients are instructed to put the feelings, images, etc. into their container, and imagine their calm place, before the therapy session concludes. This teaches clients that negative memories need not control their feeling states and can be set aside until the next phase 4 appointment.
In the third (assessment) phase of EMDR, the memory, addiction trigger, or feared future outcome is “targeted,” and “dialed up” in the client’s mind, by asking the client to notice the narrative, emotional, cognitive, and physical elements of memory, before a dual attention stimulus (DAS) usually in the form of bilateral, or side-to-side, eye movements (EMs) is initiated. This ensures that the client can feel the emotional and physical elements of the past event, which is necessary for reprocessing the memory with EMs and storing it in semantic form. It should be noted that the vividness of emotion is one reason why EMDR is only ethically provided by a trained therapist, and why clients should avoid attempting this therapy at home. Without a professional’s guidance, the re-engagement of traumatic memory can lead to emotional distress without reprocessing.
During the fourth, desensitization phase of EMDR, clients are exposed to the traumatic memory for typically thirty seconds (or less) at a time, while dual attention stimulation is provided by the EMDR-trained therapist. Clients are asked “what are you noticing,” or “what’s happening,” and told “go with that,” then mental rehearsal of the memory and DAS are resumed. This continues until clients rank the traumatic narrative 0/10, on the subjective units of distress (SUD) scale, at which point the client selects a desired positive cognition (PC) for “installation” over the top of the formerly distressing trauma memory. This installation process is phase 5 of EMDR.
Phase 6 involves the client scanning the body for any residual distress, which is targeted via DAS, while phase 7 includes closure, either as complete (with the PC as high as possible) or incomplete. Incomplete EMDR sessions are concluded with phase 2 resources, such as container and calm place. Phase 8 entails reassessment of the target, at the beginning of the next EMDR appointment, in order to determine if any tension or distressing memory content remains or has newly arisen.
How does EMDR work?
In reference to the way EMDR works, Shapiro (2001) suggested that “interrupted exposure,” of short DAS sets alternated with “check-ins” are essential to EMDR (p. 318). The model functions via continued switching between memory exposure and therapist interaction (Boudewyns & Hyer, 1996). This “distancing process” (i.e., a focus upon material other than the traumatic memory, such as eye movements and therapist verbal feedback) is associated with greater symptom improvement than exposure alone (Lee, Taylor, & Drummond, 2006, p. 105). The check-ins may also limit client avoidance of memories by ironically increasing their desire to resume reprocessing, since tasks that are interrupted are remembered better than those that are completed, and incomplete events create a drive to completion (Fox, 2020).
EMDR’s interrupted reprocessing model differs significantly from other desensitization therapies, such as prolonged exposure, in which clients are asked to vividly describe a memory for typically sixty minutes of a ninety-minute session (Foa, Hembree, & Rothbaum, 2007). For those who fear that accessing the emotions and visual images of a painful past event would destabilize them, EMDR may be the optimal, indicated treatment option.
There are several theories which seek to explain how EMDR removes the intrusive, negative emotional content from memories, present fears, and future anxieties. The orienting and relaxation response (OR) model contends that an orienting response is activated by any new stimulation (in EMDR, this is the eye movement or other DAS) (Pagani, Amann, Landin-Romero, & Carletto, 2017) and that the response prepares the organism for a potential need to react.
If no danger is present, the initial freeze response is replaced with relaxation, and reconsolidation of traumatic memory is enabled. EMs trigger this OR, allowing recognition of present safety and access to painful memories without avoidance (Pagani et al., 2017, p. 2).
The working memory model of EMDR suggests that a central executive mental system is responsible for integration of incoming sensory stimulation from subsystems such as the visuospatial sketchpad. DAS taxes the limited ability of these systems and reduces the vividness, emotionality, and somatic (physical) perceptions of negative/traumatic mental images (Pagani et al., 2017). In the same way that opening too many tabs on an internet browser can slow a computer’s processing, resulting in slowed playback of videos, DAS such as EMs interrupt and obscure the emotional vividness and imagery of negative memories.
There is EEG evidence that the EMs in EMDR activate delta (slow) wave activity in the brain, eliciting slow waves like those observed during slow wave sleep (SWS) (Pagani et al., 2017). This hypothetically enables transfer of memories from the hippocampus to the neocortex, for transformation from episodic to semantic form.
The above research supports the importance of eye movements in EMDR, but how are they provided, and what purpose do they serve? Smooth pursuit eye movements, or a smooth following of the clinician’s hand or other object, such as a light, are used in sessions. Longer, rapid sets of EMs (24-40) are administered during desensitization and reprocessing to activate client emotion and memory. Slow, short sets of EMs (4-6) are provided for relaxation, when installing a positive resource such as a container, or when engaging in the installation phase of EMDR. EMs are more effective than bilateral auditory tones, in reducing the vividness of traumatic memories (Van den Hout et al., 2011; de jongh, Ernst, Marques, & Hornsveld, 2013). While tactile stimulation (in the form of the “butterfly hug” seen performed by Prince Harry in his recent, recorded EMDR session) and auditory tones diminish the vividness of traumatic memories, this effect is larger in EMs.
