A ndie Bernard, a licensed professional clinical advisor at Rootworks Wellness in Cincinnati, worked with children and families in marginalized communities who had experienced complex trauma but didn't feel like it was real to help improve through the use of play and talk therapy.
“In treating these children and their families, I just couldn't get to the root of what was really needed to make lasting profits. With me, their bodies were still during the session when they could be, but they were activated everywhere else, ”she recalls. “I needed something more powerful than talking and playing. I needed something that could help to reshape their worldview [and] and their belief in themselves. "
This led Bernard to Eye Movement Desensitization and Reprocessing (EMDR) therapy. After applying the therapy, she finally noticed improvements in these clients.
EMDR was developed in the late 1980s when Francine Shapiro discovered a link between eye movements and a decrease in negative emotions associated with her own troubling memories. More than 30 years after EMDR was first introduced, it has not only proven effective, but has been approved by the World Health Organization, the US Department of Veterans (VA), and the US Department of Defense as the primary treatment for post-traumatic stress disorder (PTSD).
EMDR is directly related to many evidence-based therapeutic approaches such as psychoanalysis, cognitive behavioral therapy, and somatic therapy, notes Bernard, a member of the American Counseling Association. Like psychoanalysis, EMDR therapy explores clients' past, present, and future, but its goal is to help clients realize that what happened to them in the past is not happening now. The cornerstone of EMDR, explains Bernard, is the adaptive information processing model, which claims that once people have all the information they need and can adaptively see it, people move towards healing.
The ability of our body to heal itself naturally from a cut is similar to emotional healing, emphasizes Bernard. "But when we are subconsciously trapped in unsafe experiences that still feel true, the body cannot achieve this natural healing," she says. "EMDR shifts the past into the present in cooperation with the therapist so that the client can see what lies ahead and can assess the threat of today."
Bernard, an EMDR-certified therapist and counselor in training with the EMDR International Association (EMDRIA), notes that clients often come to counseling with a myopic view of their problems. EMDR therapy helps them to expand this lens and turn towards healing.
Does EMDR differ from other approaches
The first three phases of EMDR (medical history and treatment planning, preparation and evaluation) are similar to other counseling approaches in that they focus on understanding the client's full story, building a strong therapeutic relationship, creating security and the Coping to cultivate skills that are centered on the mind and body. In phase 4, desensitization, EMDR shifts to a neurobiological approach by helping the client change the way the brain and body associate the trauma with its trigger, explains Bernard. Rather than instructing the client to simply verbally share their narrative (as can be done with trauma-focused cognitive behavioral therapy), an EMDR therapist will focus the client on a targeted traumatic memory while undergoing bilateral stimulation such as eye movements. This process accelerates the client's ability to integrate the material into an adaptive neural pathway, she says, and removes the emotional charge and associated behaviors in everyday life.
This indicates an important difference between EMDR and many traditional counseling approaches: It does not require much discussion, at least during the desensitization phase. (See the sidebar below for an overview of the eight phases of EMDR therapy.) Addie Brown, a licensed professional counselor (LPC) in Virginia and a licensed marriage and family therapist in California, admits it was a challenge for her at first to the. to resist urge to reflect and validate their clients' thoughts and feelings. She had to retrain herself to follow the EMDR protocol and only respond with simple sentences like "do with it" when a client mentioned a new feeling or memory.
Brown says this aspect of EMDR can be liberating for clients who prefer not to share details about their traumatic experiences. “Some customers like the fact that they don't have to talk a lot, they don't have to give a lot of details because there are things that they find so embarrassing that they don't want to talk. [Talking about those things] can be more traumatic. They're still doing the work [with EMDR] … but they don't have to keep telling this story, "notes Brown, an EMDR-certified therapist with a private practice, Harbor Site Counseling, in Woodbridge, Virginia.
