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A Brief
Description
[from www.EMDR.com] Eye Movement
Desensitization and Reprocessing (EMDR)1
integrates elements of many effective psychotherapies in structured
protocols that are designed to maximize treatment effects. These include
psychodynamic, cognitive behavioral, interpersonal, experiential, and
body-centered therapies2.
EMDR is an
information processing therapy
and uses an eight phase approach.
During EMDR1 the client
attends to past and present experiences in brief sequential doses while
simultaneously focusing on an external stimulus. Then the client is
instructed to let new material become the focus of the next set of
dual attention.
This sequence of dual attention and personal association
is repeated many times in the
session.
Eight Phases of Treatment
The first phase is a history taking
session during which the therapist assesses the client's readiness for EMDR
and develops a treatment plan. Client and therapist identify possible
targets for EMDR processing. These include recent distressing events,
current situations that elicit emotional disturbance, related historical
incidents, and the development of specific skills and behaviors that will be
needed by the client in future situations.
During the second phase of treatment,
the therapist ensures that the client has adequate methods of handling
emotional distress and good coping skills, and that the client is in a
relatively stable state. If further stabilization is required, or if
additional skills are needed, therapy focuses on providing these. The client
is then able to use stress reducing techniques whenever necessary, during or
between sessions. However, one goal is not to need these techniques once
therapy is complete.
In phase three through six, a target is
identified and processed using EMDR procedures. These involve the client
identifying the most vivid visual image related to the memory (if
available), a negative belief about self, related emotions and body
sensations. The client also identifies a preferred positive belief. The
validity of the positive belief is rated, as is the intensity of the
negative emotions.
After this, the client is instructed to
focus on the image, negative thought, and body sensations while
simultaneously moving his/her eyes back and forth following the therapist's
fingers as they move across his/her field of vision for 20-30 seconds or
more, depending upon the need of the client. Athough
eye movements
are the most commonly used external stimulus, therapists often use auditory
tones, tapping, or other types of tactile stimulation. The kind of dual
attention and the length of each set is customized to the need of the
client. The client is instructed to just notice whatever happens. After
this, the clinician instructs the client to let his/her mind go blank and to
notice whatever thought, feeling, image, memory, or sensation comes to mind.
Depending upon the client's report the clinician will facilitate the next
focus of attention. In most cases a client-directed association process is
encouraged. This is repeated numerous times throughout the session. If the
client becomes distressed or has difficulty with the process, the therapist
follows established procedures to help the client resume processing. When
the client reports no distress related to the targeted memory, the clinician
asks him/her to think of the preferred positive belief that was identified
at the beginning of the session, or a better one if it has emerged, and to
focus on the incident, while simultaneously engaging in the eye movements.
After several sets, clients generally report increased confidence in this
positive belief. The therapist checks with the client regarding body
sensations. If there are negative sensations, these are processed as above.
If there are positive sensations, they are further enhanced.
In phase seven, closure, the therapist
asks the client to keep a journal during the week to document any related
material that may arise and reminds the client of the self-calming
activities that were mastered in phase two.
The next session begins with phase
eight, re-evaluation of the previous work, and of progress since the
previous session. EMDR treatment ensures processing of all related
historical events, current incidents that elicit distress, and future
scenarios that will require different responses. The overall goal is produce
the most comprehensive and profound treatment effects in the shortest period
of time, while simultaneously maintaining a stable client within a balanced
system.
After EMDR processing, clients generally
report that the emotional distress related to the memory has been
eliminated, or greatly decreased, and that they have gained important
cognitive insights. Importantly, these emotional and cognitive changes
usually result in spontaneous behavioral and personal change, which are
further enhanced with standard EMDR procedures.
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Introduction to EMDR
[from www.behavior.net]
This forum
grew out of an interview of Francine Shapiro by BOL Editor, Gilbert Levin.
That interview, which took place in July, 1997 is reprinted here in order to
orient newcomers to the forum. The entire interview, including contributions
from many others, is available in the EMDR Forum Archive.
