EMDR is not just a treatment “intervention,” as we say in the therapy biz. An intervention is a specific technique or strategy that a therapist uses to help a client – teaching them deep breathing, for example, or using a thought record to track negative cognitions. EMDR is an entire treatment modality, an entire approach to treatment.
The theory behind EMDR is adaptive information processing (AIP), as developed by Francine Shapiro, the founder of EMDR. AIP posits that mental health symptoms originate from maladaptively stored traumatic experiences, and that for healing to occur, those experiences and memories have to be processed fully and then linked up to adaptive information. EMDR is the process that facilitates this. For example, an adult who suffered sexual abuse at the hands of a caregiver may have the maladaptive belief that they are to blame for their experience, and that they are shameful and flawed as a result. This belief leads to symptoms for this adult like low self-worth, depression, use of substances, and other self-harm behavior. When the traumatic memories of the abuse are processed using EMDR, the memories can link to the adaptive beliefs of “I am not to blame” and “I am a decent person,” for example. The intense feelings of shame and low self-worth are reduced and the adult feels less depressed.
So how does EMDR work?
The treatment model of EMDR consists of eight phases. I’ll discuss each in turn. It is important to note that the pace of completion of each of the phases varies widely based on the individual. If a client has a significant and complex trauma history, and experiences severe symptoms like self-harm, significant dissociation, or suicidality, the first two phases (the preparation phases) will be much longer. This is necessary to maintain safety for the client and to reduce the likelihood of destabilization. Too much activation of traumatic memory networks too soon can result in flooding, flashbacks, dissociation, and retraumatization. I
History taking and treatment planning. There are many ways to approach this phase, and it is essential to keep in mind that history taking can be very activating. Some therapists approach history taking in a more chronological way, while others approach history taking thematically. The purposes of history taking include identifying major traumas throughout the lifespan, as well as childhood neglect or abuse, if present, understanding attachment patterns and attachment injuries during childhood and beyond, gathering preliminary information about significant relationships and events in a client’s life – positive as well as negative – and screening for major mental health concerns, including any history of suicidality, self-harm, substance abuse, psychosis, and dissociation. It is particularly vital to screen for dissociation during phase 1. If a client experiences significant dissociation, the therapist must provide extended preparation (phase 2) in order to be sure the client can tolerate trauma processing. Therapists also assess a client’s positive supports and resources in order to decide how quickly to proceed to trauma processing. The therapist and client also decide collaboratively on the major goals of treatment – specific trauma memories to process, perhaps, or a symptom-focused approach – how to reduce nightmares, for example, or healing early attachment wounding. The therapist and client will come up with a list of targets – memories associated with a particular treatment goal.
Resourcing and preparation. The therapist assesses the client’s internal and external resources to help with stabilization during trauma processing. The therapist also installs positive resources using bilateral stimulation (BLS). Two resources that are traditionally installed for most clients are safe calm place – a visualization allowing a client to connect with the experience of safety and peace, which can help the client self-soothe if activated during processing. Container is the other resource that most therapists will install – visualizing a strong, solid, impenetrable container to hold difficult memories or sensations that arise during processing and that are not able to be fully processed by the end of a session. These resources can be used by a client on their own, can be used by a therapist to help a client return to their window of tolerance before leaving a therapy session, and can be used to help a client re-regulate in the midst of processing. Other common resources include installing a protector figure or a nurturing figure. Clients with more significant and complex trauma histories may need much more extended resourcing. Clients with complex trauma may never have had the experience of feeling safe in their bodies, or may feel entirely cut off from their bodies. It is essential for a client to know how to connect with positive body sensations prior to beginning trauma processing. This process can take months or even years for someone who is a survivor of complex trauma.
Assessment. This is a quick phase that should only begin when the intention is to move immediately to phase 4, reprocessing, as soon as phase 3 is complete. A therapist should not begin phase 3 at the end of a session and end the session without proceeding to phase 4. Phase 3 involves activating a target chosen collaboratively by the client and the therapist and then moving quickly into processing. Activating a target memory involves bringing up an image of the worst part of the experience (I often say, “if you could take a polaroid of the worst moment of that memory, what would be in that picture?”), come up with a negative cognition that describes what they believe about themselves when recalling that memory (“I’m unlovable, I’m a failure, I’m responsible, I’m shameful, etc.), come up with a positive cognition they would rather believe about themselves when recalling that memory (I am worthy of love, I’m a good person, etc.), connect with the emotions that accompany that memory, connect with the body sensations that accompany that memory, and then move immediately to phase 4. A therapist I have consulted with often says that assessment is when we “kick the hornet’s nest” to activate the memory, and as soon as the memory feels activated for the client, to move directly to reprocessing.