Carla Parola, an LPC in private practice at Seven Centers Counseling in Phoenix, once worked with a client who was reluctant to share his story of sexual abuse as a child. She explained to the client that he did not need to reveal many details of his abuse during EMDR therapy and that he did not need to talk about the abuse until he was ready. If he decided to work on a trauma memory, all he had to do was share the picture that represented the worst part of the traumatic experience, as well as the emotions, negative cognitions, and body sensations associated with the picture. For example, the customer could choose the image of "Alone in the closet" without having to disclose what happened in the closet or what led to it, says Parola, an EMDRIA-approved advisor and moderator for humanitarian aid programs. This statement allayed the client's concerns and he agreed to continue treatment.
The use of bilateral stimulation through EMDR can be effective, but some clients are verbal in nature and are used to giving more details than is required when using EMDR therapy. EMDR-trained clinicians often tell Bernard that they have difficulty helping some clients to effectively capture and process certain traumatic memories because those clients seem to only want to talk about their feelings and feel supported by the clinician.
But there is room for clients to speak and process when they are under EMDR therapy, says Bernard. In her sessions she remains relational and listens to the client for the first 10-15 minutes. As she connects with her clients, she looks for topics related to her already targeted negative memories and the self-beliefs that come with them. For example, if a client comes in and talks about arguing with her husband because he was busy with work and aloof at home, Bernard might say: important to your mother when you were growing up. Does it feel like it fits? ”If the client agrees, Bernard turns the content back to reprocess the client's previous targeted memories and the belief that she is not important. This allows the client to see how the self-confidence she developed in her childhood shapes her thoughts, feelings and reactions in her current relationships. “That is the power of EMDR. We do not ask our clients to cope with their symptoms; we help them to know how they developed them, ”says Bernard.
In contrast to other counseling approaches that help clients make a change in their state (e.g. transition from an anxious state to a calm state), EMDR therapy helps clients make changes in their characteristics, says Bernard. As she explains, a change in state approaches the problem through the frontal cortex of the brain and helps clients learn coping strategies to deal with their symptoms, while a change in characteristics is to see what is below the state by using historical memories, The nervous system and the limbic system used to be part of the brain. The integration of new insights and beliefs through bilateral stimulation results in a property change that helps clients form more adaptive viewpoints and appropriate responses to difficult triggers.
Bernard uses an analogy to emphasize the difference between changes in state and changes in characteristics. While a change of state requires changing lanes (from a fearful road to a quiet road), a property change requires the construction of a new highway in the brain that changes the way clients see their world and themselves in it.
[clients are] "If [clients are] are only interested in changes in condition and just want to talk through their symptoms to learn ways to deal with them … that can be achieved with phase 2 of EMDR. But if [they] clearly believe, see, and want to know that the threat has changed in relation to that trigger and want to make a real property change, "then that includes the final stages of the EMDR protocol, she says.
When should EMDR be used (and not used)
G. Michael Russo, visiting professor of counseling training and addiction program coordinator at Boise State University, specializes in integrating neuroscience into counseling practice. He participated in a meta-analysis, led by Richard Balkin and A. Stephen Lenz, consisting of research studies from 1987 to 2018 to determine the overall effectiveness of EMDR in reducing symptoms of overexcitation. They found that EMDR can be an effective treatment for anxiety and trauma, but the results showed varying degrees of effectiveness – some reported high levels of effectiveness and others suggested that it might be better to choose a different intervention.
“None of the articles included in the study used neuroscientific measures. So … we are unable to investigate claims of neurological changes from EMDR, ”says Russo, an LPC in Idaho. “Some might even say that neurological changes that result from the EMDR processes are unfounded. What we can say, however, is that there could very well be an alternative explanation for client growth in EMDR sessions that is not related to eye movement, tactile, or auditory stimulation. It is possible that the relationship itself is the agent of change. ”Russo presented the results of the meta-analysis, which was accepted for publication in the Journal of Counseling & Development, during the ACA's Virtual Conference Experience last spring.
The bottom line, Russo says, is that despite the potential effectiveness of EMDR, advisors should remain critical consumers when using it with clients. You should ask yourself: When does EMDR work? When does it not work? Who is represented in research? Is this the best approach for this customer?
According to the VA, other recent meta-analyzes indicate that EMDR causes moderate to strong treatment effects in the case of PTSD symptom reduction, depression symptom reduction and loss of the PTSD diagnosis.