BOL EDITOR: Hi Francine, I am glad you have joined us here at Behavior
OnLine for this dialogue on EMDR. Let me begin by asking you to provide a
brief and concrete description of the EMDR method. -Gil
FRANCINE SHAPIRO: EMDR stands for Eye Movement Desensitization and
Reprocessing. It is a complex treatment methodology which combines various
aspects of the major theoretical orientations (e.g., psychodynamic,
behavioral, cognitive, physiological, interactional and client-centered) in
addition to a dual attention stimulus. It turns out that the method was
badly named because in addition to eye movements, handtaps or tones can also
be used--and the term “desensitization” is a limiting concept. EMDR is best
conceptualized as a method that helps to reprocess dysfunctionally stored
experiences. So far, there are fourteen controlled studies on the use of
EMDR with posttraumatic stress disorder (PTSD). The most recent four
rigorously controlled studies demonstrate that 84-90% of single-trauma
victims no longer retain the PTSD diagnosis after only three sessions.
Although some people have the mistaken impression that EMDR is a simple
technique, in fact it is a complex method that consists of eight phases,
numerous procedural elements, and a set of protocols designed to address
specific client complaints.
Treatment outcomes include a cessation of pronounced symptoms, as well as
the achievement of insights, cognitive restructuring, and a shift to more
ecological emotions. Therefore, beyond the application to PTSD, EMDR is
being used by clinicians to address the disturbing life experiences that
contribute to a wide range of problems. However, EMDR should be used within
a comprehensive treatment plan by adequately prepared clinicians who have
experience working with the clinical population in question.
BOL EDITOR: You have said a lot in a few words. I am intrigued by your
reformulation of EMDR as "reprocessing dysfunctionally stored experiences".
And soon I will invite you to spell out the theory of information processing
implied in that phrase. First, though, lets go into the eight phases of EMDR.
What are the initial phases?
FRANCINE SHAPIRO: An EMDR treatment session consists of eight essential
phases. EMDR should always be used within a comprehensive treatment plan and
is never to be attempted without appropriate training, preparation, and the
opportunity for reevaluation. The following is brief delineation of the
critical phases for EMDR treatment.
Phase One: Client History and Treatment Planning
Effective treatment with EMDR demands knowledge not only of how to use it,
but when to use it. Therefore, the first phase of EMDR treatment includes an
evaluation of the client safety factors that will determine client
selection--including the client's ability to withstand the potentially high
levels of disturbance engendered by the reprocessing. For clients selected
for EMDR treatment, the clinician takes the information needed to design a
treatment plan. This part of the history-taking evaluates the entire
clinical picture including the dysfunctional behaviors, symptoms, and
characteristics that need to be addressed. The clinician will then determine
the specific targets that must be reprocessed and the order in which they
will be attempted.
Phase Two: Preparation
The preparation phase also includes establishing the appropriate therapeutic
relationship, briefing the client on the theory of EMDR and the procedures
it involves, offering some helpful metaphors to encourage successful
processing, and training the client in a variety of self-control techniques
in order to deal with the disturbing information that may arise during and
between sessions. EMDR is an interactive model that strives to invest the
client with a sense of empowerment and control. Since avoidance behavior is
clearly a part of the PTSD configuration, it is mandatory to prepare the
client to maintain the dual-awareness of present safety and dysfunctional
material from the past which is arising internally.
Phase Three: Assessment
Assessment is the third phase of EMDR treatment, during which the clinician
identifies the components of the target. Once the memory is identified, the
client selects the image that best represents the memory. Then he chooses a
negative cognition that expresses a dysfunctional, maladaptive
self-assessment related to his participation in the event. These negative
beliefs are actually considered verbalizations of the disturbing affect and
include statements such as "I am useless/ worthless/ unlovable/ dirty/bad,"
etc. The client then identifies a positive cognition that will be used as a
replacement for the negative cognition during the installation phase of
processing (Phase Five). These statements should incorporate an internal
locus of control, when possible, such as "I am worthwhile/ lovable/ a good
person,/in control" or "I can succeed." Then the client assesses the
validity of the positive cognition equals using the 1-to-7 Validity of
Cognition (VOC) scale where 1 signifies "completely false" and 7 signifies
"completely true." The negative emotion that accompanies the target is
delineated and measured on the 0-to-10 Subjective Units of Disturbance (SUD)
scale. A rating of 10 means the greatest level of disturbance the client can
imagine and 0 means calm or emotionally neutral. Next, the client identifies
the location of the physical sensations that are stimulated when s/he
concentrates on the event. The assessment stage offers a baseline of
response regarding to the target memory, and the specific components
necessary to complete processing. The alignment of the individual components
of memory and appears to facilitate the processing of the target
information.
