Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures
In the land of treatments that are validated to work there are a few that stand out. Eye Movement Desensitization and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures is a guide to one of the most well validated: EMDR. It’s validated for treating trauma and depression. The book itself is written by the developer of the methodology, Francine Shapiro. It’s a comprehensive tome for clinicians who want to know everything that can be known short of receiving direct training and mentoring on the treatment protocol.
I’ve read and reviewed Brainspotting, which is a non-validated derivative of EMDR. As I implied in that review, staying focused on the core EMDR ideas seems appropriate for most people.
Tackling Trauma
Sometimes, simple quotes like, “It’s still an ugly picture, but not because I did anything wrong,” convey a profound wisdom. One of the things that keeps trauma victims stuck is the sense that they own some or all of what happened to them. When trauma victims realize that they have no need to take in guilt or shame because they’ve been harmed, it frees them to focus on healing.
A characteristic of unprocessed trauma is that it has the ability to intrude on the present. Instead of being woven into the neat story of our life, the trauma falls out as a random negative experience that may be relived as if it were in the present moment at any time. Any trigger can set off the chain of events that leads to the memory – a special pattern, a whiff of smoke or perfume, or something that looks vaguely familiar out of the corner of your eye. Trauma can be retriggered until it’s fully processed – which may be never. The good news is that even if trauma is never fully processed, coping skills can be developed to reduce the frequency and impact of the memory. It’s not that the memory goes away, it’s that the traumatic memory doesn’t trigger as much of a physiological response.
Adaptive Information Processing (AIP)
EMDR works, but it’s not entirely clear why it can demonstrate results so quickly. While some therapies, like cognitive behavior therapy (CBT), have been proven effective, they can take a long time to achieve results. Other therapies, such as psychodynamic therapy, have been proven to not be effective at treating PTSD, though some of them remain in widespread use. AIP posits that the way that we see the world is shaped by our prior experiences, and by reevaluating or improving our relationship with these experiences, we can see rapid changes in current and future behavior.
Bilateral Stimulation
Even though EMDR is founded on eye movement, the key seems to be bilateral stimulation – that is, stimulation of both the right and left hemispheres of the brain either through eye movement or through other senses such as auditory cues or even alternative kinesthetic stimulation. (This refers to tapping, by oneself or a helper, on alternate sides of the body or a pair of electro-mechanical vibrators placed in each hand that alternate between the two.) While other strategies for bilateral stimulation are clinically effective, eye movements, perhaps owing to their similarity to REM sleep, are more clinically effective.
The theory is that this bilateral stimulation causes different states that allow for better processing of information. Neurology has long known that the corpus callosum is important for information processing. (See Incognito, The Honest Truth About Dishonesty, The Blank Slate, and Noise.) It’s quite possible that the bilateral stimulation activates the corpus callosum and may help to synchronize brainwaves between the two hemispheres.
Trauma Black Holes
One of the problems with trauma is that repeated, untreated exposure to triggers has the potential to intensify the trauma, making it harder to be processed and easier to be triggered. We know that memories are associative. The initial trauma triggers during another situation, and now both memories are attached to each other. We remember our divorce and the moment we ran into our ex in the grocery store. (I’m purposefully picking a very tiny example.) It’s then possible that each visit to the grocery store will amplify the trauma because of the fear of encountering the ex again – and it was traumatic the last time. Each memory adds to the overall “mass” of the trauma and makes it harder to process.
Leon Festinger, in A Theory of Cognitive Dissonance, explains that when concepts are in conflict, one will move – the one that is the less connected or important than the other. If one trauma continues to be triggered and reexperienced, it will become larger, like a black hole. Black holes are simply a region of space that is so dense that even light cannot escape the gravitational pull. This is what happens to trauma left untreated – eventually, not even light can escape the gravitational pull of the trauma.
Over and Under Reactive
On the one hand, there’s no right way to respond to trauma just as there’s no right way to grieve. On the other hand, there’s a sense that some people are overreacting to an event and this leads Shapiro to believe there’s a blocked memory network – a trauma that’s not been exposed.
In some respects, she’s right. It’s an indication that something is going on. However, I hesitate to say that it’s a blocked memory, because there are so many other options – many of which are unrelated. (I had a similar criticism of Amy Edmondson’s assertion of a psychologically safe workspace in The Fearless Organization.) The other, perhaps bigger, concern is that this necessarily puts the therapist in the position of being the arbitrator of normal. That’s a bad place to be, as Carl Rogers explains in A Way of Being and Miller and Resnik address in Motivational Interviewing.