“EMDR is not limited to trauma or PTSD only. It can be used across the board, ”assures Brown. "We have so many experiences that have an emotional impact on us and this is why EMDR can be really helpful because it addresses the emotional impact we have experienced." These impacts can be trauma, as well as grief, job loss, eating disorders, or relationship problems. If a client has a strong emotional reaction to an event, or if a negative feeling or memory remains and the client wonders why she is still feeling this way, EMDR can be a good approach, she says.
Still, Brown admits that EMDR may not be for everyone, so she judges when and if she wants to use the therapy on her clients. She also explains the process to clients to determine if they are ready to begin treatment.
Brown finds three main obstacles that could prevent EMDR therapy from working with some clients. First, a client can be too emotionally distant. This often happens when family members or friends encourage a person to seek advice, but the person doesn't really think they need to be there, she says.
Second, clients may not be ready to completely let go of their emotions related to an event. Brown advises counselors to use phase 2 of EMDR therapy to explore possible barriers that would prevent the client from fully processing their feelings.
Third, an internal conflict could hinder the client's progress. If a customer is working on an issue that conflicts with their value system, they may need to work on that conflict in other ways before trying to use EMDR, says Brown. For example, a client may not want to fully process and heal their grief because they would feel guilty for having to "let go" of their pain.
Brown once worked with a client who was seeking advice because she was struggling after her son died. When Brown asked about her son, the client started sobbing as if he had died the day before and the loss was still very raw; In fact, it was 10 years since her son died. After several EMDR sessions with Brown, the client had only moderately reduced her distress level, from 10 (high distress) to 6 (moderate distress). Although she was still in great pain, the client was satisfied with this progress, Brown recalls, because she did not want to feel better.
Because EMDR therapists are excited about the potential effects of this therapy, they might be tempted to use it on any client they encounter, says Brown, but this is not an ethical practice. It reminds the advisors to remain in their area of responsibility. Recently, someone came to Brown because they wanted to use EMDR therapy to help him with obsessive-compulsive disorder (OCD). Although Brown is trained in EMDR and EMDR is a good intervention for treating OCD, she referred the person to another clinician because Brown felt incompetent to work with this particular disorder.
“Just because you are trained in a really great intervention that can be used for so many different problems doesn't mean that you, the clinician, have to use it for all of these problems if you don't have the clinical competence, addressing these problems, "she says.
Case study with complex trauma
Larisa Lomaeva / Shutterstock.com
Bernard offered to give a case study (based on a composition of their clients) to illustrate how the EMDR protocol is applied to a client with complex trauma. The client is a woman in her thirties who has experienced significant abuse and relational neglect in her family since birth. The client is functional in her day-to-day life, but struggles to let go of the shame and sense of responsibility for what happened to her. “Children are hardwired to believe that traumatic things that happen to them are their fault, and she was no exception,” notes Bernard. For many years the client overcame the trauma by distancing her mind and body from her past experiences. She had gone to counseling sessions throughout her life, but this was largely unsuccessful because she was stuck in the childhood belief loop that her past traumas were her fault.
During phase 1 of EMDR, Bernard gets to know the client and her story. EMDR allows counselors to be creative in taking a full medical history, she notes. Bernard asks the client to mark on a chronological timeline (ages 1 to 38) all the important events that influenced her or contributed to her symptoms and how she sees herself today. This includes both positive and negative experiences. Bernard sets a three-minute timer, and the client marks these events in grounded silence.
When the customer is done, Bernard looks for markings that are more pronounced than the others – for example, those with a thick line or a circle around them. She notices that a marker is bigger and asks the customer to tell her about the event. The customer says: "That's where I met my only true friend." Bernard writes this on the top of the timeline.
Bernard continues to discuss these experiences with the client, marking positive events at the top and negative events at the bottom of the timeline. Clients often get stuck seeing only the negatives, Bernard explains, so marking the timeline in this way helps show clients the duality of their experiences (ie, some are harsh while others are good or okay).
Highlighting these positive experiences is also the first step in building the client's resources, which takes place in Phase 2 of EMDR. This phase is of crucial importance for this client, as the first sessions show that she only has limited resources to assess her own relationship and physical security, which often leaves her hypervigilant, anxious and overwhelmed in everyday life.
