EMDR Interventions in Addiction

Trauma-Focused EMDR in Addicted Patients With Comorbid Posttraumatic Stress Disorder

PTSD and addiction often occur together, and the comorbidity is recognized as difficult to treat with higher treatment dropout and poorer outcome rates than for either condition alone (Flanagan, Korte, Killeen, & Back, 2016). Table 1 shows numerous studies where EMDR has been applied as TF treatment (TF-EMDR) in patients with PTSD-addiction comorbidity (Abel & O’Brien, 2010; Brown, Gilman, Goodman, Adler-Tapia, & Freng, 2015; Kullack & Laugharne, 2016; Marich, 2009; Perez-Dandieu & Tapia, 2014; Rougemont-Bücking & Zimmermann, 2012; Shapiro, Vogelmann-Sine, & Sine, 1994; Zweben & Yeary, 2006). In general, EMDR seems to have good results for comorbid PTSD symptoms but has only limited effects on addiction outcomes, although the recent study of Brown and colleagues (2015) is promising in this respect. To understand the potential of EMDR on addiction in comorbid PTSD, all literature on PTSD treatment in addiction is relevant, not only EMDR. In a recent review (Roberts, Roberts, Jones, & Bisson, 2015), all existing behavioral therapies for PTSD and comorbid substance use disorder were analyzed. The review was limited to randomized controlled trials (RCTs), so for EMDR only the Perez-Dandieu and Tapia (2014) study was included. Unfortunately, it was nevertheless rejected still, because PTSD was not established through formal and reliable means. However, the conclusion based on 13 RCTs (more than 1,500 patients) is in accordance with the Perez-Dandieu and Tapia (2014) study: trauma therapy delivered alongside addiction-treatment reduces PTSD severity—and thus is in itself highly valuable—but has only limited effect on the addiction itself. If any, the effect is at the long term; it does not immediately help patients to abstain from addictive behavior. At first sight, these findings seem to be at odds with the (uncontrolled) study of Brown and colleagues (2015), who found that voluntary TF treatment (EMDR) seems to significantly improve existing court program outcomes, even if symptoms were below PTSD-threshold (see Table 1). It may well be that the main effect of trauma therapy on addiction is indirect in that it enhances the feasibility and effectiveness of parallel or subsequent addiction treatment. It is also possible that voluntary commitment to trauma treatment is important. In accordance, the review of Roberts and colleagues (2015) found that participants allocated to a trauma-focused therapy (TFT) condition compared to treatment as usual (TAU) were less likely to complete treatment.

Because of the dropout rates and concerns about the applicability of TFT in addicted patients, some authors (Gerger, Munder, & Barth, 2014) highlight the possible benefits from non-TF trauma treatment, for example, the seeking safety group program for traumatized addicted people. However, Roberts and colleagues (2015) concluded in their review that non-TF trauma treatments are ineffective for PTSD symptomatology in addiction. Likewise, the often-recommended phase-based treatment for individuals with more complex clinical problems (Herman, 1992) is currently under serious discussion. The main objection is that there is hardly any evidence supporting this approach (de Jongh et al., 2016) and that it may unnecessarily postpone TF interventions. Supporters of a phased approach emphasize the necessity of a stabilization phase to reinforce a sense of safety and reduction of symptoms through improving self-management and emotional regulation (Cloitre et al., 2011). However, in the review by Roberts and colleagues (2015) as well as in a specific review regarding potential contraindications for PTSD treatment (Van Minnen, Harned, Zoellner, & Mills, 2012), it was found that trauma treatment can be safe and effective despite serious psychiatric comorbidity and substance use. This is also the conclusion of the researchers and authors of the research in Table 1: Although TF-EMDR can be challenging, it is feasible and safe. Nevertheless, high dropout rates in patients with high comorbidity and treatment-interfering stressors ask for novel avenues for efficacy research. In recent years, intensive TF-CBT for PTSD has been developed and found to be as effective as standard CBT applied on a weekly basis (e.g., Ehlers et al., 2014), for example, 30 hours of treatment in 5 working days (Hendriks, de Kleine, van Rees, Bult, & van Minnen, 2010) with lower dropout rates. To our knowledge, intensive TF-treatment has not yet been described for addicted patients, but the first experiences in the first author’s (WM) addiction clinic are promising.

With respect to the sequence of interventions, it was, until recently, believed that addiction treatment should precede trauma treatment; the patient should first reach abstinence before “digging up old pain.” Most experts in the field today realize that this is often not feasible and stagnating treatment, and they suggest a blended or even reversed approach (Abel & O’Brien, 2010; Roberts et al., 2015; Shapiro et al., 1994).

Summarizing, although PTSD treatment in addicted patients can be challenging, it is feasible and safe, and a significant reduction of PTSD symptoms is to be expected. There is—at this moment—little evidence that trauma treatment will improve addiction outcomes, at least not in the short term. A final remark is that these conclusions are mainly based on TF-CBT; it is conceivable that the effects of EMDR are broader because the procedure is less TF and more directed toward generalization and integration. Voluntary and well-informed commitment as well as the provision of (integrated) intensive programs may increase treatment adherence and treatment outcomes. All authors in the field emphasize the low quantity and quality of existing research compared to the significance of this mental health condition.

Trauma-Focused EMDR in Addicted Patients Without Posttraumatic Stress Disorder

Negative life experiences might underlie a wide range of comorbidity in addiