What is EMDR?
Eye Movement Desensitisation and Reprocessing
- Developed in 1980’s by Dr Francine Shapiro, a graduate psychology student at the time
- Elements of exposure treatment, CBT, psychodynamic etc
- Bilateral stimulation element unique
- Recommended by NICE as treatment of choice, along with trauma focused CBT, for post traumatic stress, EMDR equally effective but more rapid
Noticed that eye movements reduced the impact of some distressing personal problems she had been thinking about
Experimented with friends using eye movements – reported reduced distress.
Conducted clinical trial with people living with memories of abuse and war trauma
- Half of group treated with EMDR, half with traditional talking therapies
- EMDR group showed ‘significant and rapid recovery from symptoms and progressed significantly further than talking therapy group’
Now a significant body of research behind EMDR, probably more than any other single therapy
One foot in present, one in past – dual attention awareness to allow them to move between traumatic memories/events and the safety of the present
Not fully understood how it works, however, but it is not alone in this.
What it is Not…
- Not hypnosis – associative rather than dissociative
- It is not other ‘tapping therapies’ like EFT and TFT – theory behind these very different – energy meridians.
- However, in my view EFT and TFT may work because they have elements of EMDR – dual attention – both focusing on and focusing away from trauma – focus yet distraction allows safe processing?
Multiple traumas – more likely to develop PTSD
Reconciling what you think/what you feel – hypnosis in my view does this in a different way, but both act to process material, in a way in which CBT maybe doesn’t
Use of lightbars etc
Anything else from that?
Big t Trauma vs small t trauma
Evidence for cumulative ‘small’ events causing problems especially in childhood, especially where these are linked or have common themes such as abandonment, betrayal, attachment issues
What’s the difference between experiencing trauma and
having post traumatic stress disorder?
- Post traumatic stress disorder (PTSD) is a normal reaction to an abnormal situation
- Natural emotional response to a deeply shocking and disturbing experience Not everybody who is exposed to a devastating event or trauma will develop full PTSD
- Many will have some of the symptoms initially
- Used to only be diagnosed where a person endured a life threatening event
- Increasingly recognised that trauma can result from events which threaten psychological, not just physical, integrity
- Repeated adverse events (neglect, abuse) in childhood can cause complex trauma
- PTSD is more common in emergency services staff who witness repeated traumatic events
- PTSD alters brain structure, as well as body chemistry
- Has been described as a psychological injury, rather than mental health problem
- More likely to have concurrent mental and emotional health issues -
depression, anxiety, substance misuse problems, dissociative disorder
- Approx. 7.8% of Americans will experience PTSD at some point in their lives
- Women twice as likely to develop it
- 31% of people who have spent time in war zones develop it.
Factors which increase the risk of developing PTSD are:
- Nature of event - more ‘serious’ event, unpredictable or uncontrollable event
- More personal trauma – manmade as opposed to natural disaster, sexual victimisation, feelings of responsibility, and betrayal (i.e., abused by a relative, or let down by the authorities)
- Personal vulnerability factors – genetics, young age at the time, sustained trauma, lack of social support, attachment issues, other stressful events
- Greater perceived threat or danger, suffering, upset, terror, horror or fear
- Social environment producing shame, guilt, stigmatisation or self hatred, for example, a soldier who killed people in an unpopular war.
Symptoms of PTSD
Intrusive symptoms – reliving the experience
- Flashbacks – re-experiencing rather than just remembering the experience
- Intense distress at real or symbolic reminders of the trauma
- Intrusive thoughts and images
- Re-enactment in play
Avoidant symptoms – avoiding reminders of the events; numbing
- Avoiding situations which remind you of the trauma
- Being unable to express affection
- Feeling detached, cut off and emotionally numb
- Keeping excessively busy
- Repressing memories (unable to remember aspects of the event)
- Sense of a foreshortened future –seeing no point in planning ahead
- Does not talk about event
- Social withdrawal/school refusal
- Less interest in play/toys
Hyperarousal – a constant state of hypervigilance
- Disturbed sleep
- Extreme alertness
- Exaggerated startle response
- Irritability; aggressive behaviour
- Lack of concentration
- Sleep disturbance
- Temper tantrums
- Worsening performance at school.
