By Melonie Grannell, D. Clin. Psych
Eye Movement Desensitisation and Reprocessing or EMDR as it is more commonly known, is a model of psychological therapy developed by Dr. Francine Shapiro in 1987. Dr Shapiro noticed how, by moving her eyes back and forth for a period of time with limited interruptions, she was able to release disturbing feelings. She tested a theory that eye movements allowed people to safely reflect upon difficult thoughts, emotions and behaviours or experiences, to enable them to reprocess memories in their entirety to make informed conclusions, rather than conclusions based in previous life experiences and assumptions.
Initially met with scepticism, EMDR is now considered a frontline evidence based therapy in the treatment of Post Traumatic Stress Disorder (PTSD). Documented as an effective treatment by the World Health Organisation (WHO) and the NICE Guidelines in the UK, the Australian Psychological Society (APS) considers EMDR to be one of the most effective PTSD treatments available. As well as being an effective model for PTSD, the evidence base for EMDR is constantly expanding and it is now considered an effective treatment for a variety of different psychological distresses including chronic pain, grief, anxiety, eating disorders, depression, and many more. Research into EMDR has found that although similar to other psychological models, in that it treats mind and body, EMDR can reduce psychological distress in less time than other therapeutic approaches.
What is EMDR?
EMDR is a psychological approach that allows the individual to gain better clarity and understanding of memories from previous distressing experiences, whilst focusing on present distress. This exacerbated distress can be expressed in 4 ways; cognitively through thoughts, physically through physiological responses, emotionally and behaviourally. Unlike other psychological therapies, EMDR uses eye movements to reflect upon distressing, images, thoughts, emotions and physiological responses that occur in the present as a consequence of a past memory or event, rather than focusing on the actual event itself. This makes the therapy less intrusive for the individual.
The Smashed Plate
The impact of EMDR on memories and current distress can be explained using the “smashed plate” metaphor. When a plate is smashed, it breaks into many pieces, big, small and some so small they are only slight. If we were to try to repair the plate, it never quite goes back to the way it was, small pieces get lost, the pieces don’t glue back together as they once had been, ultimately, the plate is very rarely fit for purpose.
If we consider for a moment that traumatic memories are plates, when the memory impacts upon the brain, it ‘smashes’ into several pieces. These pieces are scattered around the brain, falling into several ‘containers’, each labelled with themes according to previous beliefs and experiences. When information is scattered in this way, it is especially difficult for the individual to reconnect the individual memories, thoughts and feelings in a way that is least distressing or meaningful.
To reduce this distress, the brain creates its own ‘glue’, by changing the edges of the pieces to make them fit and filling in the any gaps with other assumptions learned from previous experiences and beliefs.
Whilst these assumptions can sometimes ease distress, more often than not, the distress is exacerbated and misunderstood. As with the plate that is no longer fit for purpose, the memory is not recalled in a way that is helpful.
Traumatic memories can become “stuck” in these containers, usually stored together under similar themes, imagine containers with labels if you will, with bits of smashed plate from different plates, these containers being spread across the mind. For example, some parts are stuck in the “I’m not good enough” theme, or the “I am a failure”, or “I am not safe” themes. EMDR is effective in the release of “stuck” memories that are currently expressed in this way. In EMDR we progress through the themes or containers one at a time, focusing on a specific memory, and currently experienced images, thoughts, emotions and sensations. These themes are largely organised and developed around the first related event of its kind, additional experiences, thoughts, feelings and sensations then fall into these related containers or themes.
By stimulating both sides of the brain, (Bilateral Stimulation), these containers can be linked together to enable them to effectively ‘talk’ to each other, therefore bringing the pieces or the evidence back together again. This allows us to objectively consider the current distress and its impact upon the memory and vice versa, whilst in the safety of the therapy room. In understanding the roles of misunderstood Images, Thoughts, Emotions and Physiological Responses, the client becomes desensitised to this distress. This allows them to learn new information and create new understandings, to reprocess the memory, therefore further reducing the current distress.
EMDR can only be facilitated by a therapist who has attended accredited EMDR training. The sessions involve several parts and will often form part of a therapeutic approach that incorporates other psychological approaches.
EMDR comprises of 8 phases, the initial phases of history taking, preparation and assessment are fundamental to the process. During phase four the client is asked to recollect and focus on key emotions, body sensations, images and core beliefs associated with a distressing memory while they track the therapist’s finger for approximately 24 eye movements. The client then stops and notes how they are feeling, what they are thinking and what they are sensing in their body. The eye movements and tracking continue until any distress is resolved. For each distressing target, new positive, alternative beliefs emerge as a result of the eye movements and are reinforced with further eye movements. This occurs across a number of sessions. One of the most important outcomes of EMDR is that it doesn’t just remove the distress associated with a specific memory, it actually shifts the negative belief or assumption associated with that memory. On completion of the therapy, clients report significantly reduced distress, negative beliefs and significantly improved well-being.
The 8 Phases
Phase one of EMDR is a comprehensive history taking, understanding the clients past experiences, current distress and future goals.
