shapiro - emdr

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    1. Brhav. Thhrr. Erp. Psychmr. Vol. 10. No. 3. pp ?I l-217. 1989Prmred in Great Bntain.

    InxF-79lQ89 no0 + 0.000 1990 Pergamon Press plc.



    FRANCINE SHAPIROMental Research Institute, Inc., Palo Alto, California

    Summary The use of saccadic eye movements for treating post-traumatic stress disorder isdescribed. The procedure involves eliciting from clients sequences of large-magnitude,rhythmic saccadic eye movements while holding in mind the most salient aspect of a traumaticmemory. This results in (1) a lasting reduction of anxiety, (2) changes in the cognitiveassessment of the memory, and (3) cessation of flashbacks, intrusive thoughts, and sleepdisturbances. The procedure can be extremely effective in only one session, as indicated by aprevious controlled study and a case history presented here. It does not require a hierarchicalapproach, as in desensitization, or the elicitation of disturbingly high levels of anxiety over aprolonged period of time, as in flooding. Some speculations are offered concerning the basisfor the effectiveness of the procedure.

    A post-traumatic stress disorder (PTSD; DSM-III, 1980) is characterized by anxiety attacks,sleep disturbances, flashbacks, and intrusivethoughts - related to a traumatic event, aswell as by a variety of irrational beliefs (De-Fazio, Rustin, & Diamond, 1975). Two popu-lations susceptible to this disorder are sexualassault/molestation victims and war veterans(Burgess & Holmstrom, 1985; Figley, 1978), in

    both of which traumatic memories seem to becentral to the manifestations (Keane, Zimer-ing, & Caddell, 1985).

    It is widely believed in the behaviorallyoriented therapeutic community that successfultreatment of PTSD requires some form ofexposure to the traumatic cues to overcomeavoidance behavior and to allow for desensiti-zation (cf. Fairbank & Brown, 1987; Fairbank& Keane, 1982; Fairbank & Nicholson, 1987).

    Some have maintained that cognitive reassess-ment, in terms of redefining and findingmeaning in the event and alleviating inapprop-riate self-blame, is also a relevant aspect oftreatment (Janoff-Bulman, 1985). However, itis not apparent that either systematic desensiti-zation (SD) or flooding is particularly effec-tive; and some members of the therapeuticcommunity have voiced concern regarding theexposure of stress victims to the high levels ofprolonged anxiety used in flooding (Fairbank& Brown, 1987).

    Following encouraging clinical experienceswith the eye movement procedure on approxi-mately 70 clients and volunteers, a systematicstudy was made of 22 rape/molestation andVietnam veterans (Shapiro, 1989). In thisstudy, the subjects (ages 11-53 years: 2 = 37years) reported traumatic memories that had

    Requests for reprints should be addressed to Francine Shapiro, Ph.D., 14850 Oka Road I2 Los Gatos. CA 95030.U.S.A.

    Edirors nofe - The technique described in this article is out of the usual run. The results that are claimed in post-traumatic stress disorder are of great magnitude and rapidly achieved. It is very much to be hoped that the findings will beindependently replicated. I myself have been encouraged by observations with respect to three areas of continuingdisturbance in a case of post-traumatic stress disorder that I had largely overcome by other methods. One source ofdisturbance was the image of Mrs. K., a hostile insurance agent who was involved in the litigation following the causativeaccident. When asked to imagine Mrs. K., the patients anxiety level went up to 100 SUDS. This was not diminished by 20saccadic movements. However. 30 more rapid movements two minutes later brought the SUD level down to 0.Thereafter, the patient was consistently able to think of Mrs. K. calmly.


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    persisted for l-47 years (_I? = 23 years). Theyhad received previous therapeutic treatmentfor 2 months-25 years (a = 6 years). Theirpresenting complaints included intrusivethoughts, flashbacks, sleep disturbances, lowself-esteem, and relationship problems. A

    pivotal aspect was the memory of one or moretraumatic incidents. The dependent variables,measured at the initial session and one andthree months later, were: (1) anxiety level, (2)validity of a positive self-statement/assessmentof the traumatic incident, and (3) presentingcomplaints.

    The results of the study indicated that asingle session of the eye movement desensi-tization (EMD) procedure was sufficient todesensitize completely subjects traumatic

    memories and dramatically alter their cognitiveself-assessments. That is, while subjects in theplacebo group revealed little or no change intheir high anxiety level and low perceivedvalidity of their desired cognitions, the EMDtreatment group experienced a marked declinein anxiety, as seen in a pre-post shift of 7.45 to.13 on a O-10 Subjective Units of Disturbance(SUD) scale (Wolpe, 1982) and a concomitantincrease in rated validity of cognitions. Thistreatment effect was maintained virtually un-changed when assessed three months later andwas accompanied by behavioral shifts whichincluded the alleviation of the subjects prim-ary presenting complaints.