May also get new fears – sleeping alone, going out of the house, going to the toilet
May also get new behavioural problems – regression to previous developmental stage, self-harm, eating problems.
Perry et al (1996) defined two continuums of behavioural adaptation in coping with trauma – the hyperarousal continuum (adrenergic) and the dissociative continuum (serotonergic)
Teichler (1997) found significant neurodevelopmental changes in abused children.
When do trauma(s) or Trauma(s) become PTSD or complex trauma?
- Young age – self doesn’t fragment, it never integrates
- Personal rather than impersonal trauma
- Repeat trauma
- Young person exposed to domestic violence/verbal abuse – Teichler (2006) found these can cause more problems with limbic reactivity and dissociation than sexual abuse
- Domestic violence also has association with increased risk of other forms of abuse (15x more likely to be abused – MacFie et al 2001), also shatters expectation of protection from attachment figure – nowhere to turn
- Personal vulnerability factors
- Quality of attachments
Quality of attachment an important resilience/vulnerability factor in children, young people and adults
An infant needs to development an attachment relationship with at least one primary caregiver for ‘normal’ social and emotional development
Behaviours likely to have evolved as a survival mechanism – meeting needs for safety, security and protection
- Bowlby presented research on attachment between 1958 and 1982
- Ainsworth 1960’s-70’s reinforced concept of attachment figure as a ‘secure base’ from which to explore the world and to return to the care-giving bond
Strange Situation – 12-18 month olds – caregiver left; child’s reaction on separation and being re-united, as well as to a stranger, was studied
Young humans form attachments easily, even in less than ideal conditions
Infants in early months direct behaviour at anyone – then discriminate
May attach to more than one person but generally there is a primary attachment figure
As a child progresses in age through middle childhood to an adolescent, attachment becomes more about the care giver being available if needed, rather than in close proximity
Caregiver sensitive, timely and responsive in interaction – quick, warm, coherent and predictable
Quality felt to be more important than quantity
Fathers, or others, may become primary attachment figure if they provide care and interaction
Adults who have made sense of and resolved their own trauma can provide secure attachment
Adaptive family structure.
Strange Situation: protests care-giver’s departure, comforted on return, may be comforted by the stranger but shows clear preference for care-giver
Caregiver gives little or no response to distressed child, encourages independence, seeks to discourage crying
Disengaged family structure.
Strange Situation: Little or no distress on care-giver’s departure, little or no response to return or to stranger
Unable to use care-giver as a secure base
Care-giver inconsistent in approach – can be appropriate, can be rejecting or neglectful, may respond more with increased attachment behaviour from infant
Enmeshed family structure.
Strange Situation: distressed on separation with ambivalence or even anger on care-giver’s return
Not easily calmed by stranger
Seeking then resisting contact – anxiety due to care-giver’s inconsistent behaviours
Disorganised attachment – identified later
Care-giver’s behaviour is frightened or frightening, intrusive, negative, mis-communication, even maltreatment – correlation with abuse
Contradictory behaviours such as approaching caregiver but facing away
Incongruent family hierarchy structure – role reversals.
Strange Situation: on care-giver’s return, may show stereotypical behaviours such as freezing or rocking
Insecure patterns of attachment compromise exploration and mastery, which can adversely affect development, yet they are also an appropriate response to care-giver unresponsiveness.
65% of children in the general population have secure attachments; 35% are divided between the other attachment patterns.
Patterns of attachment can change from secure to insecure due to stress or life events, or vice versa. However, an early secure attachment seems to have a protective function (Berlin et al, 2008) for later social interactions, stability and relationships.
Reactive Attachment Disorder – recognised diagnosis rather than an attachment style – controversial and thought to be rare though recognised by ICD-10 and DSM-IV. Characterised by markedly developmentally inappropriate and disturbed ways of relating to others; a failure to develop appropriate attachment bonds to primary care-givers during early childhood.
- Inhibited – failure to initiate or respond to interaction
- Disinhibited – indiscriminate sociability/excessive familiarity.
