Eye Movement Desensitization and

Reprocessing (EMDR) for thePsychiatrist :

the basics to know about DR. LUIZA RANGEL, MD, MRCPSYCH,

CONSULTANT CHILD AND ADOLESCENT PSYCHIATRIST

EMDR EUROPE CONSULTANT AND CLINICAL SUPERVISOR

ROYAL COLLEGE OF PSYCHIATRISTS, APRIL 2017

Important NoteThis teaching session is only aimed to provide an overview onEMDR Therapy, its principles and on its effectiveness.It is NOT a formal training in this complex and powerful type oftherapy and in no way implies that the clinician will be preparedto use it with patients.Professionals interested in either knowing more about it or wishingto learn to practice it, should visit the site of the EMDR AssociationUK & Ireland and look for one of the available formal trainings.

www. emdrassociation.org.uk

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Overview Developed by Francine Shapiro in the early 1980s.Accidental finding that BLS led to an “opening up” of adaptiveemotional channels, leading to a change in the experience oftraumatic memories and the accompanying emotions, negativecognitions and body sensations

Shapiro’s (2001) AIP model conceptualizes EMDR as workingdirectly with cognitive, affective, and somatic components ofmemory to forge new associative links with more adaptive material.

EMDR facilitates the access of the traumatic memory network, so thatinformation processing is enhanced, with new associations forgedbetween the traumatic memory and more adaptive memories /information

Overview 2These new associations result in complete information processing,new learning, elimination of emotional distress, and development ofcognitive insights.

EMDR therapy uses a three pronged approach:(1) the past events that have laid the groundwork for dysfunction

are processed, forging new associative links with adaptiveinformation;

(2) the current circumstances that elicit distress are targeted, andinternal and external triggers are desensitized;

(3) imaginal templates of future events are incorporated, to assistthe client in acquiring the skills needed for adaptive functioning.

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Overview 3After successful treatment with EMDR, affective distress is relieved,negative beliefs are reformulated, and physiological arousal is reduced.Systematic research with formal treatment protocols has shown EMDReffective treatment for PTSD. Evidence-based treatment and NICE-recommended treatment for PTSD in children and adults.

EMDR is broadly used in psychological interventions with children,and it is applied to diagnosis/problems other than PTSD.

Use of EMDR with children requires adaptation of original protocoland specialized training. A range of techniques and strategies,according to age and context, can be used (i.e., story-tellingtechnique, sand tray etc).

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Overview 4EMDR is based on the idea that negative thoughts, feelingsand behaviours are the result of unprocessed memories.

The treatment involves standardized procedures that includefocusing simultaneously on (a) spontaneous associations oftraumatic images, thoughts, emotions and bodily sensationsand (b) bilateral stimulation that is most commonly in theform of repeated eye movements.

Like TF-CBT, EMDR aims to reduce subjective distress andstrengthen adaptive beliefs related to the traumatic event.

Unlike TF-CBT , EMDR does not involve (a) detaileddescriptions of the event, (b) direct challenging of beliefs,(c) extended exposure, or (d) homework

Overview 5 EMDR is a complex approach. It integrates elements of manytraditional psychological orientations and combines them in astructured protocol.

These include psychodynamic, cognitive behavioural, experiential,physiological (Siegel, van der Kolk), and interactional therapies(Kaslow et al).

Consequently EMDR contains many effective components, all ofwhich are thought to contribute to treatment outcome.

EMDR therapy has undergone more empirical testing than any otherapproach in the psychological treatment of trauma, and it has asubstantial body of evidence supporting its efficacy.

The theory behind itFrancine Shapiro (2001) proposed an “Adaptive Information Processing” (AIP)Model to explain both why traumatic memories can retain their emotional ‘sting’,as well as why EMDR usually results in less distress.

The affective, cognitive and physiological components of a traumatic memory havebeen stored in a faulty manner, due to the overwhelming emotional impact of thestressful event.

The natural processing of psychological experience is presumed to be alwaysheading towards greater adaptation, unless it is disrupted by traumatic experience.

A consequence of this faulty storage is that the memory fails to undergo our natural,“built-in” adaptive information processing which is seen with non-traumaticexperiences.

With the latter, the affective, cognitive and physiological components of the memory‘package’ typically lose strength in an adaptive manner with time.

It is presumed that this fails to occur with traumatic experiences, as evidenced by thehigh level of affective and autonomic arousal experienced by traumatised peoplewhen they recount their experience.