    Subsequent to this study, a number of newclients were treated for PTSD symptomatologyduring single desensitization sessions or mul-tiple therapeutic sessions. One of these casesis described here. First, however, a detaileddescription of the EMD procedure is pre-sented. Finally, potential underlying mechan-isms are proposed.

    General Procedure

    The effect of saccadic eye movements wasdiscovered accidentally by the author uponnoticing in herself that recurring, disturbing

    thoughts were suddenly disappearing and notreturning. Careful self-examination ascer-tained that the apparent cause was that theauthors eyes were involuntarily moving in amulti-saccadic manner when the disturbingthoughts arose. The thoughts disappeared

    completely and, if deliberately retrieved, wereno longer upsetting. The author then madeconscious use of these movements with avariety of volunteers and clients to exploresystematically their therapeutic possibilities.The present EMD procedure evolved from theobservations garnered during hundreds oftreatment sessions.

    The traumatic memory is treated by requir-ing that the client maintain in awareness one ormore of the following: (1) an image of the

    memory; (2) the negative self-statement orassessment of the trauma; and (3) the physicalanxiety response. Simultaneously, the therap-ist induces multi-saccadic eye movements byasking the client to follow the repeated side-to-side movement of the therapists finger.Although the optimal condition occurs whenall three representations are held simulta-neously in the clients consciousness, thepresence of any one of them can be sufficientto achieve full desensitization.


    The anxiety level associated with thetraumatic memories is assessed by means of the11-point (0 = no anxiety; 10 = highest anxietypossible) SUD scale (Wolpe, 1982). This cor-relates with objective physiological indicatorsof stress (Thyer, Papsdorf, Davis. & Valle-corsa, 1984), and is customarily used to moni-tor anxiety during the SD procedure.

    Since irrational beliefs are a part of thePTSD syndrome and cognitive therapy aimsto restructure them (DeFazio, Rustin, &Diamond, 1975; Keane et al., 1985), shifts inclients self-assessment of the traumatic inci-dent or their own participation in the event arealso monitored. The measure, which was de-

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    Eye Movement Desensitization 213

    vised by the author, is referred to as theValidity of Cognition scale (Shapiro, 1989). Itis a seven-point (1 = completely untrue; 7 =completely true) semantic differential scalethat aims to provide a rapid assessment of therelevant beliefs.

    Step-by-Step Procedure

    Clients are first asked to focus on thememory from which they wish relief and thento isolate a single picture representative of theentire memory (preferably the most traumaticpoint in the incident). It is unnecessary forthem to describe or discuss the memory orpicture in detail; mere awareness of the image

    will allow desensitization to proceed.In order to assess the belief statement aboutthe incident, clients are asked What wordsabout yourself or the incident best go with thepicture? Most express such beliefs as I amhelpless, I should have done something, orI have no control. For clients who havedifficulty generating an assessment statement,the therapist may suggest some alternativesafter asking them to describe their feelingsabout the past incident. Only those beliefstatements that are recognized by clients asclearly applicable to them and the incidentshould be used and, where possible, in verba-tim form.

    Clients are then directed to concentrate onthe traumatic picture and the words of thebelief statement, to (1) assign a SUD level tothem and (2) identify the physical location ofthe anxiety sensations. They are next askedhow they would prefer to feel and to supply anew belief statement reflecting the desiredfeeling (e.g., I have control, I am worthy,

    I did the best I could). They are then tojudge by means of the seven-point Validity ofCognition scale how true the new statementfeel s to them (i.e., their gut level response).Next, the folllowing instructions are given:

    What we will be doing is often a physiology check. Ineed to know from you exactly what is going on. with as

    clear feedback as possible. Sometimes things willchange and sometimes they wont. I may ask you if thepicture changes - sometimes it will and sometimes itwont. Ill ask you how you feel from .O to 10 -sometimes it will change and sometimes it wont. I mayask if something else comes up-sometimes it will andsometimes it wont. There are no supposed tos inthis process. So just give as accurate feedback as youcan as to what is happening, without judging whether itshould be happening or not. Just let whatever happens.happen.

