Understanding EMDR Eye Movement Desensitization & Reprocessing Bonnie Mikelson, LISW EMDR & Beyond

TOPICS EMDR Defined EMDR Adaptive Information Processing Model EMDR Treatment Approach Case Examples & Other Applications Origin and Hypothesized Mechanisms Research on Effectiveness

What is EMDR? Eye Movement Desensitization and Reprocessing (EMDR) is an integrative psychotherapy approach that has been extensively researched and proven effective for the treatment of trauma. EMDR is a set of standardized protocols that incorporates elements from many different treatment approaches with the use of bilateral stimulation using eye movements, tones and/or tapping. To date, EMDR therapy has helped millions of people of all ages relieve many types of psychological stress.

Definition of EMDR EMDR is an evidence-based psychotherapy for Posttraumatic Stress Disorder (PTSD). In addition, successful outcomes are well-documented in the literature for EMDR treatment of other psychiatric disorders, mental health problems, and somatic symptoms. It is a client centered approach that allows the clinician to facilitate the mobilization of the client’s own healing mechanism which stimulates an innate information processing system in the brain.

Definition of EMDR The model on which EMDR is based, Adaptive Information Processing (AIP), posits that much of psychopathology is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences. This impairs the client’s ability to integrate these experiences in an adaptive manner. ‘The past is present’, negatively impacting the person’s functioning in daily life and relationships.

The Triune Brain (Paul MacLean) Neocortex (Thinking Brain) Limbic System (Emotional Brain) Brain Stem (Physical Brain)

Trauma Storage and the Brain Neocortex (Thinking Brain) T T Limbic System (Emotional Brain) Brain Stem (Physical Brain)

EMDR is NOT a Technique EMDR is a psychotherapy approach that is guided by the Adaptive Information Processing Model and composed of integrative protocols and procedures which include the use of bilateral stimulation (BLS). Eight Phases of Treatment Three Pronged Protocol (Past, Present, Future) Forms of BLS – Eye Movement, Tones, Taps Incorporates elements of other theoretical orientations: - Psychodynamic, Cognitive, Behavioral, Client centered, Mindfulness

Origin of EMDR In 1987, psychologist Dr. Francine Shapiro made the chance observation that eye movements can reduce the intensity of disturbing thoughts, under certain conditions. Dr. Shapiro studied this effect scientifically and, in 1989, she reported success using EMDR to treat victims of trauma in the Journal of Traumatic Stress. Since then, EMDR has developed and evolved through the contributions of therapists and researchers all over the world. Today, EMDR is a set of standardized protocols that incorporates elements from many different treatment approaches.

Foundation and Principals Shapiro’s (2001) Adaptive Information Processing model, guides clinical practice, explains EMDR’s effects, and provides a common platform for theoretical discussion. The AIP model provides the framework through which the eight phases and three prongs (past, present, and future) of EMDR are understood and implemented. The evolution and elucidation of both mechanisms and models are ongoing through research and theory development.

Psychotherapy Conceptualization Psychodynamic Therapy – Foundation of problem: Intrapsychic conflicts Cognitive Behavioral Therapy – Foundation of problem: Dysfunctional beliefs, behaviors EMDR Therapy – Foundation of problem: Unprocessed memories of disturbing events that are dysfunctionally stored in neural networks.

Information Stored in an Unprocessed Memory Trauma Memory Triggers Images, Sounds, Smells, Taste, Feel Emotions Body Sensations Thoughts Meaning of Event, Belief about Self (NC)

EMDR: An Adaptive Information Processing Model When a traumatic or disturbing event happened, the natural system for processing a memory was interrupted because of high arousal and/or encoded as survival information. Information that occurred at the time of the upsetting event is stuck or frozen in the memory. Present day triggers or experiences can activate the feelings and responses in the stored memory. Persistent, intrusive thoughts Negative emotions Negative perceptions of self Physical sensations

EMDR: An Adaptive Information Processing Model “The AIP Model distinguishes EMDR from other forms of psychotherapy by viewing the present situation producing distress simply as a trigger for a past, unprocessed incident.” “EMDR’s procedures have been developed to access the dysfunctionally stored experience and stimulate the innate processing system.” (Shapiro, Journal of EMDR Practice and Research, Vol. 1, No. 2, 2007, p.71) ACES research and EMDR: Francine Shapiro, Ph.D., The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experiences, Perm J. 2014 Winter; 18(1): 71–77.

