A CONVERSATION ABOUT   EMDR WITH DR. ARNETT

Question:        Hello, again, Doctor – Stacey.
Stacey Arnett:            Welcome.

Q:        Today I’d like to talk about EMDR.
SA:      Great! One of my favorite subjects.

Q:        Why’s that?
SA:      Because in own special way it’s as amazing, and as amazingly effective, as hypnosis.

Q:        Can you say more about that?
SA:      Sure. But first let give you the basics.

Q:        Good idea.
SA:      Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapeutic treatment that was originally designed to alleviate the distress associated with traumatic memories. During an EMDR session a person pays attention to emotionally disturbing material in brief, sequential, small doses while simultaneously focusing on an external stimulus. Originally, this involved a person paying attention to shifting his eyes from right to left, back and forth repeatedly.  Nowadays we often  use other stimuli but the effect is the same: what’s known as bi-lateral stimulation of the brain.  That is, a stimulus on the right side of the body – say, a buzzer in your hand – will stimulate the left hemisphere of the brain, and a stimulus on the left side will stimulate the right hemisphere.

Q:        And what happens?
SA:      Well, after successful treatment with EMDR, people feel less emotion about their trauma, they’re able to reformulate negative beliefs and reduce physiological arousal; by that I mean all the physical sensations that often accompany remembered trauma.  For example, take a Vietnam veteran who’s had lots of therapy but never EMDR: whenever he hears a helicopter he responds as if he’s back in Vietnam and breaks out in a sweat that soaks his clothes.

Q:        I want to know more about how this works, a lot more, but first, is it true that a Canadian discovered this?
SA:      Yes. Dr. Francine Shapiro, in the early 1990s. Actually, she discovered EMDR by accident –

Q:        Like Penicillin?
SA:      Exactly.  Fleming discovered Penicillin when he noticed that a particular mold killed bacteria in a Petri dish.  Shapiro discovered EMDR when she noticed that during a time when she was dealing with her own trauma, when she shifted her eyes from right to left, left to right, it helped to relieve her emotional and physical symptoms. After she’d experimented on herself she began trying the technique with patients and, lo and behold, it worked for them, too.

Q:        OK, now just how does it work?
SA:      Well, as with hypnosis, no one can yet say for sure. But Shapiro hypothesizes that EMDR facilitates our ability to access our traumatic memories and the network where these are stored in the brain. This enhances information processing and forges new associations between traumatic memory and more adaptive memories or information. Based on experience so far it appears that all this results in complete information reprocessing of the traumatic memory, as well as new learning about the traumatic memory, elimination of emotional distress associated with the traumatic memory and the development of cognitive insights that bear on the traumatic memory.

Q:        That’s a lot to take in. Can you give me an example?
SA:      Sure. Let’s take an extreme situation: combat. Many veterans of combat continue to be overwhelmed by flashbacks and nightmares about their combat experience and often also feel tremendous survivor guilt because they believe that they should have saved friends who died. EMDR – bi-lateral stimulation of the brain while remembering the traumatic event in brief, sequential bursts – first drains the power from the memory.  This is an actual neurological process that is not yet fully understood. It appears that under extreme stress we sometimes “lock” the memory of a traumatic event in a part of the brain called the amygdala rather than processing it as we normally would, through REM sleep and dreaming. Another analogy that’s often used is that of a locked room; EMDR is the key that opens the lock and allows what’s in the room to be released and seen for what it is.  This enhances information processing; in other words, you now are able to process – actually, reprocess – information about the traumatic event without being burdened by the overwhelming emotions and physical sensations.  And once that’s been accomplished, or even as it’s going on, you begin to understand the traumatic event in a new way.  Take a combat vet who believes he should have saved his friend.  Once the emotional and physiological power of the memory has been reduced it’s possible for him to remember more clearly and to realize that, in truth, he was in another sector of the battle zone so that there was no way that he could have saved his friend. Such insights continue the process of relieving stress associated with the traumatic memory so that eventually the veteran can remember what happened in combat, as well as the loss of his friend, without hyperarousal – rapid heart beat, shallow breathing, sweating, feelings of panic – or the self-loathing and guilt that led to depression.

Q:        WOW!
SA:      Wow, indeed!  So, to repeat myself in a slightly different way,
EMDR uses a three pronged approach: first, we process the past traumatic events that have laid the groundwork for any present dysfunction and create new links with adaptive information – that is, with what we know now (for example, you’re not presently in combat); second, we target the current circumstances that elicit distress (for example, the sound of a helicopter, hearing the news of his friend’s death) and desensitize these internal and external triggers, and; third, we incorporate what are called “imaginal templates” – scenarios of what could happen (what if a helicopter flies over? What if something reminds you of your friend?) – in order to a help a person acquire the skills needed to live in the world without dysfunction caused by PTSD.