    In part, these instructions are designed toreduce performance anxiety, confusion, andthe effects of potential demand characteristics.They are particularly important in light of thefact that clients will often find difficulty initiallyin accepting the changes that are occurring andwill make such statements as: This is tooeasy, . This cannot be happening; I must be

    blocking (i.e., the emotions are not asstrong); I must be doing something wrong -the picture is changing/Im having difficultybringing the picture up/I cant see it clearly.During the EMD procedure, the picture,anxiety level, and cognitive statement do in-deed undergo rapid alteration. Therefore,clients must be reassured that the process isproceeding normally and that they shouldJust let whatever happens, happen and re-port without judging whether it should behappening or not.

    Clients are then instructed to (1) visualizethe traumatic scene, (2) rehearse the negativestatement (e.g., I am helpless), (3) concen-trate on the physical sensations of the anxiety,and (4) visually track the therapists indexfinger. The finger is moved rap id ly and rhyth-mica l ly back and forth across the line of visionfrom the extreme right to extreme left at a 12-14 inch distance from the clients face, twoback-and-forth movements per second. Thedistance traveled by the hand on each sweep is

    at least 12 inches. Very rarely, clients mayrespond better to a diagonal movement acrossthe midline of the face from their lower right toupper left (i.e., chin-level to contralateralbrow-level). The back-and-forth movement ofthe therapists finger is repeated 12-24 times,each such grouping being defined as one set.

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    For the occasional client who is unable totrack the moving finger or finds this aversive,the therapist can use a two-handed approach ofpositioning each index finger on opposite sidesof the clients visual field at eye level andalternatively lifting them. The client is in-structed to move the eyes from one finger tothe other as each is raised.

    After each set of saccades, clients are askedto: Blank it (the picture) out and take a deepbreath. They are then instructed to bring upthe picture and words again, to get in touchwith the feeling generated, and to give a SUDSrating from 0 to 10. If the SUDS level doesnot decrease after two sets of saccades, theclient is asked, Did the picture change?, orWhat do you get now/Does anything else

    come up? If a new memory has been re-vealed, it is desensitized before returning tothe old picture.

    Any new memories reported are usuallyassociated with the trauma in some way.Frequently, they are (1) other examples of thesame type of occurrence (e.g., another incidentof molestation), (2) another event that islinked by the commonly shared belief state-ment (e.g., Im not worthy, exemplified by amolestation incident or a failure at school), or

    (3) other occurrences involving the same per-son (e.g., beating or molestation by father). Ifthe new memory is emotionally loaded, itshould become the new focal point and shouldbe desensitized before continuing with theoriginal memory. Upon returning to the latter,it will frequently be discovered that the SUDSlevel has dropped considerably.

    Clients are asked periodically, with respectto the picture, cognition, and memory, Whatdo you get now? Their answers are used asevidence of change, since they often revealnew insights, perceptions, or alterations ofthe picture (e.g., I didnt do anything wrong;The picture seems further away). If ananswer reveals that a new associated l i m i t i n g be-lief has arisen (e.g., I did something wrong,along with I have no control), this belief isincluded with the picture during the next set.

    If the new cognition is a positive one, clientsare directed to Think of that, along with thepicture, and then the therapist induces a newset of saccades. The instruction, Think ofthat (with respect to whatever new insights orobservations have emerged during the set)often causes clients to continue generating newinsights and cognitions that approximate moreclosely the desired self-statement. Only whenthe insights are no longer constructive (i.e., nolonger add to an understanding or emotionaladjustment to the situation) are clients directedto return to the original picture.

    If a reduction in SUDS level fails to occurafter two sets of eye movements, it is ex-tremely important to search for a mismatchof picture, cognition, or emotions. That is, if a

    new picture or memory has been revealed, itmay not fit the cognition already being used.Likewise, if the emotion has changed, thecognitive component may be incongruent. Forinstance, the cognition, It was shameful mayhave applied to the feeling of guilt which wasthe initial emotion associated with the trauma,but not with the feeling of sadness whichreplaced it. In order to continue the desensiti-zation process, the cognition is dropped com-pletely. The same is true if the picture becomes

    altered so that it is no longer congruent withthe cognition.Parenthetically, it should be noted that the

    traumatic picture may change to a more neu-tral one (e.g., the rapist disappears from thebedroom or a leering face changes to a smilingone), making it difficult or impossible for theclient to retrieve the original image. In thiscase, it is possible to resume the desensitizationprocess (assuming that it has ceased) by discon-tinuing the cognition or replacing it with thedesired self-statement. If the original picture orfacsimile can be retrieved, it is preferable tocontinue desensitization with it in mind ratherthan with the altered version. If the picturedisappears completely, clients are instead in-structed to, Think of the incident.