Phase Four: Desensitization
The fourth phase is called "desensitization" because it focuses on the
client's negative affect as reflected in the SUDs rating. This phase of
treatment encompasses all responses, regardless of whether the client's
distress is increasing, decreasing, or "stuck." During the desensitization
phase, the clinician repeats the sets, with appropriate variations and
changes of focus until the client's SUDs levels are reduced to a 0 or 1
(when ecologically valid). This indicates that the primary dysfunction
involving the targeted event has been cleared. However, the reprocessing is
still incomplete and the information will need to be further addressed in
the crucial remaining phases. It should be emphasized that the reduction of
distress is only a by-product of the reprocessing, and during this phase the
client also gains insight, awareness of associative patterns, increase of
efficacy, and new sense of self.
Phase Five: Installation
The fifth phase of the treatment is called installation because the focus is
on "installing" and increasing the strength of the positive cognition that
the client has identified to replace the original negative cognition. For
example, the client might begin with an image of her molestation and the
negative cognition "I am powerless." During this fifth phase of treatment,
the positive cognition "I am now in control" might be installed. The caliber
of the treatment effects (that is, how strongly the client believes the
positive cognition) is then measured using the Validity of Cognition (VOC)
scale.
Phase Six: Body Scan
After the positive cognition has been fully installed, the client is asked
to hold the target event in mind, and identify any residual tension, in the
form of body sensations. These somatic feelings are then targeted for
reprocessing. Evaluations of thousands of EMDR sessions indicate that there
is a physical resonance to cognitive process that allows dysfunctional
material to be effectively targeted. Positive treatment effects are
evaluated, in part, on the basis of physical responses, a strategy that is
compatible with conjectures by van der Kolk and others that functional
memory storage resides in the declarative memory system while state-specific
physical sensations are manifested in nondeclarative memory.
Phase Seven: Closure
The client must be returned to a state of equilibrium at the end of each
session, regardless of whether reprocessing is complete. A variety of
self-control techniques may be used to close the session. In addition, the
client is briefed on what to expect between sessions, and in the use of a
journal to report on the experience.
Phase Eight: Reevaluation
The eighth phase of treatment includes the additional targeting, reaccessing,
and review necessary to ensure optimal treatment effects. After any
reprocessing session, a reevaluation of effects should be made at the
beginning of the following session. The reevaluation phase guides the
clinician through the various EMDR protocols and the full treatment plan.
Successful treatment can only be determined after sufficient reevaluation of
reprocessing and behavioral effects over time.
BOL
EDITOR: You have spelled out the EMDR procedure with exquisite clarity and
completeness.
I just visited the
EMDR Website and was impressed with
the acknowledgements there from some of the leading people in our field. It
is a marvel to me that you have been able to gain wide acceptance for a
method that on its face appears "too good to be true". How did you
discover/invent EMDR? And how on Earth were you able to overcome the
resistance it evoked.
(As I write, I am reminded of Don Nathanson's observation that you can
indentify the pioneers by observing the arrows in their backs)
FRANCINE SHAPIRO: In 1987, during a walk one day, I noticed that disturbing
thoughts I was having were suddenly disappearing, and when I brought them
back they did not have the same charge or level of disturbance as before.
Because I had been using my own mind and body as a laboratory since a bout
with cancer ten years earlier, I wondered what I had been doing to cause the
change, since generally that type of thought took deliberate engagement to
alter or dismiss. I started paying close attention to what I was doing and
noticed that when that kind of thought entered my conscious mind, my eyes
started moving in a certain way: a very rapid, ballistic, flicking movement.
I noticed that when the eye movement started, the thought vanished from
consciousness, and when I brought it back it was less valid and disturbing.
It was not a moment of great epiphany, but simply interesting and
intriguing. I thought I had stumbled upon a natural physiological process
that influenced thought.