Q:        And the theory behind this?  I assume that there is one.
SA:      Sure, there’s always a theory, that’s what shapes our understanding and guides further research. Here’s Shapiro’s hypothesis. She believes that human beings have an inherent information processing system that for the most part processes the many and varied elements of any experience so that learning takes place and we adapt. She sees memory as being stored in linked networks – neurological networks - that are organized around the earliest related event and its associated affect. So, for example, if you almost drowned when you were a child then that’s the earliest traumatic event. And if you become more and more fearful of water as time passes, then each time you feel afraid this adds to the network and creates a dysfunctional condition – let’s call it hydrophobia.  Shapiro believes that such networks contain related thoughts, images, emotions, and sensations. Her conceptual model hypothesizes that if the information related to a distressing or traumatic experience is not fully processed, then the initial perceptions, emotions, and distorted thoughts will be stored as they were experienced at the time of the event. Shapiro argues that such unprocessed experiences become the basis of current dysfunctional reactions and are the cause of many mental disorders. Based on her experience and the experience of others, she proposes that EMDR successfully alleviates many mental disorders by processing all the components of the distressing memory. When the targeted memory is linked with other more adaptive information new learning takes place, and the new, re-learned experience is then stored, along with appropriate emotions, and is able to guide the person in the future. So, once the emotions and sensations associated with the original traumatic drowning have been reprocessed, then it’s possible to learn that not all water is dangerous, and to make judgments about water based on current knowledge rather than past terror that’s been locked in the brain. The same is true for combat or any other trauma.

Q:        OK, I follow that I think.  But you’ve been talking about pretty severe trauma, near death, really.  Aren’t there lots of other things that people remember as traumatic? I sure do. For example, when my dog got run over by a car.  Whenever I remember that, I can feel tears in my eyes and sometimes I break out in a sweat.
SA:      A really good question, and a great example.  Yes, I have been talking about severe trauma, both because that’s what most people think of when they think about trauma and because EMDR was first used successfully by Shapiro and others to treat people who had experienced such trauma.  But you’re absolutely right, trauma comes in all shapes and sizes.  I expect that most children who witnessed the death of a beloved pet would feel much the same as you did, and still do, from what you say.

Q:        So am I a candidate for EMDR?
SA:      It depends.  Does sweating and feeling tears in your eyes when you remember this event create any dysfunction in your life?

Q:        Not really.
SA:      Well, then, even though EMDR could probably help you reprocess this event and relieve you of these post-trauma symptoms, if your life’s not broke, is there any need to fix it? 
            But – and this is a very big BUT – it’s important to remember that what hardly shows up as a blip on one person’s emotional radar can blow the circuits for someone else. Trauma is a subjective experience. That’s why some soldiers survive severe combat with no PTSD and others with only brief exposure to limited combat end up with major dysfunction. 

Q:        But surely some traumas always cause later dysfunction.  I‘m thinking about child abuse and rape, for example.
SA:      I think you’re probably right about that, but the degree of dysfunction will vary considerably depending on the person and the person’s experience of the event.

Q:        Why the differences?
SA:      No one knows for sure, although there’s a theory that those with poor attachments in childhood are more susceptible to trauma and prone to PTSD.

Q:        Poor attachments?
SA:      When a child fails to establish a strong and consistent bond with her parents. This certainly creates a later vulnerability.

Q:        OK, can we shift now to just how the process works? I mean, what actually happens in an EMDR session?
SA:      Another good question.  First, let me emphasize that while EMDR is an integrative approach that addresses all of a client’s problems, it is not a one session treatment.  There are a number of studies that have tested the duration and effectiveness of treatment – because people may want to check these out, later I’m going to give you references that you can include.

Q:        God idea.
SA:      Now this is just a sampling of research that’s been done. Two studies showed an elimination of PTSD symptoms in 83-90% of civilian participants after four to seven sessions (Lee, Gavriel, Drummond, Richards, & Greenwald, 2002; Rothbaum, 1997). Other studies using participants with PTSD have found significant decreases in a wide range of symptoms after three-four sessions (e.g. Ironson, Freund, Strauss, & Williams, 2002; Scheck, Schaeffer, & Gillette, 1998; S. A. Wilson, Becker, & Tinker, 1995). The only study to focus on combat veterans and address the multiple traumas of this population reported that 12 sessions of treatment resulted in a 77% elimination of PTSD symptoms (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998). On the other hand, people with multiple traumas and/or complex histories of childhood abuse, neglect, and poor attachment may require more extensive therapy. (Korn & Leeds, 2002; Maxfield & Hyer, 2002; Shapiro, 2001).