The theory behind it 2

The Adaptative Information Processing Model ( AIP Model)

The model also describes the development of personality, psychological problemsand mental disorders.

Simplified description of Shapiro’s theory:◦ All humans are understood to have a physiologically-based information

processing system.◦ The information processing system processes the multiple elements of our

experiences and stores memories in an accessible and useful form.◦Memories are linked in networks that contain related thoughts, images,

emotions, and sensations.◦ Learning occurs when new associations are forged with material already stored

in memory.

The theory behind it 3 AIP Model (Cont.)

When a traumatic or very negative event occurs, information processing may beincomplete, perhaps because overwhelming negative feelings or dissociationinterfere with information processing.This prevents connections with more adaptive information that is held in othermemory networks (or actually areas of the brain). For example, a rape survivormay “know” that rapists are responsible for their crimes, but this informationdoes not connect with her feeling that she is to blame for the attack.Memory is then dysfunctionally stored without appropriate (realistic/positive)associative connections and with many of its elements still unprocessed.When the individual thinks about the trauma, or when the memory is triggeredby similar situations, the person may feel like she is reliving it, or mayexperience strong emotions and physical sensations.A prime example is the intrusive thoughts, emotional disturbance, and negativeself-referencing beliefs of posttraumatic stress disorder (PTSD).

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The treatment itself - OverviewA goal of EMDR is to produce rapid and effective change while the client maintainsequilibrium during and between sessions.

EMDR involves attention to three time periods: past, present, and future.

Focus is given to past disturbing memories and related events, current situationsthat cause distress, and developing the skills / attitudes needed for positive futureactions.◦ Length of treatment depends upon the number of traumas and the age of exposure /

PTSD onset.

Single event adult onset trauma can be successfully treated in under 5 hours.

Multiple trauma victims may require a longer treatment time; exposure to persistenttrauma or ACEs during a child’s development, will need substantial amount oftime of treatment.

The treatment itself 2

With EMDR therapy, these items are addressedusing an eight-phase treatment approach:

Expected Treatment Duration usingEMDR

J. MORRIS-SMITH 2001

Singletrauma

Repeatedsingle traumas

Multiple traumaMultiple & complexattachment issues

Multiple, complex &chronic trauma

Attachment disorders

Temperament

vulnerability

Age of onset

Few sessions

Years oftreatment

impersonal

Personal

Overview of the eight-phase EMDRprotocol

PHASE PURPOSE PROCEDURE

History taking Obtain background information Identify suitability forEMDR treatment Identify processing targets fromevents in client’s life according to standardized three-pronged protocol

Standard history-taking questionnaires and diagnostic psychometrics ; Review of selection criteriaQuestions and techniques to identify 1) past events that have laid thegroundwork for the pathology, 2) current triggers, and 3) futureneeds

Preparation Prepare appropriate clients for EMDR processing oftargets

Education regarding the symptom pictureMetaphors and techniques that foster stabilization and a sense ofpersonal control

Assessment Access the target for EMDR processing by stimulatingprimary aspects of the memory

Elicit the image, negative self belief currently held, desired positivebelief, current emotion, and physical sensation and baselinemeasures

Desensitization Process experiences toward an adaptive resolution (nodistress)

Standardized protocols incorporating eye movements (taps or tones)that allow the spontaneous emergence of insights, emotions,physical sensations, and other memories

Installation Increase connections to positive cognitive networks Enhance the validity of the desired positive belief and fully integratethe positive effects within the memory network

Body Scan Complete processing of any residual disturbanceassociated with the target

Concentration on and processing of any residual physical sensations

Closure Ensure client stability at the completion of an EMDRsession and between sessions

Use of guided imagery or self-control techniques if neededBriefing regarding expectations and behavioural reports betweensessions

Reassessment Ensure maintenance of therapeutic outcomes andstability of client

Evaluation of treatment effectsEvaluation of integration within larger social system

FRANCINE SHAPIRO, 2014

The treatment itself 2Phase 1 - History-taking session(s).

Phase 2: Stabilization - Therapist may teach the client a variety of imagery andstress reduction techniques the client can use during and between sessions.

Phases 3 to 6 - a target is identified and processed using BLS.

It involves the client identifying four elements:

1. The worst part of the vivid visual image related to the memory

2. The negative belief about self related to that memory

3. Related emotions

4. Related body sensations.

The treatment itself 3The client is then instructed to focus on the image, negative thought, and bodysensations while simultaneously engaging in EMDR processing using sets ofbilateral stimulation.