Negative Cognitions
The important part of working with people who have trauma isn’t the trauma itself but the impact it has on their perceptions and worldview. One of the markers that is concerning is when people describe themselves with negative evaluations in the present moment. There are two components to this. First, the obvious positive/negative evaluation. Here it’s important to separate which things are statements of facts – perhaps distressing facts – and which are evaluations.
The second, equally important consideration is whether the person is speaking in the past or whether they’re speaking of their current state. For instance, “When I was in my early twenties, I was a bad person,” is a categorically different statement than, “I’m a bad person.” (The implication being that they’re speaking of their current state.) A negative evaluation in the past isn’t particularly problematic – but present moment negative evaluations can prevent recovery from trauma. (See Compassion and Self-Hate for more.)
When people are evaluating themselves negatively in the present, they may not believe that they deserve to heal from the traumas that were inflicted upon them. While this may not logically make sense, it can be a barrier to taking steps to heal. Immunity to Change explains that sometimes these beliefs are hidden and can block the progress that the person consciously wants to make.
Barriers to Change
One of the challenges when trying to help people recover from their trauma is that staying in the trauma may be serving them in some way. For instance, those on disability receive a check that may go away if they get better. While it’s probable that the person can find a job that will be more rewarding and will pay better than the disability check, that logic isn’t persuasive if you’ve been on disability for a while. It’s what you know, and it’s safe.
Another concern, beyond the financial impact of a disability payment, is how someone self-identifies. If I identify as a wounded veteran, then what would it mean to be fully recovered? Can I keep my identity, or do I need to form a new one? Immunity to Change covers in detail how to discover what the barriers might be and what can be done to remove – or work around – them.
Mismatch Between Logic and Emotion
One of observations that can happen is that a person says one thing, and it’s clear they are not emotionally in the same place. It can be an eerie feeling when talking to someone knowing that something is just not right. It can be felt as an incongruency that can’t be ignored. Someone says they’re “fine,” yet their eyes are watering like someone who just got hit with pepper spray. These observations show the need to create space for the emotion to emerge (or recede) in its own time.
Another mismatch can occur when someone tries to recall an event that has a radically different affect associated with it. For instance, the loss of someone you’re close to has a negative, sad affect, but there are times when the baseline affect is excited, rushed, or anxious where the recalled memory is insufficient to override the current emotion. This typically happens as people are immersed in grief and try to recall happy times. It’s as if these memories skip off the consciousness like a rock skipped on still water.
Waiting on the Other Shoe to Drop
Sometimes, people become afraid for things too good. “If I’m too happy, I’ll be sorry.” They believe that something bad will happen – or they don’t deserve happiness. These dysfunctional beliefs may be constraining people in their current state and preventing them from growing. It’s as if they’re constantly on the lookout for something else to go wrong to prove that they don’t deserve happiness. Rational or not, this belief system can take hold and strangle off hope for improvement.
Dual Focus
If the point of EMDR (and other approaches) is to have the person go back through the trauma, how doesn’t this retraumatize them just like flashbacks? The answer lies in the development of a skill that EMDR calls “dual focus.” That is, the person recognizes both their current, objective, state and recalls the trauma simultaneously. Progressive exposure is a proven approach to trauma harm reduction. It basically increases the degree to which someone experiences the trauma. EMDR does this by regulating the emotions and the rate at which the memories start coming in.
Dual focus on its own is a powerful skill that allows people to acknowledge the past, including their fear, hurt, and confusion, while accepting their safety.
Losing Memories
One concern that is sometimes expressed when people learn that their memories will no longer haunt them is the worry that they’ll lose them. Even bad memories people don’t want to lose, because they believe to give up these memories would take away from who they are – and rightly so. However, the other concern is the loss of positive memories. They’re concerned that something will happen, and they’ll lose the good with the bad.
Reassuringly, there is no evidence that people will lose their good memories (or bad memories for that matter).
Retaining Appropriate Emotions
While EMDR targets unnecessary suffering due to trauma, it doesn’t help with healthy, appropriate emotions. If someone is grieving a loss, EMDR won’t stop that. It’s important to realize that while some emotions may be unpleasant, it doesn’t mean they’re not useful to us. EMDR isn’t designed to remove our emotions – it’s designed to address the processing problems that keeps us stuck in inappropriate emotions.