Q:        That’s not very much therapy, especially compared to how therapy is usually done.  Does it last?
SA:      It does, but for how long depends on the person, the skill of the therapist and the length of time after treatment.  Some people resolve their trauma and that’s that.  Others may need to return some time later for more work. For example, in our hydrophobic example, if the client began to notice nervousness around water then it would be worthwhile for him to return for some further “booster” sessions.

Q:        You mentioned hydrophobia – fear of water. What about treating other phobias with EMDR?
SA:      There’s a lot of anecdotal evidence that EMDR can be helpful with a wide range of phobias. However, from the research that’s been done it appears that EMDR is most effective when the phobia is directly linked to a traumatic event; for example, dog phobia after a dog bite.  When the cause of the phobia is not known or is generalized - for example, fear of snakes or spiders – then EMDR doesn’t work any better than what’s called “exposure therapy.” That’s where a client is desensitized by being gradually exposed to ever closer encounters with the phobic object.  Personally, I’ve found that EMDR works with some phobias even when not associated with a specific traumatic event, especially when used in combination with hypnosis. Fear of flying, for example. 

Q:        You use EMDR and hypnosis together?
SA:      Often.  As treatments, they’re like friendly and cooperative sisters; they work well together and the effect of one often supports and enhances the effect of the other.

Q:        So EMDR doesn’t work for everything.
SA:      No, but then neither does hypnosis or, for that matter, any other treatment.  EMDR was designed and works best for relieving or eliminating disorders that follow a distressing experience, what’s perceived as a trauma.  It is sometimes used – I use it myself – to work with other problems such as chronic pain or phantom limb pain, but it’s unlikely to help much with conditions where the cause is primarily physiological such as bi-polar disorder or schizophrenia. For these medication is the best treatment, at least so far.

Q:        What about using EMDR to enhance performance?
SA:      Yes, I’ve found it can help people deal with performance anxiety and improve performance.

Q:        So now can you describe what happens in an EMDR session?
SA:      Sure.  During our first session, after the client tells me the nature of her problem, I take a complete history.  This often involves constructing a genogram, kind of a historical map of a client, his family, traumatic events and how they inter-relate.  This helps me identify traumatic events that we’ll be working with in our sessions.  Usually, a history is all we’ll do during the first session, and perhaps during the second as well, depending on how much relevant information we need to collect and consider in order to design the most effective individualized treatment protocol. Also, during the history we won’t discuss any traumatic events in detail.  This is to avoid retraumatizing.  In traditional talk therapy it’s assumed that talking about the trauma is necessary to heal it.  The problem with this approach is that in talking about it a person relives it over and over, and this then adds to the original trauma – retraumatization.  Once the history is clear we spend time building a person’s inner resources.  Here hypnosis can be very helpful.  By inner resources I mean helping a person find a place within that evokes a sense of safety and a positive state of feelings of well-being.  This can be an imagined place or it can be drawn from memory.  Once we’ve established inner resources then we can move on to actual EMDR.  There is a standard protocol for this process, but it often varies slightly depending on an individual, his needs and responses.  What is always the same is the use of bi-lateral stimulation while remembering a traumatic event.  I usually use buzzers that a client holds in each hand, but some therapists still prefer eye movement or tapping lightly on each knee or using earphones for audio stimulation. Specific techniques will differ with different clients.

Q:        Does using a standard protocol make any difference?
SA:      Yes, and no.  Research has shown that marked deviations from the standard protocol are not as effective.  However, within the context of that standard protocol it’s important to adapt to the history and needs of each client. 

Q:        Are there side effects?
SA:      Sometimes, but not as we think of side effects with, say, medications.
As is true with any form of therapy, a person may feel worse for a time before they feel better. For example, distressing and unresolved memories may emerge. Some people may experience reactions during a treatment session that neither they nor I have anticipated, including a high level of emotion or physical sensations. And after a treatment session, the processing of incidents/material may continue, and other dreams, memories feelings may emerge. Also, since EMDR is basically a neurobiological process, a person may continue to feel sensations in the body as reprocessing of traumatic memory continues after a session.

Q:        Well, I’ve run out of questions.  Is there anything I’ve forgotten to ask that you think is important for people to know?
SA:      No. Once again, I think you’ve been very thorough.

Q:        Any last words?
SA:      Just that while EMDR is not as well known as other treatments, it soon will be.  In my experience, it is without peer for the treatment of trauma.  In fact, it’s been recognized as such by the American Psychological Association.