Bernard asks the client what she thinks of the memory of having made this one true friend. The client replies that she has no feelings about what is becoming an issue on Bernard, which indicates that the client is experiencing some degree of dissociation.
After three months of working on creating a sense of security, developing a strong therapeutic alliance, and cultivating coping strategies, Bernard finds that the client still does not have sufficient resources to reminisce about stressful memories in the final stages to combat EMDR. Therefore, she decides to use EMDR to improve access to stabilizing resources with the customer. This allows them to approach the problem through a strengths-based approach by targeting positive (rather than negative) memories and beliefs.
"EMDR is an artful, flexible, and powerful approach to meeting every client where they are on their healing journey," says Bernard. “We can use bilateral stimulation to work through past traumas or to help them to recognize their strengths and resilience despite the trauma in the present. EMDR clinics that understand the robustness of the protocol and can apply it creatively to therapy, so many clinical decisions are possible. "
Next, Bernard writes down a list of positive things for which the client is responsible, such as surviving her previous abuse, graduating from college, and being a good teacher and parent. She asks the client, “Are you responsible for all of this?” Then she uses bilateral stimulation to develop these positive neural pathways in the client's brain. This allows the client to focus on the current positive experience rather than the negative feedback loop that stems from her previous abuse.
"While I am building up resources, I am also teaching this client past and present orientation," explains Bernard. Experiences back? It's over; You got through it. ”“ This is a powerful aspect of EMDR therapy, she claims, because it allows the client's mind and body to see that past traumas are over and they are safe.
A few months later, the client is ready to target the traumatic memories, including the thoughts, sensations and beliefs developed from these experiences. The self-beliefs shaped by her early trauma are so fundamental to her current self-image that she and Bernard have to target them one by one. After working on conditioning the memory to understand it (using bilateral stimulation), they incorporate the new insight into the body to create a new meaning. This process is repeated for each traumatic memory goal, which ultimately enables the client to revise the idea that she was responsible for what happened to her as a child.
After months of working through the traumatic memories, the client no longer feels responsible for the past abuse that happened to her. The client now sees her perpetrator as a row of dominoes and realizes that she no longer belongs in the same row.
“This shift could not have been achieved without the use of the full EMDR protocol of applying bilateral stimulation in conjunction with holding traumatic memories, images and body sensations; Processing of emotions; and redefining what experience means to [the client] from a perspective of security and the knowledge that it is in the past, ”notes Bernard.
Now the client has healthier self-confidence and stronger boundaries, works in a job that she loves, and feels safe again in her own mind and body.
Be fluid, not rigid
As an EMDR coach, Bernard saw several competent therapists doubt themselves during EMDR training, which includes five intensive days of learning new terms and concepts. She recently wrote a blog post titled "Five Things Every Newly Trained EMDR Therapist Wishes They Knew" to address these issues. In it, she reminds practitioners that they don't need to be competent to begin with. Instead, she recommends remaining curious and practicing in consultation with other EMDR-trained therapists in order to increase her self-confidence.
"EMDR is a protocol and a learning process, but it's an art when it's taught," says Bernard. If counselors are too rigid or cognitively oriented, they may have problems with EMDR, she notes, and they may not be able to establish a sense of co-regulation with the client.
"The protocol feels linear, but it is not always the case," emphasizes Bernard. Consultants should go through the EMDR phases as needed in coordination with their clients. If they try to stick with the script as well or focus too much on what stage they are in, the approach will feel rigid and affect the energy in the room, she emphasizes. Also, they may not be attuned to what the client just said or what the client needs.
Most counselors have good intentions and want to get it “right”, Bernard admits, which is why it is so important to have colleagues and counselors to help them learn and to remind them to trust their clinical instincts. She always advises her trainees to practice EMDR more fluently than rigidly.
Counselors can be loyal, “and effective towards the treatment model, while being creative and flexible at the same time,” she says. “Will it be slower at the beginning as a new EMDR therapist? Yes sir. Will it be more impactful, profound, and life-changing for you and the client than many other clinical approaches? Yes. "
Do not hurry with the process
People often assume that phase 4 – the desensitization or bilateral stimulation component – is EMDR, but that's wrong, says Bernard. If counselors move on to desensitization too quickly, clients can become over-activated. “If we bring people into intense emotional states without paying close attention to their tolerance window, they cannot remain present in their body, and if they cannot remain in their body, we do not heal them. We trigger it again, ”she explains.
