It may be argued that two millennia of epistemological apocrypha- from Hippocrates and Plato’s challenge to Aristotelian thinking that the brain is the center of how we behave rather than the heart, to the post-Darwinian refutation of Locke’s “tabula rasa” (that we are born ‘blank slates’)- has been recapitulated in fifty short years of neurobiological research, now enabling a thorough understanding of how and why eye movement desensitisation and reprocessing (EMDR) works.
This article aims to summarise the findings and outline the Australian EMDR journey.
The EMDR timeline
What is EMDR?
Even when I remember I am afraid and trembling taketh hold on my flesh.
Job xxi, 6.
I’m not sure what the trouble was, that started all of this;
the reasons all have run away, but the feeling never did.
Bright Eyes, Lua. (2005)
Put simply, EMDR harnesses our innate ability to learn from negative experiences. Whilst it doesn’t get rid of bad memories, it splits off the fear/distress and sharpens the images, retaining an easily accessible snapshot for future reference- we have wised-up.
To paraphrase Shapiro(6.):
The high level of arousal engendered by distressing life events causes them to be stored in memory with the original emotions, physical sensations, and beliefs. The flashbacks, nightmares, and intrusive thoughts of PTSD and other adverse life events are prime examples of symptoms resulting from the triggering of these memories.
Sufficient processing of those accessed memories within the standard three-pronged EMDR therapy protocol brings about adaptive resolution and functioning. It is conjectured that processing the targeted experiences transfers them from implicit and episodic memory to explicit and semantic memory systems.
The originally experienced negative emotions, physical sensations, and beliefs are altered as the targeted memory is integrated with more adaptive information. What is useful is learned and stored with appropriate affective, somatic, and cognitive concomitants.
Consequently, the disturbing life experience becomes a source of strength and resilience.
If ’10 tips to boost your resilience’ may be seen as a bug fix for the modern world, EMDR is the full upgrade, and arguably portends evolutionary change.
Stickgold(10.) gets a little more technical:
Declarative memories, those which we can “remember,” are initially stored in the hippocampus and related limbic brain structures as “episodic memories.” In the case of emotional events, the amygdala links the episodic memory to these emotions.
Thus, when an event is recalled, the original sensations and emotions are both replayed. Over time, relevant information about the event is extracted from this memory and transferred to semantic memory networks located in the brain’s neocortex. Here, the information is integrated into the individual’s store of general knowledge and becomes available for understanding events in the future.
Once this transfer has been accomplished, the hippocampal memory is largely obsolete, and both the memory trace and its links to associated affect can be forgotten, freeing up memory for storing future episodic memories. Occasionally, however, the extraction process fails and information from the episodic memory fails to be extracted, transferred, and integrated into the neocortex.
In such instances, the individual fails to “learn from the event,” and the weakening and elimination of the episodic memory and its associated affect that normally follows this transfer and integration also fails to occur.
If the episodic memory is a traumatic one, the consequence can be PTSD. Although the patient can minimize the consequences of this failure either by avoiding stimuli that would reactivate the memory or by generally blocking emotional responses to stimuli (numbing of responses), true recovery requires the re-establishment of these failed processes of cortical memory consolidation and integration.
Another researcher, Coubard(11.), expounds on non-visual EMDR modes (see below):
The reason why eye movements and emotional shifts can be associated as cause or effect is simply that they share common neural circuitry.
Taken together, rhythmic left-right eye movements are able to stimulate the limbic system (i.e. emotional brain) either directly through the retino-hypothalamic system or indirectly through the retino-collicular system. The way non-visual bilateral stimulation induces emotional shifts may be obtained via supramodal subcortical areas such as the inferior and superior colliculi.
Importantly, EMDR involves a ‘resource development and installation’ (RDI) component based on the ‘adaptive information processing’ (AIP) model (see below) premise that maladaptive/dysfunctional memory networks, when accessed and reprocessed, link with existing positive, adaptive memory networks. Thus, exploration, development and strengthening of existing positive memory networks is part of EMDR therapy.
