March/April 2024

March/April 2024 Issue

When the Past Is Present
By Deborah L. Korn, PsyD
Today’s Geriatric Medicine
Vol. 17 No. 2 P. 20

The Promise of Healing With EMDR Therapy

In light of the global worldwide mental health crisis and increased need for effective trauma-focused treatments, eye movement desensitization and reprocessing, better known as EMDR, is receiving a lot of positive attention in the media. EMDR is recognized as an effective, evidence-based treatment for PTSD and other trauma-related problems. Clinicians, however, have been using this psychotherapeutic approach to successfully treat PTSD for more than three decades.

In the late 1980s, Francine Shapiro, PhD, the creator of EMDR, inadvertently discovered that mentally focusing on a traumatic memory while moving your eyes back and forth leads to a reduction of that memory’s emotional intensity and vividness. She subsequently developed a comprehensive protocol called “eye movement desensitization,” with back-and-forth eye movements incorporated as a key treatment component, and empirically confirmed its effectiveness with combat veterans and rape survivors suffering from PTSD.

Over time, Shapiro realized that her approach also facilitated the full “reprocessing” or restructuring of thoughts and emotions related to traumatic memories, leading to the transformation of one’s sense of self. In 1991, she renamed it “eye movement desensitization and reprocessing” and introduced the Adaptive Information Processing (AIP) model to explain its clinical effects. Today, EMDR is a comprehensive, transdiagnostic psychotherapy that continues to evolve to meet the needs of those seeking treatment in our changing world.

As our notion of what constitutes trauma has expanded, EMDR’s applications have also expanded. It’s now being used to address not just “big T” traumas, such as combat, assaults, and sexual abuse, but also “small t” adverse life events, including microaggressions, failures, losses, and humiliations, as well as the impact of traumatic separations, neglect, and deprivation, in both childhood and adulthood.

The AIP Model
Shapiro’s AIP model1 proposes that psychological problems (other than those caused by organic deficits such as genetics, injury, or toxicity) are due to a failure to adequately process memories of traumatic or adverse life experiences. It provides a framework for case conceptualization, assists EMDR therapists with treatment planning, and guides clinical decision-making.

Under ordinary, nontraumatic circumstances, we spontaneously engage in cognitive and emotional activities—talking, writing, reflecting, dreaming—that help us process experiences and newly formed memories. We integrate relevant, adaptive information held elsewhere within our memory networks (eg, “I always do the best I can”) as we try to make sense of challenging situations and emotions. As memories are processed and resolved, the past is moved fully into the past. We carry on with life with less distress and, hopefully, with the added value of lessons learned.

However, under traumatic circumstances, as we are flooded with terror, shame, or a sense of powerlessness, high levels of psychophysiological dysregulation can lead to an information processing system malfunction. Under these extreme conditions, memories get “locked” in the nervous system, frozen in time, along with their associated emotions, physical sensations, images, and beliefs.

PTSD
Held in isolation, away from other critical information, traumatic memories fail to get processed and resolved. Instead, they remain primed and vulnerable to being triggered by internal or external trauma-related cues such as sounds, sensations, and emotions. Days, weeks, or even years later, when these memories get reactivated, people find themselves unexpectedly hijacked by the past.

Some may experience full-blown PTSD—intrusive symptoms like flashbacks and nightmares, numbness and avoidance, and hyperreactivity and restlessness. For others, the reactivation of traumatic memories looks more like depression, anxiety, or a phobia. Sometimes, triggered memories manifest as physical symptoms such as pain, digestive distress, panic, or difficulty breathing. Many turn to maladaptive strategies such as drinking, drugs, and other compulsive or self-injurious behaviors in an attempt to manage their symptoms. More adaptive strategies focused on self-regulation, such as relaxation or cognitive restructuring exercises, often provide only temporary relief.

From an EMDR perspective, until relevant memories, conscious and unconscious, get fully reprocessed, clients remain at risk for relapse and continued suffering. They’re unable to respond adaptively to new situations, as they remain stuck in the past, reenacting old dynamics and reaching for outdated responses in challenging situations (eg, self-blame, avoidance, self-sacrifice).

