http://jap.sagepub.com/Nurses Association

Journal of the American Psychiatric

http://jap.sagepub.com/content/4/5/140The online version of this article can be found at:

 DOI: 10.1177/107839039800400502

1998 4: 140Journal of the American Psychiatric Nurses AssociationJoan Barron, Mark A. Curtis and Ruth Dailey Grainger

Eye Movement Desensitization and Reprocessing  

Published by:

http://www.sagepublications.com

On behalf of: 

  American Psychiatric Nurses Association

can be found at:Journal of the American Psychiatric Nurses AssociationAdditional services and information for    

  http://jap.sagepub.com/cgi/alertsEmail Alerts:

 

http://jap.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

http://jap.sagepub.com/content/4/5/140.refs.htmlCitations:  

What is This? 

- Oct 1, 1998Version of Record >>

at US DEPT OF VETERAN AFFAIRS on March 19, 2014jap.sagepub.comDownloaded from at US DEPT OF VETERAN AFFAIRS on March 19, 2014jap.sagepub.comDownloaded from

140

Original Articles

Eye Movement Desensitization andReprocessing

Joan Barron, RN, CS, MN, Mark A. Curtis, RN, CS, MS, and Ruth Dailey Grainger, ARNP, CS, PhD

Joan Barron is a psychiatric clinical specialist at VeteransAffairs Medical Center in Dayton, Ohio.Mark A. Curtis is a psychiatric clinical nurse specialist atSouth Suburban Mental Health Associates in Bellbrook, Ohio.

Ruth Dailey Grainger is clinical director at Therapy ResearchInstitute, Inc., in Miami, Florida.

Reprint requests: Joan Barron, RN, CS, MN, PsychiatricClinical Specialist, Treterans Affairs Medical Center 4100West Third St., Dayton, OH 45428.

Eye movement desensitization and reprocessing (EMDR) is a therapeutic method thatwas developed in the late 1980s by Shapiro. EMDR is based on specific and repetitiverapid eye movements similar to those experienced naturally in rapid eye movementsleep. When the client holds in cognition the visual images, negative statements, and dis-tressing feelings associated with trauma memory and engages in EMDR at the sametime, a desensitization spontaneously occurs, with intensive information reprocessingleading to resolution. (J Am Psychiatr Nurses Assoc [1998]. 4, 140-144)

Western medicine has a long history of revolu-WW tionary discoveries leading to improved healthcare and quality of life. Recently, the most revolution-ary finding within the field of mental health has beenthe advent of the selective serotonin reuptakeinhibitors for the treatment of patients with depressionand the new antipsychotics for the treatment of

patients with schizophrenia.Therapeutic nonpharmacological techniques have

undergone a variety of changes such as movementfrom psychoanalysis to more brief, focused psy-

chotherapy. Most recently the advent of eye move-ment desensitization and reprocessing (EMDR) as anew psychotherapeutic modality has been viewed asexciting, promising, and revolutionary.Developed in 1987 by Shapiro, EMDR was noted to

have a dramatic effect in the treatment of patients with

posttraumatic stress disorder (Shapiro, 1989a). Al-

though exact mechanisms of action are currentlyunder study, clinical application of EMDR has demon-strated a high level of success with abating symptomsand improving coping ability. One tentative EMDRhypothesis suggests that a traumatic incident upsetsthe biochemical balance of the information-processingsystem in the brain. This imbalance prevents the infor-

mation from proceeding to an adaptive resolution, andthe perceptions of the trauma incident are locked intothe nervous system.As early as 1927, Pavlov proposed that when a trau-

matic incident occurs, the excitatory/inhibitory bal-ance, which is necessary for information processing tooccur, is disturbed. Currently, it is believed this

traumatization causes an overexcitation of a specificlocus of the brain, and an actual neural pathologiccondition occurs. Chemical &dquo;memory tracts&dquo; of the

trauma are formed in the limbic system. The strengthof traumatic memories may relate to the degree towhich certain neuromodulatory systems are activatedby the traumatic experience. Experimental and clini-cal investigations have demonstrated that memoryprocesses are susceptible to modulating influencesafter the information has been acquired (McGaugh,1990). Activation of the locus ceruleus-norepineph-rine system that projects to the amygdala in the lim-

at US DEPT OF VETERAN AFFAIRS on March 19, 2014jap.sagepub.comDownloaded from

141

During the interview the client-therapist relationship isassessed for trust and safety.

bic (emotional) system by frightening and traumaticexperiences may facilitate the encoding of memoriesassociated with the experiences. It is possible that

reproducing a neurobiological state similar to the onethat existed at the time of the memory encoding can

’

elicit the traumatic memory (Fogel, Schiffer, & Rao,1996).

