EMDR: An evidence-based treatment
This article will discuss the science and practice of how and why Eye Movement Desensitization and Reprocessing (EMDR) therapy works as a treatment method to treat PTSD, anxiety, and depression. There also is a clear description of how our EMDR trained and educated psychologist performs EMDR therapy at CHMC in Dubai. The EMDR sessions are structured, and each session is 60 minutes.
The Origins of Eye Movement Desensitization and Reprocessing (EMDR) therapy
In the late 1980s, Francine Shapiro discovered a link between eye movements and persistent disturbing memories. She noted that, while experiencing disturbing feelings, her eyes started to move fast. Consequently, this personal insight initiated her lifelong research and development of Eye Movement Desensitization and Reprocessing (EMDR) therapy.
EMDR therapy has been validated through double-blind studies and is an evidence-based treatment method. The therapy is approved by the American Psychological Association, the US Department of Veterans Affairs and the World Health Organization (WHO).
How EMDR works?
The treatment involves standardized procedures, including focusing simultaneously on traumatic images, thoughts, emotions and bodily sensations. EMDR therapy employs bilateral stimulation commonly in the form of repeated eye movements. However, sometimes bilateral sound stimulation or tapping contralateral parts of the body can be used.
EMDR helps process the negative images, emotions, beliefs, and body sensations associated with traumatic memories that seem to be stuck. Initially, the therapy was intended to treat trauma, such as PTSD (Post-Traumatic Stress Disorder). However, therapists also use it as a therapy for anxiety, depression and other psychiatric disorders.
Trauma and PTSD. The collapse of psychic defence
EMDR therapy was originally developed for the treatment of PTSD (Post-traumatic Stress Disorder). To understand the development of PTSD we must look closer at the human psychic structure using psychoanalytical terms.
Psychoanalytic theory understands human behaviour as an effect of dynamics between the mental parts of the psyche, including the Id, Ego, and Superego. The psychic trauma in PTSD appears suddenly and excessively breaking the psychic balance. A violent influx of traumatizing events exceeds the human capacity to face or integrate feelings. Violent traumatic events such as accidents, abuse, and disasters break through the Ego defence mechanisms. As a result, people store traumatic memories in their raw, unprocessed form. EMDR therapy allows the brain to resume its natural healing process and “clears” unprocessed trauma memories.
What can EMDR help with?
EMDR therapy is widely recognized as one of the best treatment methods for Post-Traumatic Stress Disorder (PTSD). PTSD was originally considered a condition caused by war trauma. Today’s PTSD definition includes as a root cause of the disorder also other traumatic events, such as car accidents, plane crashes, and violent incidents.
Moreover, therapists use EMDR for the treatment of other psychiatric conditions especially after applying other psychotherapeutic techniques. It proved to be effective as a therapy in the treatment of anxiety, depression, and behavioural difficulties.
How EMDR works?
The precise mechanism of EMDR action is unknown. It seems that several mechanisms are at work, making the treatment effective.
EMDR has proven to be very helpful in reducing/terminating distressing symptoms. Our brain has a natural way of recovering from traumatic memories and events. Therefore, traumatic experiences often resolve naturally. However, in some cases, people cannot handle the consequences (symptoms) of trauma without professional help.
The fight and flight response are our innate reaction to stress. When disturbing memories are “unprocessed” and remain disturbing, upsetting images, thoughts and emotions can create an overwhelming feeling of being back in the moment. Eye Movement Desensitization and Reprocessing therapy helps process these memories and allows for natural healing to resume. However, successful EMDR therapy is not about eradicating traumatic memories. People will still remember the trauma. Yet, it will be without triggering the fight and flight response.
EMDR: the therapeutic approach
EMDR therapy for PTSD, anxiety and depression is based on dual focus – eye movements or other distractions while focusing on the traumatic memory. The patients descend into the unconscious space of their psyche while still keeping contact with their consciousness. The opaque “wall” between the unconsciousness and consciousness gets semi-transparent. Therefore, such state allows an access to the traumatic memories making them conscious and reducing their “destructive energy”. EMDR therapy initiates the healing process allowing the patient to view the traumatic memories differently. Consequently, those memories do not distress the patient anymore. The EMDR therapy usually takes place in 60 min sessions.