Complex Trauma vs PTSD
- Prolonged exposure to trauma in the context of having no viable escape route
- Resulting in lack of control, helplessness, disempowerment and affecting, or preventing the development of, a coherent sense of self and self worth
- Repeat/sustained traumatisation, usually at a young age rather than a one off event like a RTC
- Not formally included in ICD-10 or DSM-IV but may be in later revisions
- Forms of trauma associated with complex trauma (also referred to as C-PTSD) include sexual, physical, emotional abuse and domestic violence
- Associated with attachment disorder – why?
- Repeat victimisation more likely
Borderline Personality Disorder vs Complex Trauma
- I don't like this label!
- Many people with complex trauma will have the diagnosis of Borderline Personality Disorder (Emotionally Unstable Personality Disorder in ICD-10) - Mood instability, black and white thinking, impulse control problems, disturbance of sense of self which can lead to dissociation; unstable relationship patterns and, often, self-harming in some way.
- Generally diagnosed over age of 18 when personality traits considered relatively stable
- May have tentative ‘diagnosis’ of Emerging Personality Disorder before age 18.
- A high percentage of people with a diagnosis of BPD have a history of childhood neglect and abuse
- In one study, 91% of those diagnosed with borderline personality disorder had been the victim of some type of abuse; 92 percent had experienced severe neglect as a child (Zanarini et al, 1989)
- In another, 40 percent had been sexually abused (Shearer et al, 1990)
- In many cases, the victims reported being sexually and physically abused as children by more than one person (Ogata et al, 1990, Westen et al, 1990)
- However, there are a % of people with this diagnosis who have not been abused or obviously traumatised, for which the diagnosis of complex trauma would not fit.
- Dissociation is a continuum of normal experience – for example, we may all lose track of time while watching TV – some dissociation is healthy
- However, it is generally considered a detachment from reality rather than a loss of reality as in psychosis
- Do children or adults dissociate more?
- PTSD is considered by some to be on the dissociative spectrum
- At the more severe end are disorders such as Dissociative Identity Disorder
- Children and adults may dissociate to deal with abuse or traumatic memories.
How can EMDR help with PTSD and other problems?
- Specialist trauma therapy
- Recommended by the National Institute for Clinical Excellence for the treatment of PTSD
- Quicker, and just as effective as trauma focused cognitive behavioural therapy, for treating PTSD
- Enables people to effectively process traumatic events and memories, and the negative feelings associated with them, in a safe, controlled way reducing the emotional charge of the event, replacing negative thoughts, memories and feelings with more positive, adaptive thoughts and feelings.
Research evidence has also found EMDR effective for..
- Complex trauma
- Anxiety and phobias
- Chronic Pain
- Substance Misuse
- Attachment issues
- Eating disorders
- …anywhere where there is a component of distressing/traumatic life events. Also now being used for performance enhancement.
Use of EMDR
Part of therapy – not in isolation
Important client has coping strategies – resource building
Not generally a one session fix
Eye Movements/Bilateral Stimulation
- Significance of eye movements disputed
- Now generally accepted that other forms of ‘bilateral stimulation’ such as alternating sounds, hand taps may be as effective
- Suggests that bilateral stimulation of the brain is important
- Integrating/processing material in right and left brain
- Some people feel significance of eye movements is same as REM during sleep – process through dreams
- Some people prefer hand taps - easier to associate with material
- Eye movements may be preferable where people dissociate
- Technology available – light bars, buzzers – less personal, disrupt attunement.
Important to use protocol but also understand where with training you may deviate from standard protocol e.g., with children, chronic pain
Goals of Treatment in Young Children
- Encouraging regaining normal development, present activities and future goals
- Developing regulation of affect
- Establishing trust in body sensations
- Developing reciprocity in relationships; attunement, attachment
- Trauma reduction
- Increased capacity to respond realistically to future threat
- Normalising traumatic response
- Putting traumatic experience in perspective in narrative.
Goals of Treatment in Middle Childhood
- Establishing attachment
- Providing age appropriate education re: traumatic events
- Providing age appropriate emotional skill building and social stories
- Reviewing child’s understanding of this by questioning
- Reducing trauma
- Using concrete behavioural exercises and role play
- Encouraging fun and humour to motivate
- Educational and social opportunities to build strengths, skills and help with catch-up.