Since I viewed it as a natural body/mind phenomena, I decided to see if it
would work if deliberately instigated and therefore I brought disturbing
thoughts to mind and then moved my eyes in the same manner. The same thing
happened. The thought shifted from consciousness and when I brought it back
it was less disturbing. After finding that it worked consistently for me, I
then experimented with other people to see if there was a similar effect for
them. I found that I had to use my hand to guide their eye movements since
it was difficult for them to do it on their own. Then I discovered that the
disturbance would start to decrease for everyone, but for most people it
would stop prematurely and I had to develop procedures around the effects of
the eye movements to get consistent effects.
Over the past ten years, as more difficult problems were accessed, the
procedures have gotten more and more refined and now include aspects of all
the major psychological orientations: psychodynamic, behavioral, cognitive,
body-oriented, client-centered, interactional, etc. It was a process of
evolution which also revealed that the eye movement is only one form of
stimulation that can be used. We now know that rhythmical handtaps and tones
can have the same effect as the eye movements. So the name Eye Movement
Desensitization and Reprocessing is an unfortunate one. Indeed, even the
term -desensitization- is limiting. The lessening of disturbance is really
only a byproduct of the reprocessing of information. The client also
achieves insights, connections, cognitive restructuring, enhancement of
self, etc. So, if I had to do it over again, I would call it Reprocessing
Therapy. However, EMDR has such world-wide recognition, that we retain the
abbreviation in the same way the AT&T does, even though telegraphs are not
in common use.
As to how I was --able to overcome the resistance it evoked,-- I have to say
it is not completely overcome. There abounds a tremendous amount of
misinformation about EMDR, as well as the inevitable attacks that come with
any innovation. However, we have encouraged experimentation on EMDR since
the beginning and now there are 13 completed controlled studies, which makes
it the most widely researched method used in the treatment of trauma. The
most recent, rigorously controlled studies all indicate that 84-90% of
single-trauma victims no longer have the post-traumatic stress disorder (PTSD)
diagnosis after only the equivalent of three 90-minute sessions (a review
and the citations are available at the website: www. emdr. com and in my new
book: EMDR -- BasicBooks).
Those who are accurately informed about EMDR, have tried it themselves, or
have dispassionately reviewed the literature are certainly accepting of it.
It is exciting to enter with them onto a new plateau of protocol
development, investigating ways to integrate the traditional wisdom of the
various modalities into a more refined, comprehensive practice. Experts in
various specialty populations (such as substance abuse, sexual dysfunction,
complicated bereavement, etc.) have expanded the use of EMDR to a variety of
presenting complaints. However, there are still a number of individuals who
refuse to accept EMDR until it can be explained by traditional theories.
Unfortunately for them, however, one cannot explain three-session positive
EMDR treatment effects by traditional psychodynamic or cognitive-behavioral
theories. For instance, according to the exposure/extinction/habituation
theory of flooding which has been advocated as the primary
cognitive-behavioral treatment for PTSD, there must be 15-50 hours of
exposure for positive results. Even though the controlled research on EMDR
has clearly demonstrated otherwise, I have actually heard
cognitive-behavioral academicians dismiss the results as placebo, even
though 15-month follow-ups have demonstrated robust and lasting effects. For
some, it is hard to integrate new paradigms into standard practices.
Therefore, unfortunately, I have to agree with Don Nathanson. The arrows may
be fewer, but they definitely exist.
BOL EDITOR: Your account of the moment of origin of EMDR sent a chill
through my spine. It was reminiscent of Einstein's famous ride on the
commuter train -- actually more like Gautama pausing under the Banyan tree,
because of the personal significance of your moment. That would make you
especially vulnerable to those arrows of skepticism and it's a great relief
that none of them reached your heart.
I read your response late last night and awoke with a vivid memory from my
undergraduate days. One of my most influential teachers at college was
Leslie White, the distinguished (and somehat eccentric) cultural
anthropoligist. White took fiendish delight in debunking myths ("What fools
YOU mortals be!") and saw science as the cure for the boundless distortions
that are part and parcel of the uniquely human power to make and grasp
symbols. Forty years after his lecture, I can still hear White's rhetorical
question/mantra uttered in a tone that would do justice to Howard Stern, "Do
you REALLY suppose that an ape can believe in holy water?" This was said in
a way that made it clear that the ape was on the right side of the argument.