It is possible that repetitive eye movements such asthose found in rapid eye movement (REM) sleep are thebody’s automatic information-catalyzing process, whichserves to restore balance and allow the traumatic over-

load to be resolved. The trauma pathology may be saidto &dquo;freeze&dquo; the information in its original anxiety-pro-ducing form, complete with the original image, negativeself-assessment, and negative affect. Shapiro (1989a)theorizes that the eye movements or other forms of

alternating stimulation to the hemispheres of the brainallow long-delayed learning to take place. &dquo;Undigested&dquo;or &dquo;unmetabolized&dquo; memories form blocks in the chem-

istry of the brain, tied in their own isolated neural net-works to the rest of the brain. Correcting these blocks,EMDR resolves or unfreezes this information. These

results are usually lasting over time (Shapiro, 1989a). Anumber of researchers have postulated that the REMstate serves to process information including emotional,stress-related, and survival material (Neilsen, 1991;Wilson, Becker, & Tinker, 1995). In addition, deliberate

instigation of eye movements may stimulate the corre-

sponding cortical functions, leading in turn to new&dquo;memory tracts&dquo; and thus to the

healing cognitive process. TheEMDR/REM hypothesis contin-

I ues to be researched and is not

necessarily correlated to the

observed treatment effects at this

time.

EYE MOVEMENT DESENSITIZATION ANDREPROCESSING MODEL

Shapiro describes eight phases of the EMDR model.

Phase One: Client HistoryDuring the interview the client-therapist relationship isassessed for trust and safety. The client’s level of emo-tional disturbance, presenting pathologic condition,and belief systems are explored. Adequate healthysupport systems are reviewed. General physical healthand neurological status is obtained. The potential forsecondary gain is also assessed. Targets for EMDR are

investigated.

Phase Two: Client PreparationThorough explanation of EMDR theory is essential.The client understands that he or she has the control

to stop the session at any time. Eye movements aretested for comfort with preference of direction. A safeplace is established through relaxation and visualiza-tion that may be used as an emotional catharsis when

processing trauma.

Phase Three: Client AssessmentThe client is asked to identify a target issue, which isa disturbing image, thought, or sensation identifiedwith a traumatic memory. Linked to the target memo-

ry, the client associates a negative cognition that

expresses the belief about himself or herself now. The

client relates a positive cognition of what the clientwould prefer to believe about himself or herself nowand rates how true this belief is on a Validity ofCognition scale of 1 to 7, where 1 is completely falseand 7 is completely true (Shapiro, 1989a). Currentemotions are identified. A second scale, SubjectiveUnits of Disturbance, rates from 0 to 10 how disturb-

ing the memory feels to the client now, where 0 is

neutral and 10 is the highest possible disturbance(Shapiro, 1989a).

Phase Four: DesensitizationThe client brings up the negative memory, negativecognition, and current emotions and follows the clin-

ician’s fingers with- his or her- eyes as they are moved backand forth. Movements may be

horizontal, vertical, or diagonalto client’s preference. Of note isthat side-to-side auditory or tac-

_ tile stimuli may also be used ifa visual pathologic condition

does not allow for eye movement. A therapist work-ing with an individual with a visual impairment suchas macular degeneration may use a side-to-side handtap to stimulate the EMDR response. Reassessment of

the Subjective Units of Disturbance scale occurs atthis phase.