The Self-Healing Mind
Shapiro often compared the brain’s information processing system to the body’s immune system, programmed to immediately mobilize toward healing in response to illness or injury. The AIP model suggests that an emotionally traumatized brain is capable of healing in the same way an injured body can. When a traumatic memory is “stuck” and not processing on its own, EMDR can access it and jumpstart the brain’s stalled processing, eventually moving the memory to a state of “adaptive resolution.” Along the way, older information from the client’s memory network, as well as new, relevant material (“It’s over,” “I’m safe”), gets linked in and integrated. Just as gardeners work to pull out annoying weeds from their roots rather than cutting them off up top, EMDR therapists get at their clients’ symptoms by addressing the root cause of their distress—unprocessed traumatic memories held in the nervous system.

The Eight Phases of EMDR Therapy
EMDR-trained therapists adhere to a standardized eight-phase protocol, though their approach with each client is individualized. In Phase 1, they take a thorough history and collaborate with their clients to organize a comprehensive treatment plan, identifying pertinent past traumatic experiences, current triggers and symptoms, and future behavioral goals for reprocessing.

One common approach to history taking uses a “floatback” strategy. Clinicians ask clients to attend to current feelings, sensations, and beliefs associated with a recent trigger situation. They then invite them to mindfully follow that experience through the body, back to an earlier time when they experienced something similar. In searching for reprocessing “targets,” clinicians often work to identify the “first” time and the “worst” time their clients remember struggling with an identified symptom (eg, thoughts, emotions, sensations).

In Phase 2, EMDR therapists work to establish a sense of safety and trust within the therapeutic relationship and introduce relevant psychoeducation and self-regulation skills. EMDR memory-focused work is not about “reliving” old traumas. Clients learn to maintain “dual attention” at all times, observing traumatic experiences from a distance while grounded in a present-day state of calm, oriented to the current environment and connected to their therapists.

In Phase 3, a “target memory” is identified and “activated” through a series of questions. Clients are asked to identify the image, emotions, physical sensations, and thoughts that arise as they attend to the worst part of the memory.

Then, in Phase 4, they focus on these core components of the memory and simultaneously attend to some form of “bilateral stimulation.” This might involve visually tracking the therapist’s fingers or a light back and forth, listening to alternating binaural tones, or receiving alternating taps on their hands—all of which have been shown to be effective forms of stimulation. Sets of stimuli are administered for about 30 to 60 seconds, though this might vary client to client and set to set.

After each set, clinicians ask, “What do you get now?” encouraging their clients to report on whatever emerges—images, thoughts, feelings, sensations, insights, and impulses, as well as any new content that arises. During sets, clients are reminded, “You’re a passenger on a train, just watching the scenery go by,” and they are told, again and again, “It’s old stuff; you’re safe in the present now,” to help them keep one foot firmly in the present while dipping the other into the past.

No two people reprocess memories in the same way, and the response to a set of stimuli cannot be predicted. Clients may experience waves of emotion—grief, anger, disgust, guilt, shame, or longing—or perhaps they’ll report new insights or thoughts, describe unfolding scenes, or feel an impulse to engage in some action. In the course of reprocessing, a client might imagine saying or doing something that they weren’t able to say or do back in time, such as expressing anger, physically fighting back, or fleeing. There are opportunities for developmental repair—offering comfort and validation to a “younger self”—and for the completion of “unfinished business”—speaking truth to an abuser or saying goodbye to a deceased loved one. Clients bear witness to their own stories, observing from a curious, nonjudgmental, present-day vantage point while simultaneously integrating new information and insights. They regularly report unexpected shifts in affect, cognition, and body-based experiences.

Once a target memory has been fully desensitized and is no longer disturbing to the client, a new, more positive cognition gets “installed” (Phase 5), and the body is checked for any remaining signs of distress with regard to the target memory (Phase 6). If tension or unease is detected, the reprocessing resumes with a focus on the remaining distress. Otherwise, attention shifts to activating the next identified target or closing the session.

All sessions end with a check to make sure that clients are regulated and ready to return to their lives and responsibilities, with some reflection on the changes experienced during reprocessing (Phase 7). When a target is not completely resolved, it’s reevaluated at the start of the next session to determine where to focus attention as the work continues (Phase 8).

Although EMDR therapy is described as an eight-phase process, treatment is not linear; therapists carefully monitor progress and use their clinical judgment and repeated measures to guide clients through the phases of treatment, cycling through various steps of the protocol again and again as needed with each presenting problem.

A Past-Present-Future Approach
Comprehensive EMDR treatment involves a three-pronged approach. First, (1) relevant past memories are addressed with the goal of eliminating any associated distress. Then, attention moves to (2) targeting present-day triggers and any remaining symptoms. And finally, (3) an imaginal rehearsal (“future template”) procedure is used to help clients prepare for known challenges and new initiatives. Ultimately, EMDR therapy increases clients’ capacities to reengage with the world in new and meaningful ways—with a greater sense of connection and renewed hope about the future.

EMDR Therapy’s Strong Evidence Base
Since Shapiro’s first study in 1989, there have been more than 30 randomized controlled trials demonstrating the effectiveness of EMDR therapy for adult clients with a diagnosis of PTSD. Studies have reported successful reductions in symptoms to below criterion levels2 at rates up to 95%.3 EMDR has been compared to many other therapies, but trauma-focused cognitive behavioral therapy (TF-CBT), another highly effective treatment for PTSD, has been its most common comparator in outcome studies. Most meta-analyses have revealed no differences in effectiveness between TF-CBT and EMDR in the treatment of PTSD, while several have found EMDR to be superior.4 Importantly, and unlike TF-CBT, EMDR does not involve recalling detailed descriptions of traumatic events, prolonged exposure, or homework. One meta-analysis5 found that EMDR was not only effective but also the most cost-effective of 11 therapies studied. There’s mounting evidence, as well, that EMDR therapy is a first-line treatment for individuals with a history of childhood abuse and neglect who meet criteria for a diagnosis of complex PTSD.6 EMDR’s efficacy has been formally recognized in the treatment guidelines of the World Health Organization, International Society for Traumatic Stress Studies, and the US Department of Veterans Affairs and Department of Defense, among others.

Range of Clinical Applications
EMDR is now being used with a wide range of psychological problems beyond PTSD and complex PTSD, including addictions, pain, anxiety disorders, obsessive-compulsive disorder, mood disorders, personality disorders, insomnia, and dissociative disorders.7 It’s considered a safe and efficient approach for treating individuals with comorbid psychosis8 and is also being used to reduce suicidality9 and self-injurious behavior.10 Additionally, EMDR is being applied across the lifespan, from children through older adults, and with different populations, such as first responders (doctors, nurses, emergency medical technicians), combat veterans, survivors of natural disasters and other critical incidents (eg, mass shootings), and crime victims. In medical settings, EMDR is being used to treat patients struggling with a range of issues and diagnoses, including cancer, multiple sclerosis, tinnitus, rheumatoid arthritis, phantom limb pain, and various medically unexplained symptoms. It’s being utilized in group, intensive outpatient, inpatient, and residential settings. In recent years, significant attention has been devoted to increasing the cultural competence of EMDR therapists as well, considering ways to adapt EMDR to meet the needs of marginalized communities and those facing discrimination and oppression related to race, religion, gender, and/or sexual identity.11 Finally, during the COVID-19 pandemic, it became clear that EMDR delivered virtually can be as effective as in-person treatment.12

How Does EMDR Work?
There are a substantial number of randomized controlled trials that demonstrate the positive effects of eye movements.13 Eye movements appear to reduce the intensity of negative emotions as well as the vividness of traumatic visual imagery. They also improve our ability to recall memories, lower our overall emotional arousal, and facilitate flexible thinking. There are also many hypotheses14 that attempt to explain exactly what is happening in the brain that leads to the observed reduction in distress and restructuring of cognitions. Shapiro favored the hypothesis that bilateral stimulation triggers a brain state similar to that seen in REM sleep when the negative emotions associated with memories are reduced, and the associations between memories are increased, leading to greater cognitive flexibility and insight.

At present, the hypothesis with the most empirical support is referred to as the working memory model. Working memory is employed whenever we actively focus on a task, such as counting backward or trying to hold an image in mind. However, working memory has limited capacity, which means that performing one task diminishes its capacity to engage simultaneously in another. This model proposes that, during EMDR sets, we are actually “taxing” working memory, and this, in turn, diminishes the negative emotions and vividness of the memory being held in mind.

These various hypotheses are not mutually exclusive, and it’s indeed quite possible, even likely, that multiple mechanisms work together to achieve EMDR’s impressive results. But regardless of what the mechanisms of action turn out to be, what’s clear is that EMDR is an efficient, effective, and accessible treatment option for people suffering with trauma-related symptoms.

For therapists interested in getting trained in EMDR therapy, opportunities abound. The EMDR International Association (EMDRIA), a US-based membership organization for EMDR-trained clinicians, is responsible for establishing and maintaining standards with regard to practice, research, training, and advocacy. Therapists who are curious about training possibilities can find a list of EMDRIA-approved training providers and upcoming training events at www.emdria.org/find-an-emdr-training.

Those interested in EMDR therapy for themselves or in referring someone for treatment can use the “Find an EMDR Therapist” directory on the EMDRIA website to locate practitioners in their area: www.emdria.org/find-an-emdr-therapist.

Finally, for a comprehensive guide to EMDR Therapy research, visit www.sonomapti.com/emdr-research or www.emdr.com/research-overview.

— Deborah L. Korn, PsyD, is a licensed clinical psychologist in private practice in Cambridge, Massachusetts, and an adjunct training faculty member at the Trauma Research Foundation. She’s been on the faculty of the EMDR Institute for the past 29 years and has authored or coauthored numerous articles focused on EMDR therapy, including comprehensive reviews of EMDR applications with complex PTSD. She’s an EMDR International Association-approved consultant, on the editorial board of the Journal of EMDR Practice and Research, and an international presenter and consultant on EMDR treatment for adult survivors of childhood abuse and neglect. Korn is the coauthor (with Michael Baldwin) of Every Memory Deserves Respect—a 2021 book about trauma, recovery, and EMDR therapy written for the layperson (www.everymemorydeservesrespect.com).

References
1. Shapiro F. Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. 3rd ed. New York: Guilford Press; 2018.

2. de Jongh A, Amann BL, Hofmann A, Farrell D, Lee CW. The status of EMDR therapy in the treatment of posttraumatic stress disorder 30 years after its introduction. J EMDR Pract Res. 2019;13(4):261-269.

3. Capezzani L, Ostacoli L, Cavallo M, et al. EMDR and CBT for cancer patients: comparative study of effects on PTSD, anxiety, and depression. J EMDR Pract Res. 2013;7:134-143.

4. Khan AM, Dar S Ahmed R Bachu R, Adnan M, Kotapati VP. Cognitive behavioral therapy versus eye movement desensitization and reprocessing in patients with post-traumatic stress disorder: systematic review and meta-analysis of randomized clinical trials. Cureus. 2018;10(9):e3250.

5. Mavranezouli I, Megnin-Viggars O, Grey N, et al. Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults. PLoS One. 2020;15(4):e0232245.

6. de Jongh A, Bicanic I, Matthijssen S, et al. The current status of EMDR therapy involving the treatment of complex posttraumatic stress disorder. J EMDR Pract Res. 2019;13(1):284-290.

7. Scelles C, Bulnes LC. EMDR as treatment option for conditions other than PTSD: a systematic review. Fron Psychol. 2021;12:644369.

8. De Bont P, De Jongh A, van den Berg DP. Psychosis: an emerging field for EMDR research and therapy. J EMDR Pract Res. 2019;13(4):313-324.

9. Proudlock S, Peris J. Using EMDR therapy with patients in an acute mental health crisis. BMC Psychiatry. 2020;20(1):14.

10. Mosquera D, Ross CA. Application of EMDR therapy to self-harming behaviors. J EMDR Pract Res. 2016;10(2):119-128.

11. Nickerson M. Cultural Competence and Healing Culturally Based Trauma With EMDR Therapy: Innovative Strategies and Protocols. 2nd ed. New York: Springer Publishing Company; 2022.

12. Bongaerts H, Voorendonk EM, van Minnen A, de Jongh A. Safety and effectiveness of intensive treatment for complex PTSD delivered via home-based telehealth. Eur J Psychotraumatol. 2021;12(1):1860346.

13. Lee CW, Cuijpers P. A meta-analysis of the contribution of eye movements in processing emotional memories. J Behav Ther Exp Psychiatry. 2013;44(2):231-239.

14. Landin-Romero R, Moreno-Alcazar A, Pagani M, Amann BL. How does eye movement desensitization and reprocessing therapy work? A systematic review on suggested mechanisms of action. Front Psychol. 2018;9:1395.