She advises advisors to slow down phase 2 and not to overlook or rush it. This phase helps clients prepare for the intense emotions that may arise during the later phases of EMDR by developing containment skills such as mind-body shift, deep breathing, precautionary statements, mindfulness, and grounding.
“When you work with clients with complex trauma or highly activated ones with anxiety, depression or dissociation, you will spend a lot of time building security, strengthening the therapeutic alliance and building regulatory skills to bring them up affectively below if in later reprocessing phases of EMDR, ”says Bernard.
She assesses a customer's feeling of security as soon as they enter her office and asks them why they feel safe in the room. When a client responds by saying, “I know where the front door is,” then she knows that her sense of security is low and that she needs to strengthen it in order to prepare her for EMDR. If, on the other hand, the customer replies: “I like the colors in your office and your plants”, then she knows that the customer has a higher level of security in the preparation phases.
Parola found that some clients are reluctant to proceed with EMDR therapy because they fear that the dual attention stimuli (or bilateral stimulation) involve hypnosis or that they cannot control their emotions or their body. So she introduces them to the concept of double-minded stimuli by doing a slower and shorter version of them as they establish the client's safe space in phase 2. The client chooses a place where he feels safe. Then she asks them to think about an image that represents this place and asks, “What emotions are you feeling? What are your feelings? "When the client shows a positive response, she integrates short, slow stimuli with double attention to reinforce this resource. This helps the client prepare for a faster and longer version of double attention later. Stimuli zu verwenden, wenn sie traumatische Erinnerungen wiederverarbeitet, sagt sie.
Brown stellt fest, dass einige Klienten sagen, dass sie bereit sind, ihre traumatischen Erinnerungen zu verarbeiten, aber dann in den letzten Phasen an eine emotionale Wand stoßen. Zum Beispiel kann jemand, dem seine Eltern als Kind ständig gesagt haben, dass er nicht weinen soll, sich schützen, indem er lernt, wie man sich selbst vom Weinen abhält. Wenn sie diese Barriere nicht angehen, bevor sie in die Desensibilisierungsphase übergehen, kann diese Schutzstrategie sie daran hindern, diese Emotion während der Behandlung vollständig zu spüren, erklärt Brown. Aus diesem Grund begann sie während der Phase 2 von EMDR, das Modell des internen Familiensystems (das den Geist als aus Unterpersönlichkeiten oder „Teilen“ bestehend betrachtet) mit jeweils eigenem, einzigartigen Standpunkt zu integrieren, um sicherzustellen, dass sie gemeinsam alle Teile von des Klienten und adressieren alle Barrieren, die die Heilung beeinträchtigen könnten.
„Phase 2 verändert das Leben, wird aber von vielen EMDR-Therapeuten oft übersehen“, betont Bernard. „Wenn wir aus Gründen, die außerhalb unserer Kontrolle liegen, nur begrenzte Zeit mit einem Klienten haben und ihm nur helfen können, ein zugängliches Gefühl der Sicherheit und dringend benötigte kognitive und somatische Regulationsressourcen zu entwickeln, haben wir sein Leben immer noch auf kraftvolle Weise verändert, auch ohne die Traumaaufbereitung.“
Anpassung an die Bedürfnisse des Kunden
Die EMDR-Therapie entwickelt sich weiter und verfügt nun über spezialisierte Ansätze, die auf die Bedürfnisse bestimmter Bevölkerungsgruppen oder psychische Probleme eingehen. Zum Beispiel wurde das Protokoll zur Desensibilisierung von Auslösern und zur Wiederaufarbeitung des Drangs (DeTUR) von AJ Popky entwickelt, um Sucht zu behandeln; Dieser Ansatz hilft den Klienten, ihren Wunsch nach Drogen- oder Alkoholkonsum zu fokussieren und gleichzeitig zugrunde liegende Traumata zu adressieren.