Worthy of mention is an accepted corollary of the AIP model: only the most recently reconsolidated ‘version’ of the existing network is accessible; this is consonant with two hallmarks of EMDR- quality of life outcome improvements are long lasting and iterative (repetition is central to the technique).
That the validity of the AIP-RDI theorem has been demonstrated in laboratory work on episodic memory is also important to note(5., 6., 7.):
Hippocampal and amygdaloid synaptic (inter-neuron) changes DO occur in the minutes following trauma, co-occur (and have a causal relationship) with memory and learning, and, may be modified by subsequent positive neural network co-stimulation.
One final perspective from the (diehard) dialecticians(19.)– experts in arguing back ‘n forth (all the rage in ancient Greece!)- cements RDI and AIP:
‘Differentiation’ and ‘linking’ apply to the disrupting effects of adverse life events which can be manifested in biphasic (two-phase) patterns of psychoform (mental) and somatoform (physical) symptoms. On the one hand, there are symptoms such as numbing, hypo-arousal, and avoidance, and on the other hand, symptoms of flashbacks, hyperarousal, and being overwhelmed. The first group indicates too much differentiation and the second too much linking. Adaptive information processing restores the balance between differentiation and linking. The therapist’s understanding of the client’s place on this continuum can help in the use of interventions to restore balance.
OK, what will I have to do during a session?
Basically, you will be asked to recall a distressing memory (you don’t even have to talk about it if you don’t want to!), whilst at the same time direct your attention to a side-to-side moving object (it may be the therapist’s fingers, a light source, a sound from headphones, or a vibration of a hand-held ‘paddle’) which the therapist controls (this is called ‘bilateral stimulation’ or BLS).
Again, in somewhat technical terms:
EMDR effects may be obtained by two processes acting in parallel: (i) activity level enhancement of an attentional control component; and (ii) bilateral stimulation in any sensorimotor modality, both resulting in lower inhibition, enabling dysfunctional information to be processed and anxiety to be reduced.
Is EMDR safe?
Although observed rarely in this centre’s 30+ years’ of EMDR usage to impact a person after they have left the psychologist’s room, clients are routinely advised not to drive or operate machinery after a session if they experience any adverse effects, including the following (some of which may be considered to be an unwanted but integral part of the treatment modality):
- Feeling emotionally uncomfortable: as for any psychotherapy, the process of sharing distressing thoughts, memories and feelings may in itself cause some discomfort.
- Feeling physically uncomfortable: especially for trauma sufferers, therapy may re-evoke autonomic nervous system changes akin to the ‘fight-flight-freeze’ response we usually experience when faced with a potential danger or threat. Effects you may notice include muscle tension, breathing and heart rate changes, crying, and cold sweats or nausea, with some people reporting repetitive or intense dreaming.
- Surfacing of new memories: as you recall a distressing memory, other memories may arise which can also be unsettling.
- A spill over of intense emotions: some people report feeling ‘very emotional’ for some hours/days after an EMDR session.
EMDR myths & misconceptions
- False memories: EMDR does not create memories that were not already there. As it facilitates memory re-consolidation, there may be changes over time when recalling the same memory.
- Having to talk about the unspeakable: EMDR is effective even when you remain in control of how much detail you are comfortable sharing.
- Homework: EMDR does not rely on exercises done outside the psychologist’s room, however some homework may be included if ancillary components (eg cognitive behavioural therapy or mindfulness) are used as part of your overall treatment plan.
- Dissociation: although dissociation (disconnection between a person’s thoughts, sensory experience, memory, and/or their sense of identity) sometimes accompanies the symptoms of the conditions EMDR is used to treat, it does not cause it to occur.
- It’s a type of hypnosis: although the side-to-side movement part reminds people of the ‘swinging watch’ of the hypnotist, EMDR does not utilise the same neurological processes as hypnosis.
- It’s just for post traumatic stress disorder (PTSD): No, EMDR is effective in treating the mental fallout from many adverse life events (see below).
How is EMDR structured?