After learning the powerful potential of EMDR to remove the emotional, physical effects of traumatic memories, it may be helpful to address any lingering doubts by exploring some common myths about the therapy model.
Myth 1: “EMDR is hypnosis.”
EMDR features eye movement and borrows some exercises from the hypnotic tradition, such as the “affect bridge.” This technique encourages a focus upon the physical aspects of memory, encouraging clients to allow somatic sensations to bring a corresponding memory to mind (usually the first time a client felt the negative physical sensations).
This is where the comparison to hypnosis ends. EMDR does not involve hypnotic “trance” or suggestibility (Hensley, 2015). In fact, EMDR increases emotional arousal and alertness, during desensitization and reprocessing. While clients may retrieve forgotten memories during EMDR sessions, this is not the intent or clinical purpose of the model and is not guaranteed.
Myth 2: “EMDR is just the eye movements and reprocessing of memories.”
EMDR as a treatment modality begins with history taking and ends at reassessment. Even resource development and positive visualizations offered during the preparation phase count as EMDR. EMDR reprocessing (phase 4) unfolds over three distinct stages, as past, present, and future manifestations of the presenting target issue are all targeted for desensitization and reprocessing.
Myth 3: “EMDR requires you to immediately jump into reprocessing your trauma.”
EMDR is not only exposure or desensitization; improvements in quality of life can result from the positive, strengthening visualizations (containment and calm place, among others) learned during the preparation phase. There are many modifications to the standard EMDR protocol, such as a focus upon only one image during desensitization and exposure, rather than the entire traumatic memory, or limiting the time spent focusing on a negative memory to less than ten seconds per set of DAS. EMDR successfully treats clinical concerns ranging in severity, from single-event PTSD to complex PTSD (characterized by early, frequent childhood abuse), as extension of the preparation phase or titration (shortening) of reprocessing sets may be employed, depending on severity of previous traumatic experiences and client need. There is no set timeline or expectations for addressing memories in EMDR, and treatment proceeds at a pace collaboratively dictated by therapist and client.
Myth 4: “EMDR is only useful for treating PTSD.”
While EMDR was pioneered as a PTSD treatment, the modality of treatment has been applied to anxiety disorders, obsessive compulsive disorder, and the urges accompanying addiction (Marr, 2012; Markus & Hornsveld, 2017). Any memory which causes significant distress may be targeted and reprocessed through the desensitization and installation phases of EMDR.
Finding an EMDR Therapist
After learning of the many clinical conditions that EMDR can treat and the sound research which supports the model, you may want to determine if EMDR is right for you. To get started, visit https://www.emdria.org/find-a-therapist/ and enter your zip code, city, or state, to find an EMDR practitioner close to you. EMDR can be safely, effectively conducted in person or remotely.
Please be advised that only EMDRIA-trained therapists are capable of ethically offering EMDR.
For more research on the effectiveness of EMDR, please visit https://www.emdr.com/research-overview/ and see the reference list below.
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Boudewyns, P. A., & Hyer, L. A. (1996). Eye movement desensitization and reprocessing (EMDR) as treatment for post-traumatic stress disorder (PTSD). Clinical Psychology & Psychotherapy: An International Journal of Theory and Practice, 3(3), 185–195.
Castelnuovo, G., Fernandez, I., & Amann, B. L. (2019). Present and future of EMDR in clinical psychology and psychotherapy. Frontiers in psychology, 10, 2185.
de Jongh, A., Ernst, R., Marques, L., & Hornsveld, H. (2013). The impact of eye movements and tones on disturbing memories involving PTSD and other mental disorders. Journal of behavior therapy and experimental psychiatry, 44(4), 477-483.
Foa, E., Hembree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. Oxford University Press.
Fox, J. G. (2020). Recovery, Interrupted: The Zeigarnik Effect in EMDR Therapy and the Adaptive Information Processing Model. Journal of EMDR Practice and Research.
Hensley, B. J. (2016). An EMDR therapy primer: From practicum to practice (2nd ed.). Springer Publishing.
Lee, C. W., Taylor, G., & Drummond, P. D. (2006). The active ingredient in EMDR: Is it traditional exposure or dual focus of attention? Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 13(2), 97–107. https://doi.org/10.1002/cpp.479
Marr, J. (2012). EMDR treatment of obsessive-compulsive disorder: Preliminary research. Journal of EMDR Practice and Research, 6(1), 2-15.
Markus, W., & Hornsveld, H. K. (2017). EMDR interventions in addiction. Journal of EMDR Practice and Research.
Pagani, M., Amann, B. L., Landin-Romero, R., & Carletto, S. (2017). Eye movement desensitization and reprocessing and slow wave sleep: a putative mechanism of action. Frontiers in psychology, 8, 1935.
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.).
van den Hout, M. A., Engelhard, I. M., Rijkeboer, M. M., Koekebakker, J., Hornsveld, H., Leer, A., Toffolo, M., & Akse, N. (2011). EMDR: Eye movements superior to beeps in taxing working memory and reducing vividness of recollections. Behaviour Research and Therapy, 49(2), 92-98.