These sets may include eye movements, taps, or tones. The type and length ofthese sets is different for each client.

At this point, the EMDR client is instructed to just notice whatever spontaneouslyhappens.

After each set of stimulation, the clinician instructs the client to notice whateverthought, feeling, image, memory, or sensation comes to mind.

Once the rating of distress subsides to 0, another target is chosen for processing

These repeated sets with focused attention occur several times throughout thesession. If the client becomes distressed or has difficulty in progressing, thetherapist follows established procedures to help the client get back on track

The treatment itself 4

When the client reports no distress related to the targeted memory (a SUDS of 0),(s)he is asked to think of the preferred positive belief that was identified at thebeginning of the session. At this time, the client may adjust the positive belief if

necessary, and then focus on it during the next set of distressing events.

Phase 7: closure - therapist asks the client to keep a log during the week. The logshould document any related material that may arise. It serves to remind the clientof the self-calming activities that were mastered in phase two.

Phase 8: consists of examining the progress made thus far.

The EMDR treatment processes all related historical events, current incidents thatelicit distress, and future events that will require different responses (The ThreePronged Approach)

What a session looks like…

What elements of EMDR mightcontribute to its effectiveness?

A number of treatment elements are formulated to enhance the processing andassimilation needed for adaptive resolution.

These include:

1. Linking of memory components - Simultaneous focus on the image of theevent, the associated negative belief, and the attendant physical sensations, mayserve to forge initial connections among various elements of the traumaticmemory, thus initiating information processing

2. Mindfulness : Mindfulness is encouraged by instructing clients to “just notice”and to “let whatever happens, happen.” This stabilized observer stance in EMDRappears similar to processes advocated by Teasdale (1999) as facilitatingemotional processing.

What elements of EMDR might contributeto its effectiveness? 2

3. Free association. During processing, clients are asked to report on any newinsights, associations, emotions, sensations, images, that emerge intoconsciousness. This non-directive free association method may create associativelinks between the original targeted trauma and other related experiences andinformation, thus contributing to processing of the traumatic material

4. Repeated access and dismissal of traumatic imagery. Brief exposures of EMDRprovide clients with repeated practice in controlling and dismissing disturbinginternal stimuli. This may provide clients with a sense of mastery, contributing totreatment effects by increasing their ability to reduce or manage negativeinterpretations and ruminations.

5. Eye movements and other dual attention stimuli. There are many theoriesabout how and why eye movements may contribute to information processing.

How does EMDR “work” ?Despite the advances in neuroscience which has been enabled by fMRIresearch in the last decade or so, little remains known of the neurologicalmechanisms of change associated with any psychotherapeutic approach.

EMDR is no different, in that the precise mechanisms of change can onlybe speculated upon.

Stickgold (2002) suggests that EMDR achieves its results by way ofreplicating the naturally occurring dream-based consolidation process viabilateral stimulation, which are common to both REM sleep and EMDR.

Panksepp (2012) proposed a potential neurological mechanism which couldexplain the oftentimes remarkable results of EMDR by linking itsmechanism within the broader memory reconsolidation process.

It is likely that any understanding of EMDR will have to incorporate recentfindings on memory reconsolidation process, as this phenomenon appearsto be central to ‘transformative’ psychotherapeutic models such as EMDR(Ecker et al, 2012).

While there is still some scepticism raised about the efficacy ofEMDR within psychology (Lilienfield & Arkowitz 2008), it isclear that this therapeutic approach has more than adequatelyfulfilled the requirements of an evidence based therapy.

Most psychological and psychiatric associations around the worldendorse EMDR as an evidence based approach to the treatmentof psychological trauma and PTSD.

This status was recently acknowledged by the World HealthOrganisation, which recommended this therapy as a first linetreatment option for psychological trauma based on the evidenceto its efficacy that it has shown

Is EMDR an effective treatment forPTSD?

Is EMDR an effective treatment forPTSD? 2

EMDR Therapy is recognized as an effective trauma treatment andrecommended worldwide in the practice guidelines of several internationalorganizations:

American Psychiatric Association (2004). Practice Guideline for the Treatment ofPatients with Acute Stress Disorder and PTSD: American Psychiatric AssociationPractice Guidelines.

EMDR is recommended as an effective treatment for trauma.

