Transcript Slide 1

EMDR for Professionals
Hospice of Volusia/Flagler
Lynda Majure Ruf, EdS, LMFT, LMHC
August 3, 2007
What is EMDR?
• EMDR is a psychological method for
treating emotional difficulties caused by
disturbing events.
•EMDR brings together elements from wellestablished clinical theoretical orientations.
For many clients, EMDR provides more rapid
relief from emotional distress than
conventional therapies.
What is the origin of EMDR?
•In 1987, psychologist Francine Shapiro
discovered that voluntary eye movements
reduced the intensity of disturbing thoughts.
•Although EMDR was originally developed by
Dr. Shapiro with lateral eye movements as a
core feature of its methodology, alternate
forms of bilateral stimulation are now being
used, such as alternate right-left auditory
tones and taps on the client’s hands.
EMDR: An Adaptive Information
Processing Model
• Traumatization is a disruption of the inherent information
processing system that normally leads to integration and
adaptive resolution following upsetting experiences (van der
Kolk & Fisler, 1995).
• Under normal circumstances, this information processing may
occur during thinking, talking, expressive/artistic activities,
and/or dreaming.
• In trauma, however, a malfunction of this natural information
processing system occurs such that the experience of the
trauma remains “frozen”, manifesting in persistent intrusive
thoughts, negative emotions and self-referenced beliefs, and
unpleasant body sensations.
Components of Traumatic Memory
TRIGGERS
PICTURES
EMOTIONS
TRAUMA
SENSATIONS
BELIEFS
EMDR: An Adaptive Information
Processing Model
• All humans are understood to have a
physiologically-based information processing
system. This can be compared to other body
systems, such as digestion in which the body
extracts nutrients for health and survival. The
information processing system processes the
multiple elements of our experiences and stores
memories in an accessible and useful form.
Memories are linked in networks that contain
related thoughts, images, emotions, and
sensations. Learning occurs when new
associations are forged with material already
stored in memory.
EMDR: An Adaptive Information
Processing Model (cont)
When a traumatic or very negative event occurs, information
processing may be incomplete, perhaps because strong
negative feelings or dissociation interfere with information
processing. This prevents the forging of connections with more
adaptive information that is held in other memory networks. For
example, a rape survivor may “know” that rapists are
responsible for their crimes, but this information does not
connect with her feeling that she is to blame for the attack. The
memory is then dysfunctionally stored without appropriate
associative connections and with many elements still
unprocessed. When the individual thinks about the trauma, or
when the memory is triggered by similar situations, the person
may feel like s/he is reliving it, or may experience strong
emotions and physical sensations. A prime example is the
intrusive thoughts, emotional disturbance, and negative selfreferencing beliefs of posttraumatic stress disorder (PTSD).
EMDR: An Adaptive Information
Processing Model (cont)
• It is not only major traumatic events, or “big-T
Traumas” that can cause psychological
disturbance. Sometimes a relatively minor
event from childhood, such as being teased
by one’s peers or disparaged by one’s parent,
may not be adequately processed. Such
“little-t traumas” can result in personality
problems and become the basis of current
dysfunctional reactions.
EMDR: An Adaptive Information
Processing Model (cont)
• Shapiro proposes that EMDR can assist to successfully
alleviate clinical complaints by processing the components
of the contributing distressing memories. These can be
memories of either little-t or big-T traumas. Information
processing is thought to occur when the targeted memory
is linked with other more adaptive information. Learning
then takes place, and the experience is stored with
appropriate emotions, able to appropriately guide the
person in the future. A variety of neurobiological
contributors have been proposed 4,5,6,7,8
• EMDR specifically targets traumatic material and appears
to restart “stalled” information processing, facilitating the
resolution of the traumatic memories through the
activation of neurophysiological networks in which
appropriate and positive information is stored.
What Happens during EMDR?
During EMDR, the clinician works with the client to identify the
specific problem that will be the focus of treatment.
Utilizing a structured protocol, the practitioner guides the client
through a description of a disturbing event related to his or her
presenting problem(s). The practitioner asks the client to identify
and focus on the image, cognitions, emotions, and somatic
distress associated with the traumatic memory.
While the client is engaged in eye movements or some other
form of bilateral stimulation, s/he is experiencing various
aspects of the initial memory or other related memories.
The practitioner pauses with the eye movements or bilateral
stimulation at regular intervals to ensure that the client is
processing adequately on his or her own.
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What Happens during EMDR?