EMDR therapy aims to reduce subjective distress and strengthen adaptive thinking processes related to an adverse life experience. Unlike CBT with a trauma focus, EMDR does not involve a) detailed descriptions of the event, b) direct challenging of beliefs, c) extended exposure to distressing memories, or d) homework.
Although not necessary to understand before you start EMDR therapy, the treatment consists of two components- ‘desensitisation’ and ‘resource development and installation’ (or RDI, which involves integration of upsetting information into a more adaptive, positive state)- administered in eight phases and carefully tailored to each person:
Phase 1 (history taking): symptoms, history, and expectations are discussed, and selection and ordering of target memories for reprocessing occurs. Importantly, a comprehensive understanding of both negative AND positive memories, experiences, and beliefs is attained for use in later phases.
Phase 2 (preparation/stabilisation): the EMDR model is explained and readiness for treatment assessed.
It also includes establishing the mechanics of how the treatment will be administered, including the bilateral stimulation (BLS) to be used, seating positions, and the use of stop signals.
In this and subsequent phases RDI may begin to be offered as needed.
Phase 3 (assessment): involves accessing the target memory as it’s currently being experienced and taking baseline measurements of the intensity of distress experienced.
Phases 4–6 (reprocessing): during these phases, the target memory and associated linkages to other memories are reprocessed. BLS is used to activate the brain’s inherent information processing system for 20–30 s at a time (although this may vary), with a brief check in to ensure that the process is moving forward appropriately.
By-products of reprocessing such as insights, shifts in emotional response, a new, more adaptive understanding of what happened in the past, and the assigning of new meaning to the experience are indicators that the process moving towards resolution.
The timing and duration of these phases is individually tailored according to Shapiro’s ‘three-pronged protocol’: past experiences are processed initially, present triggers that have not been resolved by addressing past experiences are next addressed, followed by the imaginal processing of future scenarios (‘future templates’).
Phase 7 (Closure): is designed to close down any session, especially a reprocessing session, whether it leads to complete or incomplete reprocessing of the target memory.
Phase 8 (Follow-up): is used after every session. It takes place in the subsequent session where the therapist asks for feedback on previous experiences globally and may re-evaluate specific target memories.
Is all EMDR the same?
No. This centre’s director urges people considering the approach to seek the services of practitioners formally trained in the technique. Peak bodies including the EMDR Association of Australia set the standards for such training.
Additionally, avoidance of ‘user’ Apps or gadgetry it is highly recommended, as widely evidenced in studies that show the “therapeutic alliance” to be a major factor in achieving quality outcomes in EMDR therapy. Indeed, when clients are asked to account for their success in psychotherapy generally, over 90% of respondents describe their relationship with the therapist as the factor of primary importance.
What can I expect?
Often omitted from research findings are the ‘customer reviews’ we all love to peruse which, especially in the early 1990’s, were viewed as so outlandish and of so similar an ilk to the attributions characterising a plethora of subsequently debunked ‘miracle cure’ psychotherapies, as to spawn a furious and prolonged scepticism within the ‘medical mainstream’. (This centre’s director vividly recalls the professional backlash she faced).
In fact, typical responses reported anecdotally by practioners DO include phrases such as “life-changing”, “magic”, “miraculous”, and “hard to believe”.
Shapiro herself notes the element of surprise/wonder commonly accompanying much feedback regarding EMDR therapy:
For many of our clients, it appears that simply reprocessing these earlier experiences allows the appropriate cognitive and emotional connections to be made and adaptive behaviors to spontaneously emerge, along with insights and positive self-concepts.
Noted author and researcher Bessel Van Der Kolk includes some of his patients’ comments on their distressing memories post-EMDR treatment:
“I remember it as though it was a real memory, but it was more distant. Typically, I drowned it, but this time I was floating on top. I had that feeling that I was in control“.
and
“Before, I felt each and every step of it. Now it is like a whole, instead of fragments, so it is more manageable“.
The Body Keeps the Score. (2014). Penguin, UK, Random House. p. 254
What can EMDR be used to treat?
