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Eye movement desensitization and reprocessing EMDR
There are two perspectives on EMDR therapy.
One was advanced by the method's creator, with a theory that eye movement provides
neurological and psychological effects that enhance the processing of traumatic
memories. The other perspective is that eye movement is an epiphenomenon,
unnecessary, and that EMDR is simply a form of desensitization.
EMDR integrates elements of imaginal exposure, cognitive therapy, psychodynamic
and somatic therapies. It also uses the unique and somewhat controversial element of
bilateral stimulation (e.g. moving the eyes back and forth). According to Francine
Shapiro's theory, when a traumatic or distressing experience occurs, it may
overwhelm usual ways of coping and the memory of the event is inadequately
processed; the memory is dysfunctionally stored in an isolated memory network.
When this memory network is activated, the individual may re-experience aspects of the original event, often resulting in inappropriate overreactions. This explains why
people who have experienced or witnessed a traumatic incident may have recurring
sensory flashbacks, thoughts, beliefs, or dreams. An unprocessed memory of a
traumatic event can retain high levels of sensory and emotional intensity, even though
many years may have passed.
EMDR uses a structured eight-phase approach and addresses the past, present, and
future aspects of the dysfunctionally stored memory. During the processing phases of
EMDR, the client attends to the disturbing memory in multiple brief sets of about 15–
30 seconds, while simultaneously focusing on the dual attention stimulus (e.g.,
therapist-directed lateral eye movement, alternate hand-tapping, or bilateral auditorytones). Following each set of such dual attention, the client is asked what associative
information was elicited during the procedure. This new material usually becomes the
focus of the next set. This process of alternating dual attention and personal
association is repeated many times during the session.
The theory is that EMDR works directly with memory networks and enhances
information processing by forging associations between the distressing memory and
more adaptive information contained in other semantic memory networks. It is
thought that the distressing memory is transformed when new connections are forged
with more positive and realistic information. This results in a transformation of the
emotional, sensory, and cognitive components of the memory so that, when it is
accessed, the individual is no longer distressed. Instead he/she recalls the incidentwith a new perspective, new insight, resolution of the cognitive distortions,
elimination of emotional distress, and relief of related physiological arousal.
When the distressing or traumatic event is an isolated incident, the symptoms can
often be cleared with one to three EMDR sessions. But when multiple traumatic
events contribute to a health problem—such as physical, sexual, or emotional abuse,
parental neglect, severe illness, accident, injury, or health-related trauma that result in
chronic impairment to health and well-being—the time to heal may be longer.
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Therapy process
1. Phase I: In the first sessions, the patient's history and an overall treatment
plan are discussed. During this process the therapist identifies and clarifies
potential targets for EMDR. Target refers to a disturbing issue, event, feeling,
or memory for use as an initial focus for EMDR. Maladaptive beliefs are alsoidentified.
2. Phase II: Before beginning EMDR for the first time, it is recommended that
the client identify a safe place, an image or memory that elicits comfortable
feelings and a positive sense of self. This safe place can be used later to bring
closure to an incomplete session or to help a client tolerate a particularly
upsetting session.
3. Phase III: In developing a target for EMDR, prior to beginning the eye
movement, a snapshot image is identified that represents the target and the
disturbance associated with it. Using that image is a way to help the client
focus on the target, a negative cognition (NC) is identified – a negative
statement about the self that feels especially true when the client focuses on
the target image. A positive cognition (PC) is also identified – a positive self-
statement that is preferable to the negative cognition.
4. Phase IV: The therapist asks the patient to focus simultaneously on the image,
the negative cognition, and the disturbing emotion or body sensation. Then the
therapist usually asks the client to follow a moving object with his or her eyes;
the object moves alternately from side to side so that the client's eyes also
move back and forth. After a set of eye movements, the client is asked to
report briefly on what has come up; this may be a thought, a feeling, a
physical sensation, an image, a memory, or a change in any one of the above.
In the initial instructions to the client, the therapist asks him or her to focus onthis thought, and begins a new set of eye movements. Under certain
conditions, however, the therapist directs the client to focus on the original
target memory or on some other image, thought, feeling, fantasy, physical
sensation, or memory. From time to time the therapist may query the client
about her or his current level of distress. The desensitization phase ends when
the SUDS (Subjective Units of Disturbance Scale) has reached 0 or 1. [1]
5. Phase V: The "Installation Phase": the therapist asks the client about the
positive cognition, if it's still valid. After Phase IV, the view of the client on
the event/ the initial snapshot image may have changed dramatically. Another
PC may be needed. Then the client is asked to "hold together" the snapshot
and the (new) PC. Also the therapist asks, "How valid does the PC feel, on ascale from 1 to 7?" New sets of eye movement are issued.
6. Phase VI: The body scan: the therapist asks if anywhere in the client's body
any pain, stress or discomfort is felt. If so, the client is asked to concentrate on
the sore knee or whatever may arise and new sets are issued.
7. Phase VII: Debriefing. The therapist gives appropriate info and support.
8. Phase VIII: Re-evaluation: At the beginning of the next session, the client
reviews the week, discussing any new sensations or experiences. The level of
disturbance arising from the experiences targeted in the previous session is
assessed. An objective of this phase is to ensure the processing of all relevant
historical events.
he following basic terms are described in Shapiro's 2001 text[1]
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Information Processing
During information processing, a physiologically-based system sorts new
(perceptual) information, makes connections between new information and
other information already stored in associated memory networks, encodes the
material, and stores it in memory.
Adaptive ResolutionWhen information processing is complete, learning takes place, and
information is stored in memory with appropriate emotion. The new
information is therefore available to guide future action.