Innate Information Processing Generally in individuals who are healthy and have a more secure sense of self, new experiences are taken in, sorted through in terms of what is useful is learned, linked to the appropriate emotions and is accessible for the person to utilize in the future. For individuals who may not be as healthy, new experiences are taken in and sorted through with a more elevated limbic or emotional response not allowing adequate processing to complete to an adaptive resolution.

Innate Information Processing Traumatization has been described as the disruption of the inherent processing system that normally leads to integration and adaptive resolution following upsetting experiences. (van der Kolk, Fisler, 1995; van der Kolk, 2014) Under normal circumstances, this information processing may occur during thinking, talking, expressive/artistic activities, and/or dreaming. In trauma, however, a malfunction of this natural information processing system occurs such that the experience of the trauma remains “frozen”, manifesting in persistent intrusive thoughts, negative emotions and self-referenced beliefs, and unpleasant body sensations.

In utero and preverbal trauma Children experiencing in utero distress and/or preverbal attachment wounds as well as adverse childhood experiences, are vulnerable to ongoing reactivity impacting physical and mental health. The distress of adverse childhood experiences negatively impacts their physiology and does not spontaneously resolve. Their continual anxiety and reactivity suggests that the information processing system has stored this experience without a resolution. The child continues to hold hyper arousal and distress in the body that sets a foundation for ongoing life problems, with reactivity in beliefs about self (not safe/lovable/powerless), emotions (fear/anger/avoidance), and body sensations (elevated heart rate & fight/flight/freeze/play dead survival responses) impacting their ability to learn and function and resulting in ongoing developmental deficits.

Example A child with Fetal Alcohol Syndrome experiences developmental deficits resulting in organic and experiential limitations in behavior and functioning. Preverbal, including womb experiences, are stored (frozen) in the brain as they were experienced at the time, shaping the child’s perception of their world and ‘the body keeps the score.” (Van der Kolk, 2014) Regardless of being in a ‘safe’ environment now, the child continues to respond as if they remain in the unsafe environment These experiences are stored or ‘frozen’ in the brain impacting both physical and mental health EMDR can target and reprocess traumatic experiences with children as young as 18 months as well as older children and adults who suffer from these experiences.

Demonstration Colleen West • Small Miracles – EMDR with Children Short Demo

Describing EMDR to a Client When a disturbing event occurs, it can get locked or frozen in the brain with the original pictures, sounds, thoughts, feelings and body sensations. Present day experiences can activate those original feelings, thoughts, images, sensations. EMDR seems to stimulate that frozen information and allows the brain to process the experience by connecting that stuck memory with other information in your brain. Similar to what may be happening in REM (rapid eye movement) sleep when we dream. The eye movements or other forms of bilateral stimulation (tones, taps) may help to process the unconscious material.

Information Processing “Bilateral stimulation” or “Dual Attention Stimulus” is suspected of jumpstarting these limbic and physiological information processing systems. Various forms of stimulation (visual, audio, and tactile) are being explored and researched.

Describing EMDR to a Client EMDR does not take away the memory. You will still remember it, but it will be more distant, vague and not as distressing. EMDR will not take away any information that is valid or that you need to hold on to for your well-being. It is your own brain doing the healing and you are the one in control during the processing of the memory. EMDR has no placebo effect.

Describing EMDR to a Client Access the dysfunctionally stored information. Stimulate the information processing system and maintain it in a dynamic form. Move the information by monitoring the free association process and initiate procedures to facilitate adaptive (appropriate, positive, functional) resolution. Desensitize: Reduce the Subjective Unit of Distress (SUD) to 0. Reprocess: Learning takes place so client adapts their understanding of the event and shifts negative cognitions to positive cognitions.

During EMDR Processing Client internally generates “corrective information” about the event rather than that information being externally generated through discussion with therapist. Therapist does not reflect, interpret, reframe or intervene in other traditional ways Client Centered - Follow the client’s processing Mindfulness – “Just notice”, “Go with that” Cognitive Interweaves – ask questions that link statements made by client and only when needed to move processing forward

EMDR | 8 Phase Protocol 1. Client History and Treatment Planning 2. Client Preparation 3. Assessment 4. Desensitization (Processing) 5. Installation (Processing) 6. Body Scan (Processing) 7. Closure 8. Reevaluation

Process Targets: A Three-Pronged Approach 1. Process Past Event Identify Core Memories – earliest memories that laid the foundation for the presenting problems. Identify Clusters/Themes – single event to represent many similar incidents 2. Process Present Event Current Triggers, Stressors, Recent Event 3. Process Future Event Template of desired thoughts, emotions, actions for future events that typically have been avoided or uncomfortable. Recent Event Protocol – for events that happened within the past three months