Phase Five: Installation of the Positive

CognitionThe client’s original positive cognition is reassessed

for validity and with the eye movement technique isinstilled. The Validity of Cognition scale is used to

assess change in the belief.

at US DEPT OF VETERAN AFFAIRS on March 19, 2014jap.sagepub.comDownloaded from

142

Phase Six: Body Scan

The client recalls the original memory with the posi-tive cognition and scans the body for any unpleasantsensation. These sensations are targeted with addi-tional sets of eye movements.

Phase Seven: Closure and DebriefingAn explanation is given to the client that processing ofinformation may continue between sessions. A journalto log associated memories or feelings or new memo-ries or feelings as they occur is recommended. A back-up safety plan, such as contacting the EMDR therapistor other identified support system, should also be dis-cussed and in place should the client rapidly decom-pensate.

Phase Eight: ReevaluationAt this phase questions to be considered include: Hasthe target issue been resolved? Has associated materi-al been activated that must be addressed? Have all

necessary targets been reprocessed to allow the clientto feel at peace with the past, empowered in the pre-

sent, and able to make choices for the future? And

have desired behavioral changes occurred?

USE IN PRACTICEEMDR was seen as highly controversial when it wasfirst introduced, and many clinicians, particularly thosedeeply involved with their own preferred treatmentmodalities, were initially skeptical. As research hasrepeatedly demonstrated the efficacy of EMDR, it has

gained more acceptance in clinical areas (Jensen, 1994;Shapiro 1989b; Wilson, Becker, & Tinker, 1995, 1996).There has been an increased interest by third-partypayers and managed care organizations in usingEMDR-trained therapists to accomplish goals faster andwith less costly longer-term psychotherapy. Manyemployee assistance programs are using EMDR forworkplace violence, accidents, and critical incidents.The Federal Bureau of Investigation has endorsedEMDR along with critical incident stress debriefing forindividuals showing symptoms after a trauma

(Solomon, 1994).Initial clinical application of EMDR was generally

at US DEPT OF VETERAN AFFAIRS on March 19, 2014jap.sagepub.comDownloaded from

143

Memories of childhood or related

traumas emerge.

limited to posttraumatic stress disorder. As EMDR hasevolved, clinicians are using this method with a vari-

ety of symptom presentations. Many clients with earlytrauma histories have difficulty progressing in therapy.This may be partly due to early memories that influ-

Many clients with early traumahistories have difficulty progressingin therapy.

ence perception and a lack of coping skills for theclient to effectively deal with current traumatic or cri-sis situations. These perceptions and ineffective cop-ing skills then may be the primary basis for presentemotional difficulties. These clients often do well with

EMDR. Many nurse-psychotherapists have been

trained in EMDR, and some are conducting researchinto its efficacy with psychological and also physio-logical conditions (Grainger, Levin, & Allen-Byrd,1994).The use of EMDR requires a high level of compe-

tence by an advanced practice licensed professional,because EMDR is an adjunct to psychotherapy. EMDRrequires clinical judgment regarding its appropriateuse. EMDR has the potential of creating powerful reac-tions, and sometimes abreactions and a thinning of theamnesic barrier may occur. It is not uncommon for the

client to recall details of the target trauma of whichhe or she had been previously unaware on a con-scious level. The clinician

should assess ego strengthand must be able to arrange

hospitalization before usingEMDR in clients who would

be in jeopardy with outpa-tient treatment alone. It is important that the nurse

using EMDR receive proper training and supervisionin its use.

Referrals ’

A wide variety of clients are appropriate for EMDRsuch as those with posttraumatic stress disorder, anxi-

ety, phobias, depression, or any neurotic symptomaticresponse. Currently, EMDR network study groups andspecial interest groups have developed protocols forusing EMDR in such varied areas as dissociative iden-

tity disorder and dissociative spectrum disorders,enhancing human performance, preventing substance

abuse relapse, and dealing with symptoms of physicalillnesses including lupus and cancer. Research withEMDR is ongoing with survivors of natural and man-made disasters, smoking cessation, and drug addic-tion.

If a nurse has a client he or she thinks might bene-fit from EMDR, a discussion with a clinician trained inEMDR will help make this decision before making aformal referral. The names of local EMDR-trained clini-

cians and information regarding EMDR training can beobtained by contacting the EMDR Network, Inc., at

(408) 372-3900.

