An introduction to EMDR therapy

by Gus Murray

Context and overview

Like many readers of Inside Out, my professional roots are in the humanistic and integrative psychotherapy tradition. As a teenager of the 1960s, I was influenced by the social movements of the time, so it is not surprising that I found my first conceptual home in the humanistic psychotherapy school, with its emphasis on individual freedom and self-determination, providing a counterpoint to the established psychoanalytic and behavioural traditions.

By the time I joined the Metanoia Institute in London to complete my master’s degree training, the movement towards integration of different orientations was firmly underway and so integrative psychotherapy became a dominant paradigm. From there on, the integrative perspective was to become a central influence for me as a practitioner and as a trainer.

However, a far bigger paradigm shift was also underway. This arose from the influence of emerging developments in neuroscience which placed a new emphasis on the role of the brain and body in human development and healing. The paradigm shift in psychotherapy has been summarised by Dr. Allan Schore (2008: 2):

I suggest that the ongoing paradigm shift across all sciences is from conscious, explicit, analytical, verbal, and rational left brain to unconscious, integrative, nonverbal, bodily-based emotional processes of the right brain. … I have suggested that nonconscious right brain affective processes lie at the core of the ‘implicit–emotional–corporeal self,’ the biological substrate of the human unconscious, and are central to a deeper understanding of the fundamental mechanisms that drive development, psychopathogenesis, and psychotherapy.

One of the implications of this for psychotherapy is to promote a more bottom-up approach emphasising the role of the embodied brain in the healing process. This paradigm shift provides a background and context within which Eye Movement Desensitisation and Reprocessing (EMDR) therapy has developed and grown over the past 30 years.

History and development
Like many things in life, EMDR therapy started with a chance occurrence. In the spring of 1987, Dr. Francine Shapiro, an American psychologist, had been diagnosed with cancer. While walking in the park, she experienced disturbing thoughts and feelings. Instead of trying to push them away or override them, she noticed that when she paid attention to them, they became less disturbing. She also noticed that while this was happening, her eyes were moving horizontally back and forth. When she experimented with doing this intentionally, she discovered that by paying attention to disturbing experiences and moving her eyes horizontally back and forth, the disturbance level decreased. When she subsequently brought her attention back to the experience, the disturbance level continued to remain low.

She shared her discovery with her professional colleagues, and the search to find an explanation began. Not surprisingly, the similarity with Rapid Eye Movement (REM) sleep was suggested. With the support of several research studies, this process remains one of the proposed mechanisms of action to explain the effectiveness of EMDR therapy. This suggests that alternate bilateral stimulations in EMDR therapy shift the brain into a memory processing mode analogous to that which occurs during REM sleep. Several additional mechanisms of action are also proposed (Murray, 2018).

Meanwhile, Dr. Shapiro and her colleagues undertook the development of clinical procedures and protocols for the delivery of EMDR therapy, as well as an ongoing programme of research into its operation and effectiveness. This was followed by the development of training programmes for practitioners and supervisors. EMDR, with its initial roots in North America, spread rapidly across the world. Europe now has 22,000 EMDR practitioners with 3,500 of these in the United Kingdom and Ireland. In 2013, EMDR was proposed as a therapy of choice by the World Health Organization (WHO) for children, adolescents, and adults who present with post-traumatic stress disorder (PTSD; WHO, 2013). As well as single incident PTSD, the World Health Organisation has included complex PTSD in its most recent classification (WHO, 2018). EMDR is similarly included in international practice guidelines in several countries including USA, Germany, France, United Kingdom, and the Netherlands. Research too has continued apace and more than three dozen randomised controlled studies have evaluated EMDR therapy for the treatment of trauma (EMDR Research Foundation, 2018). Beyond its use for PTSD and complex trauma, EMDR therapy is also used for helping people who suffer from anxiety, panic, depression, eating disorders, addictions, personality disorders, complex grief, chronic pain and many other emotional problems.

EMDR as a psychotherapy
Arising from several decades of psychotherapy practice and research, four key factors common to all effective psychotherapies, are proposed as necessary and sufficient for therapeutic change: (a) an emotionally charged relationship; (b) a therapeutic environment; (c) a rationale that provides a plausible explanation for the symptoms; and (d) a procedure to resolve the symptoms (Laska, Gurman, & Wampold, 2014).

The first two factors recognise the well-established contribution of the therapeutic relationship to psychotherapeutic outcome across a range of approaches (Norcross, 2011). This is also well recognised in EMDR therapy (Dworkin, 2013).

The remaining two factors highlight the importance of offering the patient a rationale that provides a plausible explanation for their symptoms as well as a procedure to resolve them. Over the past 30 years, EMDR therapy has evolved a very thorough rationale that can be used to help patients to understand their symptoms. This is complemented by a comprehensive set of clinical procedures and protocols for the delivery of EMDR therapy.

The Adaptive Information Processing (AIP) model (Shapiro, 2017) is used in EMDR therapy as a comprehensive framework to provide a rationale to explain patient symptomatology as well as proposing a path towards resolution. According to the AIP model, human beings are innately endowed with a physiologically-based information processing system that assimilates new experiences into existing memory networks. This model is based on the concept of neural networks, thus representing a paradigm shift from psychology to neurobiology. The AIP model (Shapiro, 2017) comprises 3 core principles:

i. Adaptive Information Processing (AIP)

ii. Dysfunctionally-linked information

iii. Adaptive Resolution with EMDR Therapy

I will now expand briefly on each of these.

(i) Adaptive Information Processing (AIP)
According to the AIP model, new experiences are processed and assimilated into existing memory networks. This occurs when neural networks carrying the incoming information can link with other neural networks in which existing resilience, adaptive capabilities, resources and experiences are encoded (see Figure 1). This reflects the Hebbian axiom: “Neurons that fire together, wire together” (Shatz, 1992: 12).

Figure 1: Adaptive Information Processing (AIP)

This helps to explain why only a small percentage of people who have a traumatic or difficult life experience go on to develop post-traumatic stress disorder. In very many cases, difficult life experiences can be processed to adaptive resolution using existing internal and external resources. The Adaptive Information Processing system is at work when we think about the experience, talk about it, dream about it, do something about it, as well as when we engage in activities to help release its impact from our bodies. We can be faced with many instances of this, such as the loss of a loved one, failing an examination, medical conditions, relationship breakdown, being passed over for promotion, and many more. Many of these experiences can be processed and integrated by drawing on our internal resilience and self- capacities as well as seeking support from other people and systems.

(ii) Dysfunctionally-linked information
In the face of trauma and other disturbing experiences, our innate processing system can become impaired or overwhelmed. This can arise from a trauma in our adult life, as for example when somebody is a victim of assault or rape. It can equally arise from developmental trauma and neglect which can often be repetitive and woven into the developing psyche. In such circumstances, experiences are encoded but remain fragmented and isolated in their original state-specific form, unlinked to existing adaptive neural networks thereby preventing them from being processed to adaptive resolution (Bergmann, 2008; see Figure 2).

Figure 2: Dysfunctionally-linked information

According to Dr. Bessel van der Kolk (2014: 180):

Normal memory integrates the elements of each experience into the continuous flow of self-experience by a complex process of association; think of a dense but flexible network where each element exerts a subtle influence on many others. [However]…. the sensations, thoughts, and emotions of trauma are stored separately as frozen, barely comprehensible fragments.

Consequently, these experiences remain susceptible to being triggered and re-experienced inappropriately in terms of time, place and context: “Being traumatized means continuing to organize your life as if the trauma were still going on – unchanged and immutable – as every new encounter or event is contaminated by the past” (van der Kolk, 2014: 53) For example, a put-down by a workplace colleague can be a trigger which sends a person back to relive unresolved experiences of being bullied at school. The strong, capable man can feel young, small and defenceless as if he was being confronted by the bully, back in the school yard.