Processing Sessions 50 minute sessions for processing. A targeted memory can require more than one session for processing to adaptive resolution. Number of processing sessions needed varies based on client, issues, trauma history 1-4 processing sessions for a single traumatic event Processing may or may not continue after session Target Past, Present, Future to get full resolution

Childhood Trauma in Adult Example Client | A 35-year-old woman sexually abused as a child by her alcoholic father. Presenting Problems | Nightmares, flashbacks, avoidance of trauma-related trigger situations, hypervigilance, guilt, self-hatred, mistrust of others, sense of hopelessness and helplessness. Negative Cognitions | It was my fault. I'm bad. I'm always vulnerable and in danger. I have no control. Positive Cognitions | I did the best I could. I'm a good person. It's over. I'm safe now. I have choices and a reasonable degree of control now.

Childhood Trauma Case Example TRIGGERS Watching a “sexual scene” in a movie Smell of alcohol Husband expressing desire for intimacy Excessive demands from boss IMAGE My father at my bedroom door telling me to take off my clothes EMOTIONS Fear Sadness Anxiety TRAUMATIC MEMORY AGE 5 Sexual Abuse by Alcoholic Father BELIEFS It was my fault I’m bad I am always vulnerable and in danger I have no control PHYSICAL SENSATIONS Tension in neck and shoulders Knots in stomach Palpitations in chest

Childhood Trauma Example – Assessment Components Picture: My father appears at the bedroom door late at night and tells me to take off my clothes. I’m about 5 years old. He smells of alcohol. Negative Cognition: I’m in danger. Positive Cognition: I’m safe now. Validity of Positive Cognition (VOC) = 2 out of 7 Emotions/Feelings: Fear, sadness, anxiety SUD Now = 8 out of 10 Body Sensation: Tension in the neck and shoulders, knots in stomach, palpitations in chest.

Childhood Trauma Example – Possible Information Processing Shifts Responsibility: Client recognizes that she was an innocent child betrayed by the person who was supposed to love and protect her. She mourns the loss of her “innocence” and expresses anger toward her father for the first time. She experiences a greater sense of compassion for herself and an increased sense of self-respect as a survivor. Safety: She recognizes that the abuse is truly over and that her father can no longer hurt her.

Childhood Trauma Example – Possible Information Processing Shifts Choices: Clients begins to acknowledge the choices she has made in her adult life (establishing boundaries with her family of origin, connections with supportive people, a commitment to therapy). She begins to consider new possibilities for the future. She expresses a desire to initiate new friendships and activities and acknowledges a renewed sense of hope and confidence.

Work Related Example Client: A 40-year old man who was laid off during the economic restructuring of his company. Presenting Problems: Sleep-onset insomnia, loss of appetite, self-medicating with alcohol, irritable, worried about the future, “paralyzed” in efforts to seek other work, fighting with his children and sometimes his wife. Negative Cognitions: I’m not good enough to retain at my company so they let me go. I’m worthless. Positive Cognitions: I have value to offer and can find an organization that recognizes this about me and is a ‘good fit’ with my skills and who I am.

Work Related Case Example TRIGGERS Friends who are still employed calling to ask how things are going Wife asking how the job search is proceeding Kids wanting more allowance IMAGE The Human Resources Director comes into my office and tells me I have 15 minutes to clear out my desk… EMOTIONS Irritable Worried TRAUMATIC EVENT BEING LAID OFF AT HIS COMPANY PHYSICAL SENSATIONS Nausea Tightness in chest Tingling in arms BELIEFS I’m worthless

Work Related Example – Assessment Components Picture: The Human Resources Director comes into my cubicle and tells me that I have 15 minutes to clear out my desk and download my computer files before my exit interview. Negative Cognition: I’m worthless. Positive Cognition: I have value. Validity of Positive Cognition (VOC) = 3 out of 7 Emotions/Feelings: Irritable, worried SUD Now = 7 out of 10 Body Sensation: Nausea, tightness in chest, tingling in arms

Work Related Example – Possible Information Processing Shifts Responsibility: Client considers whether he is at “fault”, for being on the list for layoffs. Client considers history of performance reviews and that all were average or above average. Client comes to understand that he is not at “fault.” He recognizes that this layoff had more to do with the company’s economic pressures than his worth. The client acknowledges that he has performed well, as evidenced by his written reviews, but nevertheless, he has been let go.

Work Related Example – Possible Information Processing Shifts Safety: Client explores, “Will I be okay?” He assesses his strengths and, he arrives at the idea. I will find another position because of the skills and work experiences I have accumulated. I do have the financial resources to last 6 months while I search for another position. I can borrow money from my brother if I have to.