Phase two involves preparation for EMDR, this includes an explanation for the model, informed consent is gained and preparation in the form of self regulation and coping strategies are developed. This phase can take several sessions as the therapist is required to ensure that the client has many coping strategies to choose from, as they travel along their therapeutic journey. A fundamental coping strategy in EMDR is the ‘safe place’. The ‘safe place’ is used as a coping strategy both within the session and beyond to induce calming images, thoughts, feelings, emotions and sensations. The therapist may then go on to explain how during bilateral stimulation, reprocessing of information is comparable to the ‘train metaphor’. The ‘train metaphor’ describes how whilst on a train, you sit in one place and look out of the window. As you look out of the window, you will notice that the picture changes, the information changes, you watch it from a safe distance whilst in the safety of your carriage, at each train station, you explain to your partner what you have seen between stations, then the train continues the journey, and so on until it arrives at its destination. This process is repeated until the distressing memory is reprocessed and the clients distress is desensitised, therefore the end of that specific journey. The client may then start the train journey again with a different event.
Phase three is assessment, in this we establish our target memory, identifying our thoughts, feelings, physiological response and distress. During the history taking and assessment phase, the client is supported by the therapist to identify ‘the first, the worst and most recent’ memory, related to a specific theme that reoccurs, therefore there may be a number of similar experiences throughout your life, that reinforce your current thoughts and feelings about yourself. An example may be: as a child, you had a distressing experience whilst having a blood test, you may continue to have a fear of injections, causing you to feel scared and angry. Over time, you may have developed beliefs that doctors and nurses cannot be trusted, therefore “I am unsafe” as you feel unable to approach them when ill as the fear that they will suggest a blood test is too distressing. Therefore, you avoid seeking health care, which further exacerbates your fear becoming unwell. This increases anxiety, particularly amongst other people who may be ill as you are concerned that you may become infected with their illnesses. Your current distress is continuously exacerbated, you are scared and anxious, believing that you are unsafe, that you will be contaminated by illness, you may even believe that you may die, your physiological response may be expressed through head aches, stomach pain, chronic pain, which further exacerbates the fear of health seeking. You may have began to isolate yourself from others to avoid ‘contamination’, therefore developing beliefs “I am isolated”, “People are dangerous”. Together, the therapist and client may agree that the target memory to be reprocessed in phase four, will be the experience as a child (the first), or it may be the most recent beliefs about isolation and the possible presenting dangers of people, or they may decide to reprocess the most distressing event or memory.
In phase four, desensitisation occurs using bilateral stimulation to target each memory.
Some examples of Bilateral Stimulation can be moving the eyes from side to side, by focusing on an object or light, alternating tapping of the hands, sounds in alternating ears with a set of headphones or any combination of these. By following the therapist’s fingers from side to side, or focusing on the light or object, the client is anchored into the present moment, therefore generating a sense of safety, rather than fear of re-experiencing the traumatic moment or experiencing a “flashback”. Bilateral stimulation creates a sense of relaxation which also assists in reducing anxiety whilst recalling unpleasant events, thoughts, feelings, sensations with each set lasting approximately 10-20 seconds
During this phase, Clinicians select different EMDR protocols, depending on the clients presenting difficulties. These protocols are guiding scripts that have been specifically developed to target the individuals distress carefully and appropriately. For example, the protocol for phobia differs to that of the protocol for eating disorders. The purpose is to “Liberate the client from the past into a healthy and productive present”.
Phase five, is where the “smashed” pieces of memory are reprocessed. New understandings are developed which challenge the previously established thoughts, feelings, and physiological responses. These new understandings are installed in different “labelled containers”, committing the memory to well established, less distressing or distress free themes, or beliefs.
Phase six is the body scan, in this phase, the client is asked to be aware of their whole body, to ensure that the distress is not ‘stuck’ in a physiological response, i.e. it is not represented by physical distress or tension. If physical distress is identified, we return to phase four to ensure all distress is resolved, as would be so for any resistant thought, image or emotion.
In phase seven, the debrief occurs, requesting the client to be aware and record any distress or reprocessing that continues to occur beyond the session.
Phase eight is Re-evaluation, this phase ensures the original target has been resolved, identifying if new compartments or themes have been activated that require intervention, and ensuring that the client has adjusted appropriately to their new insights. The next theme or belief, image, emotion, physical sensation, identified during the initial assessment then proceeds along the same therapeutic path.
In EMDR, the focus is upon current distressing thoughts, feelings and sensations, rather than the traumatic event itself so it can therefore feel less intrusive than some other psychological therapies. Almost anyone is suitable for EMDR, but it should not be used as a stand alone approach. It takes some time to prepare individuals for EMDR, to ensure people are safe and secure to reflect upon challenging and distressing events, and to develop protective strategies to enable the individual to cope once this distress is exposed. Engaging in EMDR, just like engaging in any therapy, is challenging; however, with commitment and focus, the outcomes are to be celebrated as you live a more fulfilled life.