The practitioner guides the process, making clinical
decisions about the direction of the intervention. The
client may process at cognitive, affective, and/or
somatic levels over the course of a given session.
The goal is the client's rapid processing of
information about the negative experience, bringing it
to an "adaptive resolution."
In Shapiro's words, this means a reduction in the
symptomatology, a shift in the negative belief to the
client's new positive belief, and the prospect of
functioning more optimally.
What Happens during EMDR? (cont)
The comprehensive "three-pronged
approach" employed in the EMDR method
addresses:
1) earlier life experience;
2) present-day stressors; and
3) desired thoughts and actions for the future.
EMDR treatment may last from 1-3 sessions
to 1 year or longer for complex problems.
Why Do Clients Seem to
Respond Well to EMDR?
•EMDR is a client-centered approach that
allows the clinician to facilitate the
mobilization of the client's inherent healing
mechanism.
•EMDR targets the physiological components
of emotional difficulties, along with negative
beliefs, emotional states, and other disturbing
symptoms.
Why and how does EMDR work?
Hypothesized Mechanisms
• Many hypotheses have been put forth to
explain the possible mechanism of
change related to EMDR, but a
definitive explanation has not been
confirmed.
• “Fortunately we do not have to know
why a demonstrably effective treatment
works before using it.” (Shapiro, 1995)
EMDR: Hypothesized Mechanisms
One hypothesis was proposed by
Harvard Medical School sleep
researcher Robert Stickgold, Ph.D. at
the 1998 EMDRIA Annual Conference:
EMDR: Hypothesized Mechanisms
"Several lines of evidence suggest that EMDR may
help in the treatment of PTSD by turning on
memory processing systems normally activated
during Rapid Eye Movement (REM) sleep but
dysfunctional in the PTSD patient. Two separate
memory systems store information in the brain.
One, located in the hippocampus, stores 'episodic'
memories, the memories of actual events in our
lives. The second, located in the neocortex, stores
general information and associations.”
EMDR: Hypothesized Mechanisms
Stickgold proposed that recovery from trauma
depends the processing of traumatic memories in
their episodic form into general semantic
memories. Literature that suggests that this
normally occurs during REM sleep but is
prevented from occurring for people who have
PTSD. In particular the arousal associated with
PTSD results in associations between the trauma
event and other related events failing to develop.
EMDR: Hypothesized Mechanisms
• Bessel van der Kolk, M.D. of Boston University
School of Medicine states (Boston Globe, 1998):
“In a recent EMDR study, in collaboration with the New
England Deaconess/Beth Israel Neuroimaging
Laboratory, brain scans were used to measure how
brain activity changes after effective treatment.”
• During EMDR two areas of the brain had increased
activation: the anterior cingulate gyrus and the left
frontal lobe. It is tempting to say that these changes
reflect an increased ability to differentiate between
exposure to a real traumatic event and confrontation
with a mere reminder of a shocking event that
occurred many years ago.
EMDR: Hypothesized Mechanisms
•EMDR through the repetitive redirecting of attention,
activates brain systems normally present during REM
sleep. Any alternating, lateralized stimulation
regimen, whether eye movements, tapping, or
binaural sound, could activate these systems by
forcing the brain to constantly re-orient to new
locations in space. In this manner, EMDR can 'pushstart' the broken-down REM machinery that is
required for the brain to effectively process traumatic
memories.”
Treatment elements of EMDR
Treatment elements enhance the processing
and assimilation needed for adaptive
resolution. These include:
1)Linking of memory components.
2)Mindfulness.
3)Free association.
4)Repeated access and dismissal of
traumatic imagery.
5) Eye movements and other dual attention
stimuli.
Treatment elements of EMDR
1) Linking of memory components.
• The client’s simultaneous focus on
the image of the event, the
associated negative belief, and the
attendant physical sensations, may
serve to forge initial connections
among various elements of the
traumatic memory, thus initiating
information processing.
Treatment elements of EMDR
2) Mindfulness.
• Mindfulness is encouraged by
instructing clients to “just notice”
and to “let whatever happens,
happen.” This cultivation of a
stabilized observer stance in
EMDR appears similar to
processes advocated by Teasdale
(1999) as facilitating emotional
processing.
Treatment elements of EMDR
3) Free association.
• During processing, clients are asked to
report on any new insights, associations,
emotions, sensations, images, that emerge
into consciousness. This non-directive free
association method may create associative
links between the original targeted trauma
and other related experiences and
information, thus contributing to processing
of the traumatic material (see Rogers &
Silver, 2002).