Dysfunctionally Stored Information
When information processing is incomplete, the information is not connected
to more adaptive information, and it is stored in a memory network with a
high negative emotional charge. It can cause reactivity and can be the cause of
various symptoms.
Reprocessing
During reprocessing in EMDR, new associative links are forged between
dysfunctionally stored information and adaptive information, resulting incomplete information processing and adaptive resolution.
Memory Networks
Neurobiological associations of related memories, sensations, images,
thoughts, and emotions.
Target Memory
The memory of a distressing or traumatic event, which still causes current
distress, and which has been selected to be targeted during EMDR treatment.
Memory Components
All components of the target memory are accessed during Phase Three to
ensure that the memory network is fully activated. These components include
the image, cognitions, emotions, and body sensations.
VOC (Validity of cognition) scale
VOC ratings are used in EMDR to measure baseline validity of the positive
cognition during Phase Three, and to assess progress being made, where 1 =
not true, and 7 = completely true.
SUD (Subjective units of disturbance) scale
SUD ratings are used in EMDR, exposure therapies, and other treatments to
measure baseline emotional or physical pain and also to assess progress being
made. This is a personal measurement of distress, where 0 = no distress, and
10 = worst distress possible.
InterweaveA specific strategy used by the clinician to assist processing if the client
appears to be having difficulty accessing more adaptive information. Ideally,
the interweave contains needed information that would have been available
except for blockage of inner pathways by trauma responses.
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Mechanism
The theory underlying EMDR treatment is that it works by helping the sufferer
process distressing memories more fully which reduces the distress. EMDR is based
on a theoretical information processing model which posits that symptoms arise when
events are inadequately processed, and can be eradicated when the memory is fully processed. It is an integrative therapy, synthesizing elements of many traditional
psychological orientations, such as psychodynamic, cognitive behavioral,
experiential, physiological, and interpersonal therapies.
EMDR's most unique aspect is an unusual component of bilateral stimulation of the
brain, such as eye movement, bilateral sound, or bilateral tactile stimulation coupled
with cognitions, visualized images and body sensation. EMDR also utilizes dual
attention awareness to allow the individual to vacillate between the traumatic material
and the safety of the present moment. This prevents retraumatization from exposure to
the disturbing memory. As EMDR is an integrative therapy which combines elements
of cognitive behavioral and psychodynamic therapies to desensitize traumatic
memories, some individuals have criticized EMDR and consider the use of eye
movement to be an unnecessary component of treatment. However, recent studies
have examined the effects of eye movement and have found that eye movement in
EMDR decreases the vividness and/or negative emotions associated with
autobiographical memories, enhance the retrieval of episodic memories, increase
cognitive flexibility,[14] and correlate with decreases in heart rate, skin conductance,
and an increased finger temperature. These physiological changes associated with
EMDR are consistent with earlier research on physiological changes associated with
EMDR. Also recent studies that have removed eye movement from the method have
found the procedure less effective.
There is no definitive explanation as to how EMDR works. There is some empirical
support for three explanations regarding how an external stimulus such as eye
movement can facilitate the processing of traumatic memories.
The first hypothesis views PTSD as a failure by the individual to process episodic
memory; the bilateral eye movement involved in EMDR facilitate interaction between
the brain's hemispheres, which then improves the processing of trauma-related
memories. This hypothesis is supported by a study that tested the effects of eye
movement on the ability to retrieve episodic memory. The study found better recall
following a horizontal eye movement task compared to that following no eyemovement or a vertical eye movement task.
A second hypothesis suggests that eye movement facilitates processing of trauma
memories by activating a neurobiological state similar to REM sleep wherein
associative links to episodic memories are formed and these memories are then
integrated into general semantic networks. Stickgold proposed that PTSD occurs
when an event is sufficiently arousing to prevent its transfer from encoding from an
episodic memory to a semantic memory. As a result of high arousal levels,
associations between the traumatic event and other related events fail to develop. He
argues that the attentional redirecting in EMDR induces a neurobiological state
similar to REM sleep. He then reviews the research that suggests that REM sleepenhances processing of episodic memory through the preferential activation of weak
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associative and semantic links. Thus in EMDR trauma-related information that is
closely associated with a target event is weakened and ancillary information loosely
related to the event is strengthened, allowing the integration of trauma-related
material with other loosely associated events in the person’s life. Support for this
argument comes from a study that found that, compared to eye fixation, eye
movement promoted attentional flexibility and increased preparedness to processmetaphorical material.
A third hypothesis links the eye movement in EMDR with the orienting response.
MacCulloch and Feldman argued that eye movement triggers the investigation
component of the orienting response, which can either produce avoidance behaviour
or inhibit avoidance responses. Inhibiting avoidance behaviour includes reducing both
negative somatic responses and cognitive changes that would allow fresh
investigatory behaviour to commence. MacCulloch and Feldman proposed that
initially when danger is identified there is a negative affect response. However a
second part of the orienting response is to scan for further danger, and this
investigatory reflex seems to accompany a positive physical response. In the authors’opinion, eye movement induces this investigatory reflex and produces a relaxation
response. A relaxation response was, in fact, found in a study that investigated the
autonomic responses of participants when they were engaged in an eye movement
task as part of EMDR treatment and when participants focused on negative memories
while engaging in eye movement [23]. However there is not a differential effect of
eye movement on a relaxation response when participants focused on positive
memories. This supports the hypothesis that eye movement is an orienting response
mechanism rather than a simple relaxation mechanism. In addition, recent research
that has examined the physiological correlates of eye movement in EMDR has found
that a clear orienting response pattern of psycho-physiological de-arousal occurs when
eye movement begins, and this de-arousal is characteristic of the physiological
changes that occur when an orienting response is elicited.