WHAT IS EMDR?
You may be told you need this therapy, but may not be told what it is or what it intended to address. This paper is intended to help you understand what this therapy involves in order to assist you in making an informed decision about whether it is right for you. Therapists who are contemplating EMDR training may find this paper useful in assessing whether EMDR would fit into their psychotherapy practice.
MDR -- Eye Movement Desensitization and Reprocessing -- is a defined, advanced and its practitioners certified by an international body, EMDRIA. EMDR therapy is a therapeutic modality that must be administered by an EMDR trained clinician or those who are currently participating in an EMDRIA-approved training. The Canadian affiliate of EMDRIA is EMDR Canada (Home - EMDR Canada).
EMDRIA provides a brief video overview of EMDR at New "What is EMDR Therapy?" Read on for more detail.
EMDRIA DEFINITION OF EMDR
The 2020 EMDRIA definition of EMDR, here somewhat abridged, is that EMDR is an evidence-based, clinician led, psychotherapy for Post-Traumatic 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. EMDR therapy helps children and adults of all ages. Therapists use EMDR therapy to address a wide range of challenges:
- Anxiety, panic attacks, and phobias
- Chronic Illness and medical issues
- Depression and bipolar disorders
- Dissociative disorders
- Eating disorders
- Grief and loss
- Performance anxiety
- Personality disorders
- PTSD and other trauma and stress-related issues
- Childhood abuse trauma
- Sexual assault
- Sleep disturbance
- Substance abuse and addiction
- Violence and abuse
The American Psychiatric Association, the International Society for Traumatic Stress Studies, the Substance Abuse and Mental Health Services Administration, the U.S. Dept. of Veterans Affairs/Dept. of Defense, The Cochrane Database of Systematic Reviews, and the World Health Organization among many other national and international organizations recognize EMDR therapy as an effective treatment.
EMDR is based on Francine Shapiro’s Adaptive Information Processing (AIP) model (Shapiro, 2001) which posits that much of psychopathology is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences. In EMDR, trauma is regarded as a memorial process—in the fullest sense of memory: the neural networks of all the senses, as well as the meaning we have made of an experience, however incomplete that meaning-making step might be. The shock of trauma impairs the client’s ability to integrate these experiences in an adaptive manner that does not interfere with functioning subsequent to the trauma. Not integrated, the memory of these experiences preoccupies the present awareness and intrudes into thoughts, emotions and affects behaviours in the present. By contrast, when memories are integrated into our autobiographical memory, we are able to access them at will, suppress them if that is expedient, knowing their place on our time line and their meaning in our life experience. In AIP terms, there is a natural homeostatic process of incorporating experiences into long-term memory that may be interrupted when the experience is traumatic. In trauma this is interrupted and unintegrated experiences, begging to be processed, rob attentional resources from the present experience. Avoidance strategies to avoid unpleasant unintegrated memories result in recourse to a variety of tension reducing behaviours such as eating, drinking, drugging, cutting, addictions both process and physical, risk taking, etc.
Many protocols exist for delivering EMDR therapy to clients and in situations that are specialized and/or circumscribed. The Standard EMDR Protocol is an eight-phase process to facilitates the resumption of the normal homeostatic process of experiential integration into autobiographical memory. This treatment approach targets three “prongs”: past experience, current triggers, and future potential challenges. It results in the alleviation of presenting symptoms, a decrease or elimination of distress from the disturbing memory, improved view of the self, relief from bodily disturbance, and resolution of present and future anticipated triggers.
The core EMDR treatment approach to the resolution of traumatic and disturbing adverse life experiences is accomplished with a unique standardized set of procedures and clinical protocols which incorporates dual focus of attention (the traumatic past and the safe present), at the same time as alternating bilateral visual, auditory and/or tactile stimulation (BLS). This process activates the components of the memory of disturbing life events and facilitates the resumption of adaptive information processing and integration.
“Processing” is the fourth of eight phases of EMDR treatment, but the stereotype of EMDR therapy is that it is essentially if not only BLS. In fact the other seven phases of EMDR treatment are very beneficial to the client and essential to treatment effectiveness.
THE EIGHT PHASES OF THE STANDARD EMDR TREATMENT PROTOCOL
Client History Phase (Phase 1), the clinician explores targets for future EMDR reprocessing from negative events in the client’s life, prepares a treatment plan with attention to past and present experiences, and future clinical issues. It is also important to identify positive or adaptive aspects of the client’s personality and life experience. The clinician may need to postpone completing a detailed trauma history when working with a client with a complex trauma history until the client has developed adequate affect regulation skills and resources to remain stable.