Treatment elements of EMDR
4) Repeated access and dismissal of
traumatic imagery.
• The brief exposures of EMDR provide
clients with repeated practice in
controlling and dismissing disturbing
internal stimuli. This may provide clients
with a sense of mastery, contributing to
treatment effects by increasing their
ability to reduce or manage negative
interpretations and ruminations.
Treatment elements of EMDR
5) Eye movements and other dual
attention stimuli.
• There are many theories about
how and why eye movements may
contribute to information
processing.
The Eight Phases of EMDR Treatment
The eight phases of the EMDR protocol represent a
comprehensive treatment approach incorporating
many well-established elements of psychotherapy and
the novel element of bilateral stimulation.
1. Client History and Treatment Planning
2. Client Preparation
3. Assessment
4. Desensitization
5. Installation
6. Body Scan
7. Closure
8. Reevaluation
The Core of EMDR Treatment
ASSESSMENT PHASE
DESENSITIZATI0N PHASE
INSTALLATI0N PHASE
The Core of EMDR Treatment
ASSESSMENT PHASE
•Presenting Issue
•Picture
•Negative Cognition (NC)
•Positive Cognition (PC)
•Validity of Cognition (VOC)
•Emotions/Feelings
•Subjective Units of Distress
(SUDS)
•Location of Body Sensation
The Core of EMDR Treatment
DESENSITIZATION PHASE
•Potential Responses: Pictorial Processing,
Cognitive Processing, Emotional
Processing, Sensory Processing
•Associative Links and Feeder Memories
•Informational Plateaus:
•Responsibility, Safety, and Choices
INSTALLATION PHASE
•Integration of Positive Cognition with
•Targeted Information and VOC Check
Examples of Cognition
Negative Cognitions
Positive Cognitions
I am a bad person.
I am a good person.
I am worthless (inadequate).
I am worthy; I am worthwhile.
I am shameful.
I am honorable.
I deserve only bad things.
I deserve good things.
I cannot trust my judgment.
I can trust my judgment.
I cannot succeed.
I can succeed.
I am not in control.
I am now In control.
I am powerless.
I now have choices.
I am weak.
I am strong.
I cannot protect myself.
I can (learn to) take care of myself.
I am stupid.
I have intelligence.
I am Insignificant (unimportant).
I am significant (important).
I am a disappointment.
I am okay just the way I am.
I deserve to die.
I deserve to live.
I deserve to be miserable.
I deserve to be happy.
I cannot get what I want.
I can get what I want.
I am a failure (will fail).
I can succeed.
I have to be perfect (please everyone). I can be myself (make mistakes).
I am permanently damaged.
I am (can be) healthy.
Reprinted with permission of the EMDR Institute, Inc.
Childhood Trauma Case Example
Client
A 35-year-old woman reports that she was sexually abused as a child by her
alcoholic father.
•Presenting Problems: Nightmares, flashbacks, avoidance of trauma-related
trigger situations, hypervigilence, guilt, self-hatred, mistrust of others, and a
sense of hopelessness and helplessness.
•Negative Cognitions: It was my fault. I'm bad. I'm always vulnerable and in
danger. I have no control.
•Positive Cognitions: I did the best I could. I'm a good person. It's over. I'm safe
now. I have choices and a reasonable degree of control now.
Assessment Components
•Picture: My father appears at the bedroom door late at night and tells me to
take off my clothes. I'm about 5 years old. He smells of alcohol.
•Negative Cognition: I'm in danger.
•Positive Cognition: I'm safe now.
•VOC=2
•Emotions/Feelings: Fear, sadness, anxiety
•SUDS=8
•Location of Body Sensation: Tension in the neck and shoulders, knots in
stomach, palpitations in chest.
Childhood Trauma Case Example
TRIGGERS
•Watching a “sexual scene” in a movie
•Smell of alcohol
•Husband expressing desire for intimacy
•Excessive demands from boss
PICTURES
My father at my
bedroom door telling
me to take off my
clothes
EMOTIONS
Traumatic Memory
Fear, sadness, anxiety
Age 5
Sexual Abuse by
Alcoholic Father
SENSATIONS
•Tension in neck and shoulders
•Knots in stomach
•Palpitations in chest
BELIEFS
•It was my fault
•I’m bad
•I am always vulnerable
and in danger
•I have no control
Childhood Trauma Case Example
Possible Information Processing Shifts Related to Concepts of
Responsibility, Safety, and Choices:
Responsibility:
•Client recognizes that she was an innocent child betrayed by the person who
was supposed to love and protect her.