Goals of treatment in Adolescence
- Build attachment/social connectivity/where to get emotional support
- Reduce trauma
- Enhance skills and strengths and coping strategies
- Identifying when problem theirs/others
- Psycho-education and normalising traumatic experiences
- Developing a narrative and insight
- Building and enhancing future and future choices.
Eight Phase, Three Pronged Treatment
To address the past present and future aspects of a disturbing memory which has not been processed, and thus has been stored in a maladaptive way, which means that it or the sensory experiences associated with it are frequently ‘triggered’. When a distressing or traumatic event occurs, it may overwhelm the usual cognitive and neurological coping mechanisms, causing the brain to go into shock, and be ‘misfiled’. EMDR acts to:
- process (reduce emotional impact of memory, not forgetting but desensitising) – the past
- reduce the influence of the memory (current symptoms) in the here and now (not getting triggered and reactivating the feelings and sensations associated with the trauma) – the present
- allow clients to develop more adaptive coping strategies - the future
Phase 1 – History taking
- History taking – emphasised more and more as vital
- The younger the child the more to involve parents/carers in history taking and assessment of presentation/family system and impact of trauma (involve them as child wishes during treatment phase but should generally be out of young person’s sight line and agree level of involvement)
- Develop overall treatment plan
- Identify and clarify potential targets for EMDR - clusters
- Maladaptive beliefs identified, e.g, I can’t trust people, I can’t protect myself.
Phase 2 – Resource Building
- May use elements of this from beginning depending on distress tolerance, coping strategies, resilience (I often use hypnosis)
- Develop safe place – elicit comfortable feelings, positive sense of self, use slow eye movements (EMs) or hand taps to install this and strengthen positive feelings
- Helper figures/safety devices with younger people, good memory, achievement, safe person in the room
Phase 3 - Preparation
- Developing EMDR targets – ‘snapshot’ – target preferably image but could be ‘the worst part’, most representative of a cluster of events – floatback – ‘when was the first time you felt…’
- Negative core beliefs identified – safety, control, worth – ‘I’ statements, e.g., I’m unlovable; I’m not safe; I’m powerless – negative statement about the self which feels particularly true when the client focuses on target
- Identify Positive Cognition (preferred positive belief about the self when thinking about the target image/event), e.g., ‘I’m safe now’. ‘I’m lovable.’ (‘I can keep myself safe now’, ‘I can be loved’ ‘I did the best I could’)
- Identify SUDS (Subjective Units of Distress) associated with holding the target image and negative core belief together:
- 0 = no disturbance/distress, 10 – the worst imaginable
For younger children – ‘how big is the upset?’ show with outstretched hands, use artwork, smileys
- Identify Validity of Cognition (how true the Positive Cognition feels) from when thinking about the target:
- 1- completely untrue – 7 – completely true
- Establish whether EMs or other BLS preferred
- ‘Scenery from the train’ – moving through it rather than stopping
- Stop signal
- Targeting past tends to reduce distress in the here and now and anxiety about the future
- Ideally process worst event first – tends to have knock on effect on other linked events, but if unable to tolerate, start with less traumatic material
- Don’t NEED to know what they’re processing, but is helpful – non verbal therapy, can be useful where first languages differ - refugees
Phase 4 - Treatment
Experiential – no rights or wrongs
- Bodily sensation/sensory material
- ‘Random’ thoughts/material
- Links to other events
May change, may not
Client focuses simultaneously on:
- Target image
- Negative cognition
- Disturbing emotion or feelings
- Bodily sensation
Asked to ‘just notice’ what they experience.
EMs/hand taps for approx 15-30 seconds, looking out for changes which indicate processing – changes in breathing, facial expression etc.
Reassurance: ‘That’s it’ ‘You’re doing well’ ‘Just notice’ ‘It’s old stuff’ – can distract from experience.
Client to feed back what they noticed/experienced (younger children – can ask to draw it).
Don’t reflect on their experience: ‘Just notice that’ ‘Just go with that’.
Repeat process of EMs/hand taps then feedback
- Where ‘looping’ or ‘stuck’, or maladaptive beliefs emerge, therapist may use cognitive interweave to shift things forward/question, e.g., ‘Does a seven year old have that much power?’ ‘Who enjoyed the abuse more?’