Preparation Phase (Phase 2), the clinician acquaints the client with the therapeutic framework of EMDR providing sufficient information for the client to give informed consent to treatment. Also during this phase, the client learns grounding skills, practices the mindful stance of dual awareness, develops skills in self-soothing and in affect regulation that facilitate dual awareness during the reprocessing sessions and help maintain stability during and between sessions. Assessing the client for dissociative tendencies is an aspect of ensuring affective stability. Accomplishing these tasks may be supported by techniques from other therapeutic modalities. An overarching task during this phase of treatment is that the client establish a relationship of trust with the therapist that is sufficient to give the client a sense of safety and foster the client’s ability to tell the therapist what s/he is experiencing throughout the reprocessing. Some clients may require a lengthy preparation phase for adequate stabilization and development of adaptive resources prior to dealing directly with the disturbing memories. Occasionally, the therapy may temporarily return to Phase 2 if in assessing or processing more sensitive target memories, it is apparent that more stabilization is needed.
Assessment Phase (Phase 3): Significant issues, incidents identified in Phase 1 are reviewed with the client. There may be several incidents that are thematically related, such as being bullied at various ages and in various contexts. Once a specific representative experience has been identified (the target), the clinician asks the client to select the image or other sensory experience that best represents it. A negative belief (the Negative Cognition or NC) is elicited that expresses the client’s currently held maladaptive self-assessment related to the experience. Sometimes the NC emerges organically in the client’s account of the experience. The client is asked about the emotions evoked when pairing the image or other sensory experience and the negative belief, and to identify the location of the physical sensations in the body that are stimulated when concentrating on the experience, as well as to rate the level of disturbance utilizing the 0 to 10 Subjective Units of Disturbance (SUD) scale. Finally, the therapist elicits a positive belief (the Positive Cognition or PC) connecting the experience to more adaptive memory network(s), with the client rating and felt validity of the positive belief, utilizing the 7 point Validity of Cognition (VoC) scale. Sometimes the PC emerges organically in the client’s account of the experience.
Desensitization Phase (Phase 4): The memory is activated and the clinician asks the client to notice his/her experiences while the clinician provides alternating bilateral stimulation. The client then reports these observations. These may include new insights, associations, information, and emotional, sensory, somatic or behavioural shifts. The clinician uses specific procedures and interweave other content if processing seems blocked. The desensitization process continues until the SUD level is reduced to 0 (or an ecologically valid rating), assisting the client throughout in maintaining an appropriate level of arousal and affect tolerance.
Installation Phase (Phase 5): the therapist first asks the client to check for a potential new positive belief related to the target memory. The client selects a new belief or the previously established positive cognition. The clinician asks him/her to hold this in mind, along with the target memory, and to rate the selected positive belief on the VOC scale of 1 to 7. The therapist then continues alternating bilateral stimulation until the client's rating of the positive belief reaches the level of 7 (or an ecologically valid rating) on the VOC Scale.
Body Scan Phase (Phase 6): The therapist asks the client to hold in mind both the target event and the positive belief and to mentally scan the body. The therapist asks the client to identify any positive or negative bodily sensations. The therapist continues bilateral stimulation when these bodily sensations are present until the client reports only neutral or positive sensations.
Closure Phase (Phase 7): This occurs at the end of any session in which unprocessed, disturbing material has been activated whether the target has been fully reprocessed or not. The therapist may use a variety of techniques to orient the client fully to the present and facilitate client stability at the completion of the session and between sessions. The therapist informs the client that processing may continue after the session, provides instructions for maintaining stability, and asks the client to observe and log significant observations or new symptoms.
Re-evaluation Phase (Phase 8): At this stage the stability of treatment effects on targets previously processed. As Leeds (2016) points out, the stability of treatment effects needs to be assessed at the micro level – the specific impact of the previous session -- and at the macro level – re-evaluation of the work as the treatment plan is nearing full implementation. At the micro level, the treatment plan is adjusted session-wise as a Phase 8 step, based on new memories, present triggers and anticipated future challenges arising for the client; for each, Phases 3-8 are repeated. In addition to assessing the overall stability of treatment effects, systemic influences are also assessed as a macro level consideration.