Memory Consolidation
Peter Levine lays out a comprehensive view of the relationship between Trauma and Memory in his book. James Pennebaker shares similar conclusions about how processing works in Opening Up. In the end, we need time to take our implicit memories that were laid down during a trauma and convert them to explicit, autobiographical memories. The need for a person-dependent amount of time to be able to process memories is one of the proposed reasons that CISM doesn’t work. (See Critical Incident Stress Management).
The point of working with trauma is to assist this conversion, but intervening too early can interfere with the internal processing and make it harder to make progress.
It’s How You Deal with It
It doesn’t matter what happens to you. What really matters is how you deal with it – or, said differently, what you do with it. We’re all going to experience trauma of some form or another. No one gets through life uninjured. What decides how we’ll live the rest of our lives is how we choose to deal with what has happened to us.
Self-Blame the Victim
It’s wrong, but it’s better than the truth. It’s the way that children of neglectful and abusive parents see themselves as the problem. Rather than accepting that their parents are defective and incapable of being the kind of parents that they need, the child sees that, if they are just good enough, their parents will finally give them the love they deserve. (See Trauma and Recovery for more.)
This same phenomenon occurs across time when trauma survivors believe that they have some role to play in the trauma that was inflicted upon them. Shapiro even shares a quote she used in therapy in response to a client blaming themselves for their trauma: “I’m confused. Are you saying that a 5-year-old girl can cause an adult to rape her?” The logic is the same. If we’re not responsible for the situation, then we can’t control our behavior and protect ourselves from it happening again. This is one of the foundations of Internal Family Systems (IFS), which says that we have internal protectors that are trying to prevent us from being harmed again. (See No Bad Parts.)
Real But Not True
While listening, we can – and should – acknowledge the emotion and how those sorts of emotions may be understandable, even if we don’t accept them as objective truth. Emotions are necessarily valid for that person. It’s not a good idea to say, “You’re not afraid.” It sounds nonsensical to even say it or write it. Even in the less enlightened time I grew up, people didn’t say you didn’t feel that way, but they did imply that some feelings weren’t okay. “If you keep it up, I’ll give you something to cry about,” was something that many children heard as I was growing up.
The problem is that even if we understand how someone developed an emotion or feeling, it doesn’t mean that it’s objectively the right – or best – feeling. While many people love animals like dogs and cats, one wrong experience can make people very afraid of them. We developed a good relationship with a delivery driver to the point we invited him to join us for Thanksgiving dinner. He politely declined. He was a lovely man who was deathly afraid of our dogs. For context, our dogs can walk with us off-leash and wouldn’t hurt a fly, but that didn’t change his feelings of fear.
Hopefully, this illustrates that just because the feeling is valid – because he had it – doesn’t make it objectively best or right. Said differently, it may not be adaptive to the circumstances.
Pay No Attention
There’s a famous line from The Wizard of Oz: “Pay no attention to that man behind the curtain.” While it wasn’t effective in the movie, sometimes, we can receive signals from others that a topic that has come up isn’t important. People try to minimize an aspect of their history or of their suffering. They say it’s “fine” or it’s “done” or that they’ve “worked through it.” While these are undoubtedly true in some cases, they’re not necessarily true in all cases. Strong attempts to avoid a topic can be a struggle for power and control, or they can be a signal that there’s something lurking in the darkness – something that should be addressed.
My general rule is that if you push in, and people become more insistent that there’s nothing there, I get more curious and concerned. If they move focus to other, seemingly productive, areas of conversation, it may truly be that it’s nothing and they simply want to focus time and attention in other areas.
The Monster Within
You can’t escape the monster within. It’s the refrain of those who are scared of their emotions and what they may do – or they’ve decided that they are a monster, and they deserve the suffering they have. (See Cognitive Behavioral Treatment of Borderline Personality Disorder.) Deserving their suffering is a kind of balance to the scales kind of logic, where if they’re causing harm to others, they should have suffering themselves. (See Compassion and Self-Hate.)
Addressing the sense that someone is irredeemable and therefore should be subject to suffering is work on changing the way they view themselves –and the process of redemption. It’s about helping the person understand that they’re not permanently stuck in their past.
It’s understanding that there are no cosmic scales upon which our deeds are weighed. There are no early transgressions that make us permanently bad, evil, or unlovable. Everyone can make positive steps in their life. Some of those steps may be coming to realize the tools that people have to manage their emotions so that they’re not as afraid of them.
One way to learn to control the monster within is through Eye Movement Desensitization and Reprocessing Therapy.