The What, Why, and How of EMDR
Eye Movement Desensitization Reprocessing and Other Forms of Bilateral Stimulation
What is EMDR?
Eye Movement Desensitization Reprocessing (EMDR) is a treatment protocol developed by Dr. Francine Shapiro in 1987. Originally developed to assist clients in processing specific traumatic memories, EMDR protocols and the principles behind them have been adapted to also assist with other mental health concerns including anxiety, somatic distress, and phobias. Though the original protocol was for therapists to assist clients by having them move their eyes, this method falls under a larger umbrella of methods called bilateral stimulation (BLS) – actions that engage both sides of the brain. These may be accomplished by using devices that send mild electronic pulses from one hand to another, clients tapping their own feet or shoulders, and even walking or drumming.
EMDR is often represented as short-term treatment that focuses on a few sessions in which traumatic memories are reprocessed through BLS. However, that is only one of the steps in a larger protocol that includes relationship building, assessing client’s needs, and building coping skills prior to the reprocessing, and then integration sessions following. EMDR is often weaved into larger treatment plans that include classic talk therapy and referrals for additional services such as group therapy or medication management. Not all clients are good candidates for EMDR, so providers will often discuss risks and benefits of this method as well as alternatives that may be more effective. Additionally, adaptations can be made based on client preferences, symptomology, and the therapeutic setting in which it will occur.
How does EMDR work?
EMDR is usually accomplished using an Eight Phase (or step) process. Each phase is vital to the process, but some may not occur in the exact order and/or providers may loop back to earlier phases very quickly, depending on the targets that are being worked on and client responses. The Eight Phases are as follows:
Intake/Treatment Plan: The provider will take time to thoroughly understand client histories, their current symptoms, and challenges they face. Based on this information, providers and clients co-construct a treatment plan, so both parties have an agreement regarding what events/symptoms will be targeted by the treatment, expected length of treatment, and ways progress will be measured.
Preparation: Providers and clients work together to create a set of coping skills that will be used during the rest of treatment, a process known as resourcing. These skills may include, but are not limited to, grounding skills, calming imagery, metaphorical devices, and crisis protocols. This phase may be one of the longest phases of the treatment, as it is very specifically tailored to each individual client’s needs and should be well practiced prior to moving forward.
Assessment: Providers and clients work together to determine the order in which each memory/symptom will be addressed, assigning numbers based on how distressing each is in the present.
Activation & Desensitization: Providers help clients experience distress associated with each memory/symptom in real time. It is at this point that providers will apply bilateral stimulation until the subjective distress is decreased.
Installation: Providers will continue BLS while helping clients attach positive thought processes and sensations to the target symptoms/memories.
Body Scan: Providers may ask clients to scan their body for residual tensions or symptoms, and Phases 4 & 5 may be repeated until clients report a reduction to minimal/no distress.*
Closure: Providers and clients discuss what has been accomplished, and providers assist clients in grounding themselves prior to ending each session.
Re-assessment: At the beginning of the next session, providers and clients will review the last session, the impacts it had during the week, and what will be accomplished that day.
Why Does EMDR Work?
Francine Shapiro is said to have recognized the power of BLS during a walk in which she was thinking about some difficult memories. It is said that she noticed that, as her eyes moved from side to side to look at the trees, her emotions became more calm. It is from this experience that Dr. Shapiro developed the EMDR protocol. It was originally difficult to discern why EMDR worked so well, at times dismissed as a placebo effect by its critics. However, more recently, two theories have emerged regarding why BLS is so effective in decreasing the distress associated with memories and other cognitive processes.
The Working Memory Theory: This theory supposes that BLS is effective because the task of moving one’s eyes (or paying attention to other BLS) taxes clients’ working memories while also requiring clients to engage older, target memories/sensations. This dual task causes the older memory to be re-experienced while the brain is busy engaging in a menial task, which leads it to be associated with a more neutral experience. When the memory is then returned to long term storage, it is distilled from the original, more intense experience in which it was created.
The Adaptive Information Processing Model: This theory is based on the idea that traumatic memories and adverse experiences are stored in neural networks that are unconnected to networks that are associated with more positive experiences. Thus, when clients fire negative thoughts, they may have a difficult time finding their way back to positive ones. This theory supposes that Phase 4 and Phase 5 of EMDR move the targeted memory/symptoms from these isolated networks and encourage them to become associated with positive neural networks. Thus, when clients think of the negative memory/symptom, they begin to have an easier time shifting focus to more positive experiences.
Will it Work for You? Research, Benefits, and Limitations
There are no guarantees that any one therapy will work for any given individual, which is why a thorough intake assessment is necessary prior to initiating EMDR and providers and clients should have ongoing discussions regarding client expectations and whether goals are being met. That said, from a research perspective, EMDR has been found to be highly effective in treating trauma, anxiety, and other mental health symptoms. An early study by Kaiser Permanente found that 100% of patients with a history of a single trauma and 77% with multiple-trauma history no longer met diagnostic criteria for Post Traumatic Stress Disorder after six 50-minute EMDR sessions, and these results were mostly maintained at 3- and 6-month follow up appointments (Marcus, Marqui, & Sakai, 1997; Marcus, Marqui, & Sakai, 2004). As a testament to its efficacy, in their practice guidelines, the Department of Defense has listed EMDR as being a trauma treatment that is effective for all populations, and in 2004, the American Psychiatric Association placed it with Cognitive Behavioral Therapy and medication as being a primary treatment for trauma.
A benefit of EMDR is its adaptability to client presentation and preferences. It can be conducted via telehealth, and BLS can be achieved using multiple modalities, depending on client preferences. It can also be adapted to clients who have disabilities that impair one or more functional areas, including sight, hearing, and mobility. Clients undergoing EMDR have also noted the benefit of not having to describe the details of their distress memory or symptom to their provider. This may be a benefit if clients either lack words to describe their experiences or do not wish to do so for any reason.
Limits of EMDR are the structured approach and the possibility of clients experiencing an increase of symptoms prior to their resolution. This is why many providers will take a lot of time engaging clients in Phase 1 (the intake and orientation as to what to expect) and Phase 2 (preparing for treatment by practicing grounding skills), as these help clients feel well prepared for what is to come.
As with any therapeutic approach, the most important predictor of goal attainment is the therapeutic relationship. Time should be taken to build trust with your provider, and it is imperative not only that you feel you can talk to your provider about what is or is not working but that they are able to receive that feedback and make adjustments within the realms of their ethical, training, and best practice guidelines.
*When clients do not have a specific memory or thought process associated with their distress, such as in complex PTSD, or when distress is primarily a bodily sensation, Phase 6 may be completed before or simultaneously to Phase 4.
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Dr. Elisa Woodruff (she/they) has been studying neuroscience-specific interventions on a general level since 2016, including receiving a graduate certificate in trauma informed counseling in 2018. More recently they have become certified in EMDR by one of the country’s leading experts in the field, and Neuropsychotherapy, which is a method of addressing challenges using exercises that strengthen the brain. Dr. Woodruff is also trained in the assessment and treatment of ADHD and has extensive experience working with people who have chronic illness and those on the LGBTQIA+ spectrum of identities. For those wishing for a more traditional approach, Dr. Woodruff is also trained in classic models such as Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, and modern psychodynamic theories. Please call 630-297-7559 if you are interested in working with Dr. Woodruff to create a treatment plan that is unique to your goals, strengths, and personal preferences.