Therapeutic phases of EMDR
Eye Movement Desensitization and Reprocessing therapy is structured. The “classical” EMDR therapy evolves through eight phases: 1) history taking and treatment planning, 2) preparation, 3) assessment, 4) desensitization, 5) installation, 6) body scan, 7) closure and 8) re-evaluation.
1) History taking and treatment planning
EMDR Therapy treatment begins with Phase 1, which is the history-taking phase. The goal of Phase 1 is to gather information to create an AIP informed case conceptualization and treatment plan. The therapist determines which memories to target for reprocessing and in what order. Phase 1 is also the starting point for developing a therapeutic alliance and the emergent therapeutic relationship. The therapist’s stance during Phase 1 is non-judgmental, supportive, and understanding of the client’s clinical complaints. Inadequately processed memories triggered by daily life demands are the driving force behind the patient’s symptoms. The therapist’s ability to attune to the Patient and titrate the intensity of history taking is crucial to Phase 1’s success.
Typically, Phase 1 for a PTSD or adjustment disordered patients is limited to a few sessions. However, for patients with multiple symptoms over a broad context, dissociative symptoms, or personality difficulties, Phase 1 may take longer.
Indicators and procedures
During Phase 1, the therapist uses indicators such as Direct Questioning (DQ), Floatback Technique (FB), and Affect Scan (AS) to identify the network of memories. The therapist also searches for indicators of inadequately processed and maladaptively encoded memory. They are the nodes in EMDR Therapy and contain past sensory information, thoughts and emotions influencing the present. Node activation generates symptoms in the present.
2) Preparation
In the phase 2 of EMDR Therapy, called preparation phase, the therapist explains the EMDR therapy process, terms, and therapy targets. Moreover, the preparation stage addresses the patient’s concerns and questions. The crucial point is the creation of a therapeutic alliance between the clinician and patient.
Phase 2 of EMDR Therapy called preparation phase, is about determining if the client is ready for processing. The therapist explains the EMDR model and addresses any concerns the client may have about the treatment. They establish how the treatment will be administered, including the bilateral stimulation, seating positions, and a stop signal in case the client needs to stop during processing. During Phase 2, the therapist offers resourcing interventions as needed, even though the use of these interventions is not limited to this phase and can be used throughout the treatment, especially in patients with complex symptoms. The number of Phase 2 sessions required to prepare the patient for subsequent memory reprocessing varies from person to person. A positive experience with bilateral stimulation and subsequent reprocessing sessions appears to lead to a favorable outcome in the treatment of PTSD patients.
3) Assessment
During this phase, patients are asked to access each target in a controlled and standardized way to be processed efficiently. The EMDR therapist identifies various aspects of the target to process. In the first step the patient must select a specific well memorized image from the target event. Then he must select a negative self-confidence statement related to the event.
Even if the patient intellectually understands that the statement is false, it doesn’t mean that he integrated it emotionally. These negative beliefs are verbalizations of disturbing feelings that still persists. The patient then chooses a positive self-statement. This statement should include an inner sense of control such as “I can do it”. If the dominant emotion is fear, such as after a natural disaster, the negative perception may be “I am in danger”. The positive perception can be: “Now I’m safe”. The “I am in danger” fear can be viewed as a negative perception.
Cognitive validation
While the danger is over the fear is trapped in the memory. Positive perceptions should reflect what is actually relevant in the present. At this point, the therapist asks the patient to rate how true the positive beliefs are, using a 1 to 7 Validity of Cognition scale. “1” corresponds to “completely false” and “7” corresponds to “completely true”. It is important to give a score that reflects what the person “feels” rather than “thinks”.