Adverse life experiences impacting your ongoing mental health
Shapiro and others have challenged the view that EMDR can only be used in formally diagnosed trauma conditions such as PTSD. Research(9.) has shown that general life experiences (eg, relational problems, problems with study or work) can be the source of even more posttraumatic stress symptoms than major trauma itself.
Hence, patients presenting with anxiety, depression, hypervigilance, frequent anger, etc, should be evaluated for adverse experiences contributing to current dysfunction. Two randomised controlled studies have demonstrated the effectiveness of EMDR therapy in treating distressing life experiences that do not meet the criteria for traumatic events in the diagnosis of PTSD.
According to the AIP model, current experiences link into already established memory networks and can trigger the unprocessed emotions, physical sensations, and beliefs inherent in earlier-stored adverse life experiences. In this way, when the past becomes present and patients react in a dysfunctional manner, it is because their perceptions of current situations are coloured by their unprocessed memories.
Adverse childhood experiences
Adverse childhood experiences including household dysfunction, bullying, sexual abuse, neglect, and humiliation, may contribute to ongoing problems such as anxiety, lack of focus, hopelessness, toxic guilt/shame, poor self-image, angry outbursts, inattention, avoidance behaviour, sleep disorders, and impulsivity, often attracting diagnoses (such as attention deficit hyperactivity disorder) later in life that may subvert root-cause treatments such as EMDR.
Additionally, neurodevelopmental research(15.) highlights the importance of determining for those with a history of childhood abuse or neglect, what developmental windows might have closed before important neurological infrastructures were set in place.
The AIP conceptualisation provides the basis for a comprehensive evaluation of the clinical picture, the targets selected for treatment, and the procedures used during reprocessing. Unlike traditional exposure or cognitive behavioural therapies which involve extended focused attention on the disturbing event, EMDR reprocessing sessions promote an associative process that clearly reveals the intricate connections of memories that are triggered by current life experiences.
The psychological impact of debilitating medical conditions
A wide range of patients suffering from debilitating medical conditions can also benefit from EMDR therapy. For instance, the utility of psychological services for burn victims has been reported, with EMDR therapy specifically recommended on the basis of both effectiveness and brevity of treatment.
A number of researchers have reported positive outcomes of EMDR therapy for the treatment of both chronic pain and phantom limb pain. Completed processing is posited to involve an alteration of the originally stored memory through a process of integration and reconsolidation.The change in the targeted memory results in an elimination of those pain sensations that are not caused by physical nerve damage. Successful elimination and/or reduction of pain to tolerable levels has been reported after 2 to 9 EMDR therapy sessions.
The stress of undergoing rehabilitation- patients, carers, families
Rehabilitation services can benefit from EMDR therapy to support both patient and family members. The traumatic impact of dealing with life-threatening, incapacitating disease can be mitigated by incorporating relatively few memory-processing sessions to address distressing medical experiences, current situations, and fears of the future. As reported:
Using this approach is useful on three levels:
1. It can facilitate the processing of the traumatic event in the patient and the whole family.
2. It can rapidly re-establish a secure interpersonal context between the patient and his or her caregiver by reducing the high arousal level.
3. It can transform the health service into a network of support for patient and family, offering help in managing the emotional vulnerability connected with physical vulnerability, thus buffering the adverse impact of worsening clinical conditions.
Dealing with grief
EMDR therapy can also be used to help support family members dealing with the death of a loved one. The results of both prolonged debilitation and sudden death can involve trauma symptoms that include distressing intrusive images of the suffering patient. The family member is often unable to retrieve positive memories of the deceased, which further exacerbates and complicates the grieving process.
The following is a (in no way comprehensive) summary of ‘conditions’ cited to respond to EMDR:
How long does EMDR therapy take?
The various estimates that have been proposed by Shapiro and others (between 5 and 12 sessions) are based loosely on experiences with widely varying cohorts of symptom mix, intensity, history, and comorbidity.
This centre asserts that positive change should be evident within 3-6 sessions, reinforced with an additional similar number of sessions, and maintained periodically by 1-2 ‘top-up’ sessions as planned or initiated as new issues arise.