Israeli National Council for Mental Health: Guidelines for the assessment andprofessional intervention with terror victims in the hospital and in the community.Jerusalem, Israel. Bleich, A., Kotler, M., Kutz, I., & Shalev, A. (2002).

EMDR is one of three methods recommended for treatment of terror victims.

California Evidence-Based Clearinghouse for Child Welfare (2010). TraumaTreatment for Children: http://www.cebc4cw.org.

CREST (2003): Clinical Resource Efficiency Support Team of the Northern IrelandDepartment of Health, Social Services and Public Safety, Belfast. The management ofpost traumatic stress disorder in adults.

Is EMDR an effective treatment for PTSD?3

EMDR and CBT were stated to be the treatments of choice.

Department of Veterans Affairs & Department of Defense (2010). Clinical PracticeGuideline for the Management of Post-Traumatic Stress. Washington, DC. EMDRwas placed in the category of the most effective PTSD psychotherapies. This “A”category is described as “A strong recommendation that clinicians provide theintervention to eligible patients. Good evidence was found that the interventionimproves important health outcomes and concludes that benefits substantiallyoutweigh harm.”

Dutch National Steering Committee Guidelines Mental Health Care (2003).Multidisciplinary Guideline Anxiety Disorders. Quality Institute Heath CareCBO/Trimbos Institute. Utrecht, Netherlands.

Is EMDR an effective treatment forPTSD? 4

EMDR and CBT both designated as treatments of choice for PTSD.

Practice Guidelines of the International Society for Traumatic Stress Studies NewYork: Guilford Press. Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009).Effective treatments for PTSD. EMDR listed as effective treatment for PTSD, andwas given an AHCPR “A” rating for adult PTSD. This guideline specifically rejectedthe findings of the previous Institute of Medicine report, which stated that moreresearch was needed to judge EMDR effective for adult PTSD. EMDR use withchildren - AHCPR rating of Level B was assigned. Since the time of this publication,three additional randomized studies on EMDR have been completed (see below).

French National Institute of Health and Medical Research, Paris, France. INSERM(2004). Psychotherapy: An evaluation of three approaches. EMDR and CBT werestated to be the treatments of choice for trauma victims.

National Institute for Clinical Excellence.National Collaborating Centre for MentalHealth (2005). Post traumatic stress disorder (PTSD): The management of adults andchildren in primary and secondary care. London

Is EMDR an efficacious treatment forPTSD? 4

Trauma-focused CBT and EMDR were stated to be empiricallysupported treatments for choice for adult PTSD.

SAMHSA’s National Registry of Evidence-based Programs and Practices(2011) . The Substance Abuse and Mental Health Services Administration isan agency of the U.S. Department of Health and Human Services (HHS).This national registry cites EMDR as evidence based practice for treatmentof PTSD, anxiety, and depression symptoms.

United Kingdom Department of Health (2001). Treatment choice inpsychological therapies and counselling evidence based clinical practiceguideline. London, England. Best evidence of efficacy was reported forEMDR, exposure, and stress inoculation

Is EMDR an effective treatment forPTSD? 6

Trauma-focused CBT and EMDR are the onlypsychotherapies recommended for children, adolescentsand adults with PTSD.

World Health Organization (2013). Guidelines for themanagement of conditions that are specifically related tostress. Geneva, WHO. Trauma-focused CBT and EMDR are the only

psychotherapies recommended for children, adolescents andadults with PTSD. “Like CBT with a trauma focus, EMDR therapy aims toreduce subjective distress and strengthen adaptive cognitionsrelated to the traumatic event. Unlike CBT with a traumafocus, EMDR does not involve (a) detailed descriptions of

EMDR Effectiveness - Meta-analyses

EMDR therapy has been compared to numerous psychotherapy protocols.

It should be noted that Trauma-Focused CBT and Exposure Therapy use one totwo hours of daily homework and EMDR uses none.

The most recent meta-analyses are listed below:

Bisson, J. et al (2013). Psychological therapies for chronic post-traumatic stressdisorder (PTSD) in adults. Cochrane Database of Systematic Reviews 2013 – CBTand EMDR therapy are superior to all other treatments.

Bradley et al, (2005). A multidimensional meta-analysis of psychotherapy forPTSD. American Journal of Psychiatry, 162, 214-227. EMDR is equivalent toexposure and other cognitive behavioural treatments and all “are highly efficaciousin reducing PTSD symptoms.”