Parola, die EMDR-Sandschalen-zertifiziert ist, verwendet manchmal Sandschalentechniken in den acht Phasen der EMDR-Therapie. Zum Beispiel kann sie ein Kind die Figuren im Sandkasten benutzen lassen, um einen sicheren Ort darzustellen, während sie das Kind in eine bilaterale Stimulation einbezieht, indem sie einen Pinsel langsam über die Hand des Kindes hin- und herbewegt.
Berater können auch Änderungen am Achtphasenprotokoll vornehmen. Bernards Fallbeispiel veranschaulicht eine Anpassung der Anpassung des Protokolls an die Einrichtung von Ressourcen und adaptiven Selbstvertrauen, anstatt Traumata zu verarbeiten, weil die internen Ressourcen des Klienten anfangs so gering waren.
Bilaterale Stimulation ist eine weitere Möglichkeit, wie Berater das Protokoll an die individuellen Bedürfnisse der Klienten anpassen können. Augenbewegungen sind die am häufigsten verwendete und am besten erforschte Form der bilateralen Stimulation, aber Ärzte können auch Klopfen, taktile Stimulation oder akustische Töne verwenden. Bernard findet die Verwendung von Tappern für die bilaterale Stimulation hilfreich für Menschen mit Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung oder die sehr ablenkbar sind, da sie die Augen schließen und sich auf ihren Körper einstellen können. Bei Kunden, die sich dissoziieren oder die Schwierigkeiten haben, ihre Emotionen zu kontrollieren, verwendet sie oft eine Lichtleiste (eine Leiste mit LED-Lichtern, die sich hin und her bewegt) oder Fingerbewegungen, weil die Nähe es ihr ermöglicht, Veränderungen in den Augen der Kunden zu bemerken, wenn sie das verfolgen Bewegung.
Brown entdeckte, dass einige ihrer Kunden den Lichtbalken nicht für die bilaterale Stimulation verwenden wollten und sie während der Aufbereitungsphasen nicht vor ihnen sitzen wollten. Also hat sie sich angepasst, um ihren Bedürfnissen besser gerecht zu werden. She often sits off to the side where she can still observe them from a safe distance, and she allows clients to use different types of bilateral stimulation. Most of her clients prefer holding pulsers that vibrate, but she has one client who chooses to simply tap on the side of their leg.
Research continues to shed new light on ways EMDR can be used to help clients who are struggling with trauma and other mental health issues. Two recent articles in EMDRIA’s Go With That magazine discuss how EMDR can be used to address racialized trauma and addiction.
Bernard notes there is promising research highlighting that just taxing working memory (and not necessarily with bilateral stimulation) shows signs of decreasing the emotional charge around traumatic memories.
Bernard appreciates that Shapiro’s theory has given her an eight-phase protocol that allows her to be with her clients in extraordinarily profound ways: “Any therapy that sees the person as a whole — brain, body and mind — that asserts it’s not about what’s wrong with you but what happened to you, that teaches what happened to you then is over and we’re here now, and that says the information your body is sending to you is an important part of your own healing … is a gift to the therapeutic community at large.”
1) History and treatment planning (discuss the client’s history, develop a treatment plan, assess the client’s internal and external resources)
2) Preparation (build a therapeutic alliance, explain EMDR, set expectations, build the client’s coping strategies)
3) Assessment (identify the event to reprocess, establish a baseline with the Subjective Units of Distress (SUD) and Validity of Cognition measures)
4) Desensitization (use bilateral stimulation while the client thinks about the traumatic event with the goal of reducing the client’s SUD to zero)
5) Installation (strengthen a positive belief that the client wants to associate with the target experience until it feels completely true)
6) Body scan (ask the client to think about the target event and positive belief while scanning the body from head to toe, process any lingering disturbances with bilateral stimulation)
7) Closure (help the client return to a calm state)
8) Reevaluation (discuss recently processed memories at the beginning of a new session to ensure the client’s distress is still low and positive cognition is strong, determine future targets and directions for continued treatment)
(Information adapted from EMDRIA)
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Lindsey Phillips is the senior editor for Counseling Today. Contact her at [email protected].
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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.