Reprocessing. This is the phase that most people think of when they think “EMDR.” As you recall from phase 3, assessment, we have now “kicked the hornet’s nest” through a series of questions – image, negative cognition, positive cognition, emotions, and body sensations, along with a Subjective Units of Distress (SUDS) score of 0-10. A SUDS score is the client’s rating of how disturbing the memory is, from a 0 (not disturbing at all) to a 10 (the worst disturbance imaginable). The SUDS rating helps the therapist track how well the memory processing is proceeding. The goal is to get a target memory down to a SUDS of 0. Once the memory is activated, and the therapist has taken a SUDS score, the therapist begins the bilateral stimulation (BLS) of the client’s choice. Bilateral stimulation allows the client to maintain dual attention – a foot in the present and a foot in the past, in the memory – and also facilitates the movement of the memory. Bilateral stimulation involves some sort of left-right sensory input. This can be eye movements – the EM in EMDR – your eyes moving from left to right, following the therapist’s fingers, or sometimes a pointer or a light bar. This can also be auditory tones, alternating between the left and the right ear, or tactile – either the client taps on their own knees or shoulders, alternating left to right, or they can hold buzzers that alternate buzzing on the left and the right. Bilateral stimulation alternately engages the left and the right side of the brain, and is thought to mimic the eye movements that happen during REM sleep, the phase of sleep during which memories from the day are processed and, ideally, stored. If a traumatic experience happens that is not attended to – that is, the person does not receive care and attention to help make the experience less frightening – the memory is maladaptively stored and can continue to cause symptoms and flashbacks until it is processed in EMDR.
So, the therapist begins BLS. Usually, each BLS set involves 24-36 full passes – left to right and back again counts as 1. The pace is pretty quick, as opposed to BLS during resourcing, which is slow and only tends to happen in sets of about 6-12 passes. The therapist will stop the BLS or tell the client to pause, if the client is self-tapping. Then the therapist will ask, “what came up?” or “what did you notice?” or something to that effect. The client will then share, briefly, the major theme of what emerged during the passes – maybe a change in the image, a thought, another memory, a body sensation, an emotion – there is no “wrong” answer. The information the client provides helps to guide the therapist about what to do next – whether to continue processing with limited feedback from the therapist, whether to ask a question or to redirect the client slightly if they seem to be stuck, or maybe whether to return to the target to check the progress of the intensity of the target. If the client reports that the SUDS of the memory is a 0, processing stops there, and the therapist moves on to the next phase, installation.
Phase 5: Installation
When the client reports that the memory has reduced in intensity to a 0 on the SUDS scale, the therapist will install a positive cognition connected with the target image. The client will have come up with a positive cognition during assessment – a positive thought that they would like to think about themselves when thinking of the target memory. For example, if a client’s memory is of failing out of an important class in college, their initial negative thought about the memory may have been “I am a failure” or “I can’t do anything right” or “I am defective,” or something like that. Now that the memory is a 0, their positive cognition may be something like “I can handle challenges” or “I am competent in many areas” or something. The therapist will ask the client how much they believe that statement, on the validity of cognition (VoC) scale of 1 to 7 – 1 being “I don’t believe it at all” and 7 being “I completely believe it.” If the client reports a 7, the therapist will ask the client to think of the target image of the memory while also thinking about the positive cognition, and add the client’s chosen method of BLS. The therapist will use slow, short sets of BLS, like during resourcing and preparation. If the client does not respond a 7, the therapist will have the client use some longer, faster BLS sets to see what is keeping the positive cognition from being a 7, and continue until the client reaches a 7. If the client struggles to reach a 7, there may be something blocking the memory from processing fully, and the therapist and client may need to return to phase 4, reprocessing, to investigate what could be blocking progress.
Phase 6: Body Scan
After reaching a 0 SUDS and a 7 VoC score, the therapist will ask the client to scan their body for any residual negative sensations or disturbance. If the client notices any, the therapist will then begin fast and long BLS sets to try to process out any additional disturbance. When the client reports that their body feels clear, the memory has reached a 0, 7, clear and is fully processed. If the client is struggling to feel clear in their body, it is possible that there is a blocking belief that is getting in the way of fully processing the memory. The therapist and client should spend time attempting to discern what is blocking the processing.
Phase 7: Closure
When a session comes to an end, either with a memory fully processed or with a partially processed memory, it is essential to return the client to a calm and regulated state before ending the session. The therapist can do this in a number of ways – using one of the client’s resources, like safe calm place, or using a container to contain thoughts, memories, and emotions that may have been activated. The container image allows clients to “store” these thoughts, feelings, amd memories until they need to be accessed in a therapy session. When
they are stored, they do not dysregulate a client between sessions. The therapist should also educate the client about how other thoughts, memories, body sensations, and feelings could emerge between sessions, and what to do to manage them.
Phase 8: Re-evaluation
When a memory has been fully processed in a previous session – the client reaches a 0 SUDS, a 7 VoC, and a clear body scan – the therapist should check in with the client at the beginning of the next session to see if anything has changed with the memory in the intervening time between sessions. If some disturbance has re-emerged, the therapist and client should re-engage in processing the memory and the therapist should be curious about what may be blocking the memory from processing fully. If the memory is still a 0, 7, clear, great! It is time to move on to the next target memory for reprocessing. Go back to phase 3 and start again.
Please feel free to comment or reach out to me if you have any comments or questions about EMDR! I love talking about EMDR and its life-changing capabilities.