SUMMARYEMDR processes images, memories, associations,thoughts, and emotions that often flip rapidly througha client’s mind like shuffled playing cards. Memoriesof childhood or related traumas emerge. Some peoplecry out in rage, grief, or fright, reliving events. After itis over, clients are not simply desensitized and lessanxious; they have learned something. Their thinkinghas changed. It has been a common experience thatno matter how hard they try to recapture the previ-ously strongly felt emotional response, they are phys-iologically unable to. A &dquo;neurological event&dquo; has

occurred.

According to Shapiro (1995, 1996), EMDR is a validtreatment for treating patients with posttraumaticstress disorder. EMDR protocols are also being usedfor dissociative identity disorder, phobic disorders,substance abuse, body dysmorphic disorder, and

- performance enhancement.EMDR incorporates work

with disturbing images, sen-sations, thoughts, and emo-

- tions together with bilateralstimulation such as eye

movements and alternating tones or taps to shift trau-matic memories into a nondisturbing form. EMDR is

. not a simple technique and cannot be reliably or eth-ically used by merely reading a manual or seeing ademonstration. Formal training and supervised prac-tice are essential to develop the skills needed for safeand successful application of EMDR.

REFERENCESFogel, B., Schiffer, R., & Rao, S. (1996). Neuropsychiatry. Baltimore:

Williams & Wilkins.

Grainger, R.D., Levin, C., & Allen-Byrd, L. (1994, August). Treatmentproject to evaluate the efficacy of eye movement desensitizationand reprocessing (EMDR) for survivors of a recent natural disas-

at US DEPT OF VETERAN AFFAIRS on March 19, 2014jap.sagepub.comDownloaded from

144

ter. Presented at the American Psychological Association AnnualConvention, Los Angeles, CA.

Jensen, J.A. (1994). An investigation of eye movement desensitiza-tion and reprocessing (EMD/R) as a treatment for post traumat-ic stress disorder (PTSD) symptoms of Vietnam combat veterans.Behavioral Therapy, 25, 311-326.

McGaugh, J. (1990). Significance and remembrance: The role ofneuromodulatory systems. Psychological Science, 1(1), 15-25.

Nielsen, R. (1991). Affect desensitization: A possible function ofREMs in both waking and sleeping states. Sleep Research, 30, 10.

Pavlov, I.P. (1927) Conditioned reflexes. New York: Liveright.Shapiro, F. (1989a). Efficacy of the eye movement desensitization

procedure in the treatment of traumatic memories. Journal ofTraumatic Stress, 2, 199-223.

Shapiro, F. (1989b). Eye movement desensitization: A new treatmentfor post-traumatic stress disorder. Journal of Behavior Therapy &Experimental Psychiatry, 20, 211-217.

Shapiro, F. (1995). Eye movement desensitization & reprocessing:Basic principles, protocols, and procedures. New York: TheGuilford Press.

Shapiro, F. (1996). Eye movement desensitization and reprocessing(EMDR): Evaluation of controlled PTSD research. Journal ofBehavior Therapy & Experimental Psychiatry, 27, 209-218.

Solomon, R.N., & Kaufman, T. (1994, March). Eye movement desen-sitization and reprocessing: An effective addition to critical inci-dent treatment protocols. Paper presented at the FourteenthAnnual Meeting of the Anxiety Disorders Association of America,Santa Monica, CA.

Wilson, S.A., Becker, L.A., & Tinker, R.H. (1995). Eye movementdesensitization and reprocessing (EMDR) treatment for psycho-logically traumatized individuals. Journal of Consulting andClinical Psychology, 63, 928-937.

Wilson, S., Becker, L.A., & Tinker, R.H. (1997). Fifteen-month fol-low-up of eye movement desensitization and reprocessing(EMDR) treatment for posttraumatic stress disorder and psycho-logical trauma. Journal of Consulting and Clinical Psychology,65, 1047-1056.

at US DEPT OF VETERAN AFFAIRS on March 19, 2014jap.sagepub.comDownloaded from