Work Related Example – Possible Information Processing Shifts Choices: Client explores, “Will I be okay?” He questions whether he must remain in the same industry and concludes that he can look at other industries hiring people with his skill set. He assesses the time and costs needed to change careers and decides that he will stay in the same line of work but search within several different industries. He feels more encouraged for having arrived at this greater sense of choice.

EMDR Applications EMDR is not a cure all or magic bullet. Studies report positive therapeutic results for a wide range of populations and issues: Depression and Other Mood Disorders Generalized Anxiety Disorders, Panic Attacks, Phobias PTSD, Grief, Traumatic Bereavement Abuse and Neglect – Emotional, Physical, Sexual Accidents, Medical Treatments, Natural Disasters Addictions, Dissociative Disorders Somatic Problems – chronic pain, phantom limb pain, gastrointestinal, migraines, eating disorders, body image Vicarious Trauma Performance Enhancement (work, art, sports) Children, Couples, Veterans, Police Officers, Firefighters

Research on Effectiveness 24 controlled studies have consistently found EMDR effectively decreases / eliminates symptoms of PTSD for the majority of clients in studies. EMDR designated effective for PTSD by: American Psychiatric Association Substance Abuse and Mental Health Services Administration (SAMHSA) International Society for Traumatic Stress Studies U.S. Department of Veteran Affairs, U.S. Department of Defense The World Health Organization (2012, for children & adults) The California Clearinghouse for Evidence Based Practice in Child Welfare Many international health and government agencies Other studies on many other symptoms, disorders. For research summaries, visit www.emdria.org.

Why and how does EMDR work? Dr. Francine Shapiro wrote in her 2001 textbook: “Theories as to why EMDR works are currently only speculations – and will probably remain so for many years.” “Fortunately we do not have to know why a demonstrably effective treatment works before using it. If we did, no form of psychotherapy and few pharmaceuticals would be used.” “By analogy, although it took decades to discover why penicillin works, it was used in the meantime because its positive effects were dramatic and reliable.”

Why and How Does EMDR Work? Hypothesized Mechanisms Neurophysiology REM Sleep Orienting Response Working Memory Parasympathetic Response

Hypothesized Mechanisms of How and Why EMDR Works REM Sleep Reconsolidation of information Orienting Response Alternating bilateral stimulation shifts client focus from traumatic material to external stimuli which disrupts the traumatic associative networks, so learning can occur.

REM - Hypothesized Mechanisms of How and Why EMDR Works Robert Stickgold, Harvard Medical School Sleep Researcher, Journal of Clinical Psychology (2002) wrote: “Several lines of evidence suggest that EMDR may help in the treatment of PTSD by turning on memory processing systems normally activated during Rapid Eye Movement (REM) sleep but dysfunctional in the PTSD patient.” “Two separate memory systems store information in the brain. One, located in the hippocampus, stores ‘episodic’ memories, the memories of actual events in our lives. The second, located in the neocortex, stores general information and associations.”

REM - Hypothesized Mechanisms of How and Why EMDR Works Stickgold continues… He proposed that recovery from trauma depends on the processing of traumatic memories in their episodic form into general semantic memories. He reviews the literature that suggests that this normally occurs during REM sleep but is prevented from occurring for people who have PTSD. In particular the arousal associated with PTSD results in associations between the trauma event and other related events failing to develop.

REM - Hypothesized Mechanisms of How and Why EMDR Works Stickgold continues… “EMDR through the repetitive redirecting of attention, activates brain systems normally present during REM sleep.” “Any alternating, lateralized simulations regimen, whether eye movements, tapping, or binaural sound, could activate these systems by forcing the brain to constantly reorient to new locations in space” “In this manner, EMDR can ‘push-start’ the broken-down REM machinery that is required for the brain to effectively process traumatic memories”

EMDR Resources EMDR International Association | www.emdria.org --to find an EMDR trained therapist, search Find a Therapist EMDR Research Foundation | www.emdrresearchfoundation.org Francine Shapiro Library | http://emdr.nku.edu EMDR Basic Training, Education & Consultation | www.emdrconsulting.com; www.emdrandbeyond.com

Contact Information for EMDR Training, Consultation & Therapy EMDR & Beyond Bonnie Mikelson LISW, Director Amy Cowan, LMHC, Director Therapy Services Sara Coen, LMHC Therapist 1501 42nd Street West Des Moines, Iowa www.emdrandbeyond.com