Focus on present triggers and anticipated future challenges relates to an overarching principle of standard comprehensive EMDR treatment: the three-pronged approach that encompasses past events, present triggers, and the exploration of adaptive outcomes for related anticipated future challenges.
Here-and-Now Approach: The above description of the eight phases of the standard EMDR protocol outlines the structure of EMDR treatment which may give the impression that EMDR is a mechanical process as the word protocol may suggest to some. However, for any EMDR protocol to be effective, elements more akin to art, essential to any successful psychotherapy, must be present:
- an alliance of trust between the client and therapist and a feeling of safety within the session
- ongoing informed consent, even if implicit
- crafting of the interventions and cognitive interweaves, and pacing of the work to dynamically changing capacities of the client
- an attunement by the therapist to:
- the client’s moment-to-moment readiness to proceed, groundedness in their dual awareness of their memories and the present context in the therapist’s office. This includes situations where the client says they are ready to proceed with processing but the therapist’s assessment of them in the session is that they are not (e.g., too tired, already outside their window of tolerance due to recent events in their life)
- specifically in EMDR and also in CBT and narrative therapy, the exact words of client’s description of their memory which make it compelling to them. These words must be reflected in the NC and PC and adjusted as the client refines these ideas during treatment.
- in EMDR, Gestalt therapy and sensori-motor psychotherapy, the client’s somatic and behavioural tells that may signify changes in autonomic arousal and depth of connection to memories to which the client is not mindfully aware in the moment.
- non-verbal, non-narrative, non-cognitive aspects of the memory that are stored in other senses– visual, auditory, tactile, olfactory – and/or in movement, gesture or context.
Innovation, Flexibility and Clinical Judgment as Applied to Particular Clients or Special Populations: As a psychotherapy, EMDR unfolds according to the needs, resources, diagnosis, and development of the individual client in the context of the therapeutic relationship. Therefore, the clinician, using clinical judgment, emphasizes elements differently depending on the unique needs of the particular client or the special population. EMDR treatment is not completed in any particular number of sessions. It is central to EMDR that positive results from its application derive from the interaction among the clinician, the therapeutic approach, and the client. In treatment tailored to the client’s history, the three-pronged basic treatment protocol (past events, present triggers possible future triggering situations) may need to be altered in order to address all three prongs in a manner suited to the client’s stability, readiness and situation. There may be situations where the order may be altered or prongs may be omitted, based on the clinical picture and the clinician’s judgment.
In addition to Francine Shapiro’s seminal work (2001), an excellent, current summary of standard protocol theory, practice guidelines and protocols is provided in Leeds (2016). In recognition of Francine Shapiro’s lifetime contributions to trauma treatment, EMDR practice and research, EMDRIA has established the Francine Shapiro Library as an online resource. Marilyn Luber has authored several volumes to assist in the tailoring of EMDR treatment to special situations and specific populations (Luber, 2009, 2010, 2013, 2015, among others). Ongoing developments and new research are reported in the Journal of EMDR Practice and Research, published by Springer on behalf of EMDRIA.
THERAPY OR TECHNIQUE?
Although EMDRIA describes EMDR as a comprehensive psychotherapy, Marich (2011) suggests that empirical examination of how EMDR is applied by practitioners shows that that it is also used as a) an adjunct to other approaches, b) a technique in an eclectic practice of psychotherapy, or c) as a framework to inform and shape other therapeutic modalities. More specifically Marich’s four faces of EMDR can be summarized as follows:
Face 1. protocol oriented EMDR – the Standard Protocol described above: EMDR as a therapeutic modality
Face 2. flexible EMDR – such as Parnell’s Attachment Focused EMDR: EMDR as a therapeutic modality
Face 3. EMDR as a technique – introduced in the context of some other super-ordinate modality
Face 4. EMDR-informed interventions - such as EMD (Keissling)
The question conceptual framework hinges on whether EMDR or some other modality is primary. The author’s orientation is Face 1. above, but would argue that other modalities can inform the Preparation (Phase 2 of EMDR) as well as some cognitive interweaves during Phase 4 Processing and Phase 8 Future Template work.
One controversial side issue with Face 3., is the practice some therapists to farm out EMDR treatment of their long-term clients to an EMDR specialist, like a dentist sending a patient to an endodontist for a root canal. Treating EMDR as an adjunct technique provided by a specialist called in on an ad hoc short-term basis is a problematic practice because the client’s sense of safety in the dual awareness of EMDR processing necessitates a strong therapeutic alliance between the client and practitioner that cannot easily be created in a drop-in context, and may be undermined if the client is expecting to be back with long-term therapist after a few sessions. In addition, a trusting therapeutic alliance may be very slow to develop for deeply traumatized clients who do not experience safety and trust easily.