- Where ‘nothing’ or positive experience, therapist may redirect client back to target memory and re-evaluate SUDS
- Aim to get SUDS down to 0 (or 1) – may not be possible with chronic pain or complex trauma
- May need to be repeated for other events after positive cognition installed for this event
Common to not process everything – incomplete session – ask what the most positive thing to have come up during the session is and do short set of EMs/hand taps on this
Finish with safe place/lightstream/containment exercise – can do slow short EMs or hand taps of safe place to install
Phase 5 – Installation - when processing on target has been completed
- Don’t just process level of distress but install positive cognition
- Has the positive cognition changed? Do they feel differently about target now? Does something else fit better?
- Hold together target and PC – VoC 1-7
- New sets of EMs/hand taps
- Repeat till VoC minimum of 6 preferably 7.
Phase 6 – Body Scan
- Only when all events have been processed
- ‘Scan your entire body. Notice anywhere you feel anything.’
- If distress, pain, discomfort or distress:
- EMs/hand taps until body scan clear or positive feeling
Phase 7 - Debriefing
- Review of progress
- Info and support
- Advised processing may continue through insights, memories emerging, dreams, different feelings – generally positive or tolerable
Phase 8 – Re-evaluation
- Checking in with client – any new sensations, insights or experiences in the week
- SUDS re-evaluated
- Ideally done when work complete too
- Memory remains but without the emotional charge or distress.
Children and Adolescents
Some young people 9+ can use standard protocol.
- Usually can use standard adult protocol
- Some difficulties envisaging positive future
- May under/overestimate strength of feelings
- Parent/carer present if wanted/needed
Younger children/those at young developmental stage may struggle with NC and PC or eye movements as opposed to hand taps.
Can be used at age of 2-3 but very much adapted, never EMs, more creative, parent/carer involved much more, target memory given by parent.
Age-related protocols of 2-3, 4-5, 6-8, 9-12 years.
Use creative means of expressing feelings, e.g., drawing memories, experiences or feelings.
Where someone has a learning disability, or regresses back in age when thinking about the trauma, or is stuck at the developmental age where the trauma happened, you would need to consider using the protocol appropriate to their developmental stage.
Keep in treatment window (window of tolerance) – not dissociated or hyperaroused – may need to increase window of tolerance to enhance resilience/resources.
Be wary of them closing eyes – dissociation; however, hand taps can ground.
- Brain may lose 50% of its normal volume with sustained and lengthy abuse/neglect
- De Bellis et al (1999) found children with PTSD to have 7% smaller cerebral volume.
- Also has capacity to make new connections – the younger, the better.
Children (also adolescents at a younger developmental stage) are more concrete in their experiences and might generalise less across experiences
Children/young people are more likely to be retraumatised if a further trauma occurs
Re-integrating and developmental catch-up occurs after processing of complex trauma – grow physically
Egocentric view of world leads to more guilt, shame
Grieving for losses can only occur after trauma work and before forming new attachments
Involve parents much more – where parents have been traumatised, work with them first
- Have to be able to support child appropriately (so do you as a therapist!)
- Need to believe and validate child’s experience
- Be able to tolerate child’s affect
- Managing their own emotional response so it does not override/divert from the needs of the child
Work with the family to:
- Stop the transmission of trauma
- To hand down to the next generation a story and not a trauma
- Enhance attachments.
- ‘Nothing new’
- Eye movements don’t play a central role – many champions of EMDR acknowledge this may not be the case – efficacy mainly due to exposure, though traditional exposure therapy and EMDR are quite different processes
Advise EMDRIA approved training
Advise only going to a therapist who has this training and who is a mental health professional
‘Hybrids’ of EMDR or ‘EMDR’ are being taught to hypnotherapists and other therapists; I am concerned about the possibility of this being taught in this way and used potentially for very serious issues.
EMDRIA approved training:
- Part 1 – basic training – ok for simple issues in psychotherapeutic context
- Part 2 – supervision and review day
- Part 3 - (advanced) – for more complex trauma, specific protocols such as pain.
Child and adolescent training
- Level 1
- Level 2
- After completing Part 3 general EMDR