    If the SUDS level remains unchanged, butclients can identify a body location (e.g.,

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    Eye Movement Desensitization 21.5

    tightness in the stomach) for the feeling/emotion, they are instructed to concentrateonly on the body sensation while new sets ofsaccades are generated. They then usuallyreport a change of body sensation and theSUDS level decreases. When the body sensa-tions of anxiety cease changing or disappearentirely (as is most often the case), clients areinstructed to return to the picture of thetrauma and the standard EMD procedure isresumed.

    When the SUDS level reaches 0 or 1(generally after 3-15 sets of saccades), clientsbeliefs in the validity of the desired cognitionsare tested by asking, How do you feel abutthe statement [desired cognition]from 1 (completely untrue) to 7 (com-

    pletely true): Regardless of their assignedValidity of Cognition rating (i.e., even if it hasalready reached 7). clients are asked tovisualize the original picture, along with thedesired cognition, and another set of saccadesis generated. Then the question is repeated anda new measure taken. If self-rated validity ofthe statement consistently increases, this pro-cess is repeated. If another memory and/orcognition seems to be interfering, the entireprocedure is repeated on the new material.

    The latter situation is exemplified by aVietnam veteran who was attempting to acceptas valid the cognition, I can be comfortably incontrol (Shapiro, 1989). When asked to re-spond to the validity of the statement after theoriginal image had been desensitized, he said,I am not worthy to be comfortably in con-trol. This cognition of lack of worth wasrelated to a different trauma which needed tobe desensitized, and then still another trauma,having to do with failure, was revealed.When these two additional traumas were de-sensitized, the client assigned a rating of 7 tothe words: I can be comfortably in control.When no other trauma or competing cognitionis elicited and clients indicate that the positivecognition is installed (usually after one-to-three additional sets at a validity level of 6 or7) the EMD procedure is terminated.

    Follow-up sessions have consistently demon-strated that the picture and cognition remainaltered. Most often, the emotional level of0--1 SUDS is maintained, although occa-sionally a new emotion arises (e.g., anger,instead of the earlier anxiety). It appears thatthe predominant emotion will be desensitizedduring the first session, allowing other pre-viously masked emotions to surface. Veryoften this changing of emotions occurs duringthe initial treatment session, at which time theyare all desensitized. If the emotion surfaceslater, however, the EMD procedure can beused to desensitize it at that time.

    Case Study

    A 63-year-old women had been raped 15months previously. Her presenting complaintswere daily intrusive thoughts, flashbacks (in-cluding those consistently invoked by seeingthe guard dog that she had purchased after therape), inability to be alone, nightmares, and aself-described feeling of being spacey (i.e.,extremely forgetful of things that had comenaturally before, such as fastening seatbelts,remembering wallet and checkbook, etc.). Hersummation statement was, I have lost controlof my life and the details of my life.

    The therapist treated three memories of therape during a single 50-minute session: (1)seeing the masked rapist appear from aroundthe corner, holding a gun; (2) oral copulation;and (3) vaginal penetration. The openingcognition for all three was, Im over-whelmed; the desired cognition was, Itsover. The desensitization proceeded in stan-dard form, with the client holding in awarenessthe picture, cognition, and anxiety level. Theinitial memory was of the appearance of themasked rapist. The client provided an openingSUDS level of 10 which was reduced to 0(complete desensitization) in four sets, atwhich time she was no longer able to maintainclearly the original picture and was asked

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    Eye Movement Desensitizat ion 217

    desensitized, cognitions restructured, the pic-tures remain altered or difficult to retrieve, andthe therapeutic effects on presenting com-plaints persist.

    syndrome and post traumatic stress response. In A. W.Burgess (Ed.), Rape and sexual assauh: A research

    Multiple sessions have been necessary forsome combat veterans and for one sexual cult

    victim who had been abused over a seven-yearperiod. Nevertheless, one-to-three individualtraumatic memories can be treated in a singlesession which, for many PTSD victims may besufficient to eliminate the pronounced symp-tomatology. It must be emphasized, however,that while the present description containssufficient information to desensitize approxi-mately 60-70% of PTSD-related traumaticmemories, specialized and intensive training isnecessary to approach the highest success

    rates.The EMD procedure is novel and still in theprocess of refinement. To increase its credibil-ity in the therapeutic community it is necessarythat the successes be independently replicated.The outlook is promising in that therapists inboth the United States and Israel, having beeninstructed in the procedure, appear to beobtaining comparable results. Published re-ports are expected to appear in the comingyear.


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