•She mourns the loss of her "innocence" and expresses anger toward her father
for the first time.
•She experiences a greater sense of compassion for herself and an increased
sense of self-respect as a survivor.
Safety:
•Client experiences a dramatic increase in her distress level as her memories of
abuse are desensitized and reprocessed.
•She recognizes (at a cognitive, affective, and somatic level) that the abuse is
truly over and that her father can no longer hurt her.
Childhood Trauma Case Example
Possible Information Processing Shifts Related to Concepts of
Responsibility, Safety, and Choices (cont):
Choices:
•Client begins to acknowledge the choices she has made in her adult
life (establishing boundaries with her family of origin, connections with
supportive people, a commitment to therapy).
•She begins to consider new possibilities for the future.
•She expresses a desire to initiate new friendships and activities and
acknowledges a renewed sense of hope and confidence.
Work-Related Case Example
Client
A 40-year-old man who was laid off during the 'downsizing' of his company.
•Presenting Problem: Sleep-onset insomnia, loss of appetite, self-medicating with
alcohol, irritable, worried about the future, "paralyzed" in efforts to seek other work,
fighting with his children and sometimes with his wife.
•Negative Cognitions: I'm not worthwhile enough to retain at my company so they
let me go. I'm worthless.
•Positive Cognition: I have value to offer and can find an organization that
recognizes this about me and is a 'good fit' with my skills and who I am.
Assessment Components
•Picture: The Human Resources Director comes into my cubicle and tells me that I
have 10 minutes to clear out my desk and download my computer files before my exit
interview.
•Negative Cognition: I'm worthless.
•Positive Cognition: I have value.
•VOC=3
•Emotions/Feelings: Irritable, worried
•SUDS=7
•Location of Body Sensation: nausea, tightness in chest, tingling in arms
Work-Related Case Example
TRIGGERS
•Friends who are still employed calling to ask how things are going
•wife asking how the job search is proceeding
•kids wanting more allowance
PICTURES
The Human Resources
Director comes into my
office and tells me I have
10 minutes to clear out
my desk...
EMOTIONS
Irritable, worried
BEING LAID OFF
AT HIS COMPANY
SENSATIONS
Nausea, tightness in chest, tingling in arms.
BELIEFS
I’m worthless.
Work-Related Case Example
Possible Information Processing Shifts related to
Concepts of Responsibility, Safety, and Choices:
Responsibility:
•Client considers whether he is at “fault”, for being on the list
for layoffs. Practitioner and client explore client's history of
performance reviews and note that all were average or above
average.
•Client comes to understand that he is not at "fault." He
recognizes that this layoff had more to do with the company's
economic pressures than his worth.
•The client acknowledges that he has performed well, as
evidenced by his written reviews, but nevertheless, he has
been let go.
Work-Related Case Example
Possible Information Processing Shifts related to
Concepts of Responsibility, Safety, and Choices:
Safety/Survival:
•Client explores the question, "Will I be okay?"
•In assessing his strengths, he arrives at the idea, "I will find
another position because of the skills and work experiences I
have accumulated. And I do have the financial resources to
last 6 months while I search for another position. I can borrow
money from my brother if I have to.”
Work-Related Case Example
Possible Information Processing Shifts related to
Concepts of Responsibility, Safety, and Choices:
Choices:
•Client at first confronts his fear of "having no choices." He
questions whether he must remain in the same industry and
concludes that he can look at other industries hiring people
with his skill set.
•At this point, he assesses the time and costs needed to
change careers and decides that he will stay in the same line
of work but search within several different industries.
•He feels more encouraged for having arrived at this greater
sense of choice.
Efficacy and Endorsement of EMDR?
International Treatment Guidelines
Recommending EMDR
International Treatment Guidelines
• American Psychiatric Association (2004). Practice Guideline for the
Treatment of Patients with Acute Stress Disorder and Posttraumatic
Stress Disorder. Arlington, VA: American Psychiatric Association
Practice Guidelines
– EMDR given the highest level of recommendation (category for robust
empirical support and demonstrated effectiveness) in the treatment of
trauma.
•
Bleich, A., Kotler, M., Kutz, I., & Shalev, A. (2002). A position paper
of the (Israeli) National Council for Mental Health: Guidelines for the
assessment and professional intervention with terror victims in the
hospital and in the community. Jerusalem, Israel.
–
EMDR is one of only three methods recommended for treatment of terror
victims.