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EMDR Effectiveness - Meta-analyses 2

Davidson et al, (2001). Eye Movement Desensitization and Reprocessing(EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69,305-316. EMDR therapy is equivalent to exposure and other cognitivebehavioural treatments.

Lee, C.W. & Cuijpers, P. (2013). A meta-analysis of the contribution of eyemovements in processing emotional memories. Journal of Behaviour Therapy &Experimental Psychiatry, 44, 231-239. The effect size for the additive effect ofeye movements in EMDR treatment studies was moderate and significant. For thesecond group of laboratory studies the effect size was large and significant.

Maxfield, L., & Hyer, L.A. (2002). The relationship between efficacy andmethodology in studies investigating EMDR treatment of PTSD. Journal ofClinical Psychology, 58, 23-41. A comprehensive meta-analysis reported themore rigorous the study, the larger the effect.

EMDR Effectiveness - Meta-analyses3

Rodenburg et al (2009). Efficacy of EMDR in children: A meta - analysis.Clinical Psychology Review, 29, 599-606. Results indicate efficacy of EMDRwhen effect sizes are based on comparisons between EMDR and non-establishedtrauma treatment or no-treatment control groups, and incremental efficacy wheneffect sizes are based on comparisons between EMDR and established (CBT)trauma treatment.

Seidler et al (2006). Comparing the efficacy of EMDR and Trauma-FocusedCognitive-Behavioural Therapy in the treatment of PTSD: a meta-analytic study.Psychological Medicine, 36, 1515-1522. Both therapy methods tend to beequally effective in the treatment of PTSD.

Watts, B.V. et al. (2013). Meta-analysis of the efficacy of treatments forposttraumatic stress disorder. Journal of Clinical Psychiatry, 74, e541-550. doi:

10.4088/JCP.12r08225. CBT and EMDR were the most often-studied types ofpsychotherapy. Both were effective.

Is it effective for other clinical disorders?

EMDR was developed as a treatment for traumatic memories and research hasdemonstrated its effectiveness in the treatment of PTSD

Shapiro states that it should be helpful in reducing or eliminating other disordersoriginated following a distressing experience.

It is not anticipated that EMDR will alleviate fully the symptoms arising fromphysiologically based disorders, such as schizophrenia or bipolar disorder. However, case report studies suggest alleviation PTSD symptoms in patients suffering fromsevere mental illness.

In Shapiro, 2002, applications of EMDR are described for complaints such asdepression (Shapiro, 2002), attachment disorders (Siegel, 2002), social phobia(Smyth, & Poole, 2002), anger dyscontrol (Young, Zangwill, & Behary , 2002),generalized anxiety disorder (Lazarus, & Lazarus , 2002), distress related toinfertility (Bohart & Greenberg, 2002), body image disturbance (Brown, 2002),marital discord (Kaslow, Nurse, & Thompson, 2002), and existential angst (Krystal,Prendergast, Krystal, Fenner, Shapiro, Shapiro, 2002).

Is it effective for other clinicaldisorders? 2

In addition to studies assessing the effectiveness of EMDR in the treatment ofPTSD, phobias, and panic disorders, some preliminary investigations haveindicated that EMDR might be helpful in other disorders. These include:

- dissociative disorders (Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen,1995);

- performance anxiety (Foster & Lendl, 1996; Maxfield & Melnyk, 2000);

- body dysmorphic disorder (Brown et al., 1997);

- pain disorder (Grant & Threlfo, 2002); and

- personality disorders (Korn & Leeds, 2002; Manfield, 1998).

- phantom limb pain (Vanderlaan, 2000; Wilensky, 2000; S. A. Wilson, Tinker,Becker, Hofmann, & Cole, 2000).

All such applications should be considered in need of controlled research forcomprehensive examination.

BibliographyHenley, B (2015) -The EMDR Primer, 2015, SpringerPublishing Co Inc.Lanius, R & Paulsen, S (2012) - “The Neurobiology ofTraumatic Dissociation”, Springer Publishing Co.Panksepp, J & Biven,L (2012) – The Archaelogy of Mind.Shapiro, F (2001) - Eye Movement Desensitization andReprocessing : Basic Principles, Protocols and Procedures,Guildford Press, New York.Stickgold, R (2002) – EMDR: A Putative Mechanism forAction. J Clin Psychology, Vol. 58(1), 61-75.Van der Kolk, B (2015) -”The Body Keeps the Score’,Penguin.For an annotated list of research visit: www.emdr.com -

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