Is there more than one type of EMDR?
The literature is replete with studies and opinion regarding EMDR ‘offshoots’, for example ego state-based, belief-focussed, mindfulness-based etc.
It is beyond the scope of this article to comment on these, suffice it to say that EMDR therapy is adaptable to and potentially synergistic with other psychotherapeutic approaches, such that it(17.):
can integrate in a structured way various active elements from different psychotherapeutic approaches (empathic listening, psycho-education, psychometric tests, cognitive restructuring, association of memories, modification of inappropriate early schemas, use of Socratic interrogation and metaphors, exhibition in imagination, desensitization, relaxation, work taking into account sensations, behavior and systemic context, mindfulness …). It is therefore an “integrative” psychotherapeutic approach.
For the interested…EMDR neurobiology update
EMD: theoretical frameworks
The above may be categorised as psychological, psychophysiological or neurobiological proposed mechanisms of action.
AIP: 3-d model
At the beginning of trauma processing, the spiral of the AIP system is wide because the opposites of the individual are far apart, unconnected, and with little dialectical movement between them. The individual’s perception is rigid and one-dimensional. It is also partial because the vertical dialectical movement is limited and parts do not change into greater wholes. During processing, the horizontal dialectical movement begins to flow naturally and opposites get closer to each other, gradually resulting in new syntheses. As processing expands further, vertical shifts emerge. This is depicted in the narrowing of the spiral movement moving upwards as the individual acquires a more balanced and whole perspective. Understanding the oscillating nature of the AIP system can help the therapist make clinical choices of when and how to intervene if processing is stuck.(18.)
New focus on the Insula
Adding to knowledge of the amygdala, hippocampus, pre-frontal cortex, cingulate gyrus, and HPA axis referred to in previous articles are more in-depth studies(10.) regarding the role of the insula region of the brain.
Your right frontal insula “lights up” when you feel all the quintessential human emotions—love, hate, lust, disgust, gratitude, resentment, self-confidence, embarrassment, trust, distrust, empathy, contempt, approval, disdain, pride, humiliation, truthfulness, deceit, atonement, guilt. It also “lights up” when you feel strong sensations, from physical pain to ‘butterflies’ in the stomach or a tingling in the loins.
This dual physical-emotional sensitivity is not just a coincidence. The right frontal insula is where conscious physical sensation and conscious emotional awareness coemerge. Consider this amazing fact: the right frontal insula is active both when you experience literal physical pain and when you experience the psychic “pain” of rejection or the social exclusion of being shunned. It lights up when you feel someone is treating you unfairly. Scanning experiments have proven all this, and the results are profound. Welcome to one of the most important regions in the human brain.
Advances in neuro-plasticity research: neuronal recycling theory
Findings now indicate(14.):
1. Brain plasticity has spatial as well as temporal dimensions; neural networks are adaptive over time with regard to:
- The location (axon, dendrite, pre/post synapse) and intensity (storage, release thresholds) of neurotransmission.
- The shape, size, and conductivity (myelin sheathing) of neurons.
- The grouping and relative proportion of specialised neuronal types (non-synaptic, spindle).
- The distribution of supply/support structures (glial cells and vascular tissue feed/heal neurons).
2. A priori learning begins in utero. Even, for example, where there is no actual visual input, neuronal spikes are auto-generated and flow through the retinas to the visual cortex, as if the brain is rehearsing for sight.
3. Whilst it has become accepted that synaptic plasticity makes the brain malleable (the brain of a two year old contains twice the number of synapses as an adult), new research is challenging the view that our brain circuits nevertheless remain subject to inherited anatomical constraints:
Each new cultural object we invent, must find its ‘neuronal niche’: a set of circuits whose initial function is sufficiently similar to its new cultural role, but also flexible enough to be converted to this new use…cultural learning must rely on the re-purposing of pre-existing neuronal architecture, whose properties it recycles(14.).
If you think that you or someone you know may benefit from EMDR, please do not to hesitate to contact our friendly admin. team on 07 3831 4452.
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