International Treatment Guidelines
Recommending EMDR
•
Chambless, D.L. et al. (1998). Update of empirically validated
therapies, II. The Clinical Psychologist, 51, 3-16.
– According to a taskforce of the Clinical Division of the American
Psychological Association, the only methods empirically supported
for the treatment of any post-traumatic stress disorder population
were EMDR, exposure therapy, and stress inoculation therapy.
•
CREST (2003). The management of post traumatic stress disorder in
adults. A publication of the Clinical Resource Efficiency Support Team
of the Northern Ireland Department of Health, Social Services and
Public Safety, Belfast.
– Of all the psychotherapies, EMDR and CBT were stated to be the
treatments of choice.
International Treatment Guidelines
Recommending EMDR
•
Department of Veterans Affairs & Department of Defense (2004). VA/DoD
Clinical Practice Guideline for the Management of Post-Traumatic Stress.
Washington, DC.
http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm
–
•
Dutch National Steering Committee Guidelines Mental Health Care (2003).
Multidisciplinary Guideline Anxiety Disorders. Quality Institute Heath Care
CBO/Trimbos Intitute. Utrecht, Netherlands.
–
•
•
•
EMDR was placed in the "A" category as “strongly recommended” for the treatment of
trauma.
EMDR and CBT are both treatments of choice for PTSD
Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD:
Practice Guidelines of the International Society for Traumatic Stress Studies
New York: Guilford Press.
In the Practice Guidelines of the International Society for Traumatic Stress
Studies, EMDR was listed as an efficacious treatment for PTSD.
INSERM (2004). Psychotherapy: An evaluation of three approaches. French
National Institute of Health and Medical Research, Paris, France.
–
Of the different psychotherapies, EMDR and CBT were stated to be the treatments of
choice for trauma victims.
International Treatment Guidelines
Recommending EMDR
•
National Institute for Clinical Excellence (2005). Post traumatic stress disorder
(PTSD): The management of adults and children in primary and secondary care.
London: NICE Guidelines.
–
•
Sjöblom, P.O., Andréewitch, S . Bejerot, S., Mörtberg, E. , Brinck, U., Ruck,
C., & Körlin, D. (2003). Regional treatment recommendation for
anxiety disorders. Stockholm: Medical Program Committee/Stockholm City
Council, Sweden.
–
•
Of all psychotherapies CBT and EMDR are recommended as treatments of choice for
PTSD.
Therapy Advisor (2004): http://www.therapyadvisor.com
–
•
Trauma-focused CBT and EMDR were stated to be empirically supported treatments
for choice for adult PTSD
An NIMH sponsored website listing empirically supported methods for a variety of
disorders. EMDR is one of three treatments listed for PTSD.
United Kingdom Department of Health (2001). Treatment choice in
psychological therapies and counselling evidence based clinical practice
guideline. London, England.
–
Best evidence of efficacy was reported for EMDR, exposure, and stress inoculation
Research: Efficacy of
EMDR
•Civilian & Combat-related PTSD
•Meta-analysis of Treatments for PTSD
•Panic Disorder & Phobias
•Somatoform Disorders
•Symptoms arising after a natural catastrophe
•Trauma in children, conduct disorders
•Test Anxiety
•Crisis Intervention
•Grief
•Substance abuse and addictions
•Performance enhancement
•Dissociative Disorders
EMDR Research
•There is much research in progress. Over
125 publications to date.
•See “Efficacy of EMDR,” updated yearly by
the EMDR Institute.
•www.emdr.com
•www.emdria.org
EMDRIA & EMDR-HAP
•EMDRIA is the professional organization that
operates independently of the Institute
•Governs training
•Organizes annual conference
•HAP – Humanitarian Assistance Programs
•The mental health equivalent of Doctors
Without Borders
•Primary focus is on training local therapists
within crisis or underserved communities
•Provides low cost basic training in EMDR
HAP Training
•Affordable, high-quality, local training
•$300 per person per Part (total $600)
•Commercial trainings average $1600
•Two, three day weekends
•Friday – Sunday, eight hours each day
•10 hours of didactic + 10 hours of supervised practice
•Average of three months apart
•10 hours of case consultation
•Sponsoring agency’s role:
•Supply participants (minimum 18)
•Furnish appropriate location and A/V supports
•Manage registration and payment of fees
•Light refreshments (optional)
•May provide 20 CEUs per part (not offered by HAP)
•Participant requirements:
•Masters level mental health clinician with valid licensure
•Full time clinical work (30 hrs/wk) in a non-profit setting