Subjective disturbance
We can logically “know” that something is wrong, but we are most driven by how it “feels”. The assessment phase also identifies negative emotions (fear, anger) and physical sensations (tightness in the stomach, cold hands) associated with the target. Clients also rate their negative beliefs, but using a different scale called the Subjective Units of Disturbance (SUD) scale. This scale, which rates emotion from 0 (no disturbance) to 10 (worst), is used to rate the disturbance the client is experiencing. The goal of EMDR treatment in the next phase is to decrease the SUD score for disorders and increase the VOC score for positive beliefs
4) Desensitization
In the desensitization phase of EMDR, the therapist guides the patient through bilateral stimulation in order to help him to identify his negative thoughts, memories, and feelings. At the beginning of this phase the therapist instructs the patient of three types of bilateral stimulations (BLS). The therapist may refocus on the traumatic memory or move on if the emotion is no longer triggered. The patient reports changes after each set of bilateral stimulation. After having identified the negative thoughts and feelings “the installation” of positive beliefs takes place.
Bilateral stimulations (BLS) technics
The most effective technic is the “eye movement”. Therapists often employ bilateral stimulation engaging eye movements from side to side. The speed of stimulation is in general fast, with one movement per second. Eye movements may be similar to rapid eye movement (REM) sleep, which occurs as we dream. If the “eye movement” is not feasible the therapist can use tapping, auditory pulses or blinking lights.
5) Installation
When desensitization is complete, the installation phase begins. In this phase, the positive beliefs that were expressed in the assessment phase are used to replace the original negative ones. In this phase, the patient strengthens his positive beliefs connected to the targeted traumatizing event. As the effects of the desensitization phase help the client process traumatic memories and regain a sense of power and control over their situation, these positive ideas are reinforced and used to overcome the past. While it may not be possible to Gette patient fully to the most confident rating on the VOC scale of a positive belief (i.e., to believe wholeheartedly that it is true), it is possible to reach a point where next steps can be imagined and followed. From here, self-confidence and healthier feelings can be developed and internalized further.
6) Body scan
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In this phase, the therapist will ask the client to think about the original traumatic memory and to pay attention to any physical sensations that appear. The trauma might remain physiologically stored in the body causing various physical symptoms such as pain, numbness, heart racing etc. It is important for the patient to understand the reason of the body scan in order to create the connection between feelings and body. The body scan helps to identify the level of distress whether it has been lessened or completely neutralised. The aim is achieving no physical impact when the memory is brought to mind, to be sure the dynamics of the encapsulated trauma are taken out in all senses, mental, emotional and physical. If a sensation is reported that is uncomfortable, further processing will take place until the discomfort subsides. Once the symptoms vanished, the reprocessing is complete.
7) Closure
The closer phase in EMDR is important when a memory is not fully processed. Due to a complex nature of a trauma, it can take different amounts of time to fully process a memory to resolution in EMDR. Some people can process several memories in one session, while others may need several sessions for one memory.
It may happen that the therapist and patient end the session while not being able to fully process a memory. In such case the therapist implements a series of exercising to return the patient to a calm state. The goal of the closer phase is to ensure that the patient can return to their normal life without feeling overwhelmed or distressed by the trauma. By taking care to end sessions in a calm and peaceful manner, the therapist can help the patient to continue making progress in future sessions.
8) Re-evaluation
Phase 8 of EMDR is re-evaluation. This phase happens after the initial visit. The therapist evaluates whether positive effects have been maintained and if any new memories have emerged. Re-evaluation is crucial to determine the success of the treatment over time.
EMDR can bring relief almost immediately. But it’s important to complete all eight phases of treatment. Completing the full treatment is as important as finishing a course of antibiotics.
When EMDR is complete, attention has been brought to past memories that contribute to the problem. Present situations that cause distress have also been addressed. Finally, the therapist identifies the skills the client needs for the future.
It’s crucial to seek treatment from a therapist trained in EMDR. Positive outcomes depend on specialized training and professional consultation. With the guidance of a trained therapist, emotional healing and increased confidence for the future are possible.
How to choose an EMDR Therapist – EMDR Therapy in Dubai
Finding an EMDR therapist might be a complicated journey. Firstly, you therapist should be a psychologist additionally EMDR-trained, licenced, and certified in using this treatment technic. The second important aspect is the compatibility and safety. Look for a therapist who you feel comfortable with, can trust, and can build a relationship with. This means looking for a certified EMDR therapist who has competence in the issues you are struggling with, a cultural fit, and a personality that works for you. It’s best to talk to a trained medical provider, including an EMDR therapist, before starting EMDR therapy. They can provide more information and answer any questions you may have.