For White the essence of science was doubt and he coined a verb to describe
that essence: Science is NOT-knowing.
It's clear from all you have said above that you embrace fully the
scientific paradigm and the fundamental skepticism at its heart. I invite
your comment (even though I know I haven't really framed a question).
FRANCINE SHAPIRO: I wholeheartedly agree that the tools of scientific
investigation are crucial to eliminate error and objectively evaluate that
which can be observed in order to counterbalance the possible distortion
caused by subjective interpretation. However, to my way of thinking, the
essence of science is investigation--not doubt. If science is used in the
service of humanity, its mandate is to explore and expand the bounds of
knowledge. The springboard is then curiosity and the goal is KNOWING. If
doubt becomes the driving force of science then it often is subverted to the
goal of debunking anything that cannot currently be measured or explained.
Science then takes on the stature of religion and the dominant myth that is
accepted is that one should not entertain, accept, or believe that which
cannot be currently proven. Unfortunately, this eliminates from the arena
all those things for which there are so far insufficient theory,
measurements, and conceptual frameworks.
If one is an ape, one is reduced to that which can be understood and
conceptualized in that framework. If one is a human being, there is the
ability to apprehend the ineffable and the possible. The goal is to develop
the tools of science to understand the governing principles of mind, body,
and nature--from the subatomic to the universal. While an ape might not
believe in holy water, neither would it believe in--nor have been able to
conceptualize--the atom. And without the capacity for symbolic thought and
conceptualization beyond the realm of what is known, all progress ceases.
BOL EDITOR: You have said that EMDR is a method that enables "reprocessing
dysfunctionally stored experiences". That phrase implies that most
experiences, including those that carry high affective are stored in a
"functional" way and therefore do no harm to the person.
How much can you say or speculate about such functional storage? How it
occurs and where? And what are the conditions that lead to "dysfunctional
storage? In other words, what usually "goes right" and what goes wrong in
the case of trauma?
FRANCINE SHAPIRO: The clinical observations of EMDR treatment effects seem
to dovetail with conjectures by van der Kolk and others regarding memory
storage. That is, when a memory of a past event is functionally stored it is
in declarative or narrative memory. If it is dysfunctionally stored it is in
motoric memory and retains the physical sensations and high level of affect
that was there at the time of the event. With EMDR, we see clients start at
a high level of affect and physical sensations and after treatment that is
no longer there, and learning has taken place.
Traumatic events can cause dysfunctional storage. However, I think trauma
can be defined in a number of ways. We can say the *big T* trauma that a
clinician needs to designate a diagnoses of PTSD (like a rape, kidnapping,
combat) , or *small t* traumas which are the ubiquitous experiences which
have a negative impact upon the self and psyche. If you bring up a memory of
a childhood humiliation you may find that the emotions and physical
reactions are still there.
If so, I would consider them dysfunctionally stored in unprocessed form.
That is the perceptions are unchanged since the time of the event and
learning has not taken place. The unprocessed experience may be contributing
to problems in the present that are related--such as difficulty with groups,
relationships, learning, authority, etc.
I think affect and evolution theorists could contribute here regarding why
certain experiences are ingrained and unchanged. It may be due to certain
developomental windows. It may be due to the interaction of types of
neurotransmitters and high arousal. We are biologically determined to
respond in certain ways when danger and survival fears surface. It may be
that experiences such as being humiliated in childhood are the evolutionary
equivalent of being cut out of the herd. At any rate, if you bring those
earlier experiences to mind and you get no negative physical reaction, but
adaptive/adult related thoughts spontaneously emerge, then I would say the
information is appropriately processed.
Why one experience is processed and not another, or why one person processes
it and not another, may be due to earlier nurturance history that made the
experience more tolerable, sufficient counterexamples, or biological
determinants, or perhaps being comforted/calmed soon after the distress.
Many maladaptive behaviors, negative beliefs, and attitudes that people
carry around seem to be caused by these types of dysfunctionally stored
events with affects that are easily triggered in the present. They do not
have to be *big T* traumas to cause them, and the associations revealed
during processing are fascinating to watch.
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