1. Variants on the Standard Protocol
- the inverted standard protocol (Hoffman, 2010): begins with the future and present prongs of focus rather than the past (Standard Protocol)
- EMDr, EMD (Keissling) - used to restrict the scope of memories access in Standard Protocol processing
- A-TIP (Keissling) - restricted individual processing in acute, very recent trauma; not considered EMDR by EMDRIA
- R-TEP (Recent Traumatic Episode Protocol) for use in disaster situations (Shapiro & Laub, 2008)
- EMDR-PRECI (EMDR Protocol for Recent Critical Incidents. - Jarero & Artigas, 2014)
- G-TEP (Group Traumatic Episode Protocol) (Shapiro, 2014 – see Shapiro & Moench, 2018)
- G-TEP RISC (G-TEP for Remote Individual and Self Care) for delivery of remote individual treatment, for example, as is necessary during the corona virus pandemic. (Shapiro, 2020)
2. Attachment Focused EMDR (Parnell, 2013)
3. Addiction protocols
- dTUR (Popky,2010)
- FSAP (Miller, 2012)
4. Imaginal Nurturing (Steele, 2010) – working with the wounded inner child
5. The Progressive Approach (Gonzalez & Mosquera, 2012) - using BLS when the client is not ready for trauma processing
6. (others too numerous to mention)
Gonzales, A., & Mosquera, D. (2012) EMDR & Dissociation: the Progressive Approach. (selfpublished, available on Amazon)
Hoffman, A. (2010) The inverted EMDR standard protocol for unstable somplex post-traumatic stress disorder. In M. Luber (ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Special populations, pp. 313-329. New York: Springer.
Jarero, I., & Artigas, L. (2014). The EMDR protocol for recent critical incidents (EMDR-PRECI). In M. Luber (Ed.), Implementing Early Mental Health Interventions for Man-made and Natural Disasters: Models, Scripted Protocols and Summary Sheets (pp. 217-232). New York: Springer.
Keissling, R. - https://www.emdrconsulting.com
Leeds, A. (2016) A Guide to the Standard EMDR Therapy Protocols for Clinicians, Supervisors & Consultants. New York: Springer.
Luber, Marilyn (2009) EMDR Basics and Special Situations. New York: Springer.
Luber, Marilyn (2010) EMDR Scripted Protocols: Special Populations. New York: Springer.
Luber, Marilyn (2013) Implementing EMDR: Early Mental Health Interventions for man-made and natural disasters. New York: Springer.
Luber, Marilyn (2015) EMDR Treating Anxiety, Obsessive-Compulsive, and Mood-Related Conditions. New York: Springer.
Marich, J. (2011) EMDR Made Simple: 4 approaches to using EMDR with every client. Eau Clair, WI: Premier Publishing & Media
Miller, R. FSAP – Feeling-State Addiction Protocol. New Hope Counselling.
Miller, R. (2012) Treatment of behavioral addictions utilizing the feeling-state addiction protocol: a multiple baseline study. Journal of EMDR Practice & Research, 6(4), pp. 159-169.
Parnell, L. (2013) Attachment Focused EMDR: Healing Relational Trauma. New York: Norton.
Popky, A. J. DeTUR for EMDR Therapy: EMDR Professional Training
Popky, A. J. (2010) The desensitization of triggers and urge reprocessing (DeTUR) protocol. In M. Luber (ed.) EMDR Scripted Protocols: Special Populations (pp. 489-511). New York: Springer.
Shapiro, E. & Laub, B. (2008) Early EMDR Intervention (EEI): A Summary, a Theoretical Model, and the Recent Traumatic Episode Protocol (R-TEP). Journal of EMDR Practice and Research 2(2), 79-96.
Shapiro, E. & Moench, J. (2018) G-TEP (Group Traumatic Episode Protocol, 7 th ed.)
Shapiro, E. (2020) G-TEP RISC (G_TEP for Remote Individual and Self Care) earlyemdrintervention.org
Shapiro, F. (2001) EMDR: Basic principles, protocols and procedures (2nd ed). New York: Guilford.
Steele, A. (2010) Imaginal Nurturing, Ego States & Attachment: an integrated approach to early deficits. (EMDRIA approved) Self-published. www.april-steele.ca.