(iii) Adaptive resolution with EMDR therapy
EMDR therapy facilitates the effective processing of traumatic or disturbing life experiences to adaptive resolution. This is achieved, firstly, by enabling patients to access their positive, adaptive neural networks that link to their external resources as well as to their internal capabilities and self-capacities. These positive resource states may consist of their own resilience and experiences of self-agency and positive self-regard, plus support networks with other people. It may also include cultural, spiritual, social or any other resources. While accessing their positive resource networks, patients are also enabled to access and activate memory networks holding dysfunctionally stored experiences. The protocols and procedures of EMDR therapy are then used to stimulate their innate processing system whereby the unlinked networks are ‘unlocked’ and the impaired linking and binding systems are repaired, facilitating access to adaptive resources (Bergmann, 2008; see Figure 3). The protocols and procedures of EMDR therapy will be described and illustrated more fully in the clinic practice sections that follow.

In summary, the Adaptive Information Processing model proposes that we are endowed with an innate neurobiologically-driven system that enables us to process experiences towards health and wellbeing. This system can become impaired or overwhelmed in the face of trauma and other disturbing experiences whereby memories of these experiences are encoded in isolated neural networks, unprocessed and unlinked to existing adaptive networks. In such circumstances, EMDR therapy can facilitate the effective processing of traumatic or disturbing life experiences to adaptive resolution.

The clinical practice of EMDR therapy
With the Adaptive Information Process providing the bedrock, the focus now moves to the clinical practice of EMDR therapy. The clinical practice of EMDR therapy is underpinned by key principles outlined below.

• Dual attention
  Dual attention is proposed as a primary mediator of EMDR therapy (Leeds, 2014). This involves remaining strongly oriented to present safety and resourcefulness while at the same time appropriately accessing the disturbing material. It is often summarised in the phrase: ‘keeping one foot in the present and one foot in the past’ This is a core feature of all effective trauma therapy and its facilitation needs ongoing and careful monitoring and regulation throughout the therapy process.

• Bilateral stimulation
  One of the more unique features of EMDR therapy is the use of bilateral stimulation (BLS). This is done primarily using bilateral eye movements with the additional options of using bilateral sounds and bilateral sensory tapping. Two consistent effects have been shown to arise from the use of bilateral eye movements:

  i. A de-arousal or calming effect – a shift from sympathetic to parasympathetic activation.ii. A decrease in the disturbance levels and enhanced access, retrieval and processing of disturbing memories (Leeds, 2014)

• Eight-phase protocol
  EMDR therapy utilises a structured 8-phase protocol to guide the therapeutic process. This provides a very good balance of structure and clinical flexibility in the treatment process. The standard protocol can be applied to the processing of past, present of future experiences.
• Regulation-focused
  EMDR therapy assists clients to maintain an optimum level of regulation by enabling them to monitor and modify their levels of hyper-arousal and hypo-arousal within the window of tolerance (Ogden et al., 2006; Siegel, 1999).
• Mindful attention
  Mindful focus enables us to pay attention to our own experiencing in the present moment. While processing disturbing experiences, instead of asking clients to talk about them, they are asked to simply notice them as they follow repeated sets of bilateralstimulation. One of the constantly repeated phrases is: ‘Notice that’.
• Relational
  As already described, EMDR therapy occurs in the context of an attuned therapeutic relationship. This is occurring at both the conscious and unconscious levels. As with other therapeutic approaches, acknowledging and attending to the relational dynamics is a core part of EMDR therapy.
• Bottom-up and top-down processing
  In the face of trauma and other disturbing experiences the frontal lobes go offline, and the limbic and brain stem areas take over (van der Kolk, 2014). Consequently, the traumatic experiences become manifest as emotional and sensory fragments – images, sensations and sounds. EMDR therapy provides a bottom-up focus in targeting and processing these emotional and somatic elements in a regulated and safe manner. It also utilises top-down interventions including psycho-education, mindfulness, identifying negative and positive cognitions, and accessing resource states (see Figure 4).

EMDR therapy in action with a case example
The EMDR 8-phase protocol provides the clinical framework to guide EMDR Therapy.

Phase 1 – History taking and treatment planning
Sandie (pseudonym), age 36, presented with severe anxiety, flashbacks, low mood, low self- esteem and social phobia. She linked her symptoms to an experience of workplace bullying by a colleague. She was out of work on certified sick leave. History-taking showed a stable family background but also an experience of prolonged bullying during post-primary school. On exploration, it was determined that Sandie’s recent experience of workplace bullying had reawakened (triggered) her earlier experience of school bullying.

Phase 2 – Preparation
The focus of this phase is to enable the client to get ready to access and process the disturbing material. It involves developing a therapeutic alliance, psychoeducation, as well as enabling the client to mobilise her internal and external resource networks to support her in accessing and processing the disturbing material. Through a friend, Sandie was already familiar with EMDR therapy and was motivated and aware. She had good family support and had two good friends. Mobilising her internal resources took some time; EMDR resource development and installation methods, including the use of bilateral stimulation, were used to assist this process.

Phase 3 – Assessment
This phase brings the disturbing material into focus. The client is assisted to identify a specific target experience including its primary components. This involves eliciting an image, current negative belief, desired positive belief, current emotion, and physical sensation.

Sandie focused on specific memories from her experience of school bullying and was able to call up relevant images, cognitions, emotions and physical sensations. Using a scale of 0 to 10, Sandie reported current moderate-to-high subjective disturbance (SUD) levels arising from these memories.

Phase 4 – Desensitisation
The focus of this phase is on reprocessing the disturbing experience to adaptive resolution. This is done by enabling the client to attend to the target memory from a position of present orientation and safety, while following repeated sets of bilateral stimulation. She is invited to notice what she is experiencing and report this between short sets of bilateral stimulation. Sandie experienced strong emotional and somatic responses during this phase – trembling and shaking, emotional arousal and release. These responses subsided as the work progressed. She also reported the images becoming less vivid and further away, as well as more positive thoughts spontaneously arising. Adaptive resolution in this phase is indicated by a SUD level of 0.

Phase 5 – Installation
Having reprocessed the target memory, the focus of this phase is to enable the client to install a relevant positive, adaptive core belief in place of the negative belief that arose from the traumatic experience. This, too, is assisted with bilateral stimulation. Sandie identified a number of important positive beliefs that she then installed in the course of her therapy.

Phase 6 – Body scan
This phase focuses on the somatic dimension of the disturbing experience inviting the client to complete a body scan to identify remaining areas of disturbance, tension or discomfort. Bilateral stimulation is used to assist the processing of these. Sandie used this phase very effectively to process residual somatic disturbances.

Phase 7 – Closure
In this phase the client is assisted to bring the session to a close in a safe and supportive way and receives appropriate direction to assist her in the coming days.

Phase 8 – Re-evaluation
This phase occurs at the beginning of the next therapy session. The client is asked to report on her experiences since the last session. The target memory is reviewed, and a determination is made on the next stage of the work.

Sandie reprocessed several target memories from her prolonged experience of school bullying over several weekly therapy sessions. It was then time to return to her experience of workplace bullying. This was assessed and while the disturbance had decreased, it continued to be significant. The workplace bullying was then targeted and processed using the procedure described above. This enabled her to process and resolve much of the shame and fear she was carrying as well as restoring positive self-beliefs. Arising from this, she decided to seek a transfer to a different section of the organisation and was then ready to return to work.

EMDR as an integrative psychotherapy
While EMDR is a comprehensive psychotherapy system in its own right, I would concur with the view that: “….the use of EMDR therapy can be fully compatible with most of the known psychological orientations” (Shapiro, 2018: 19). Indeed, EMDR therapy offers clinicians the scope to utilise interventions from many different approaches to assist the therapy process. Many of the techniques and resources that are used to assist the client to maintain regulation within the window of tolerance are drawn from the somatic therapies. Likewise, many techniques used in working with dissociative process are drawn from ego state approaches. For some clients, processing occurs in a reasonably spontaneous way along the lines described above. The role of the therapist then is to stay out of the way. However, for many clients, accessing the disturbing material can be difficult and processing can become restricted or blocked. In EMDR therapy, interweaves are used by introducing material from other approaches to ‘jump-start’ blocked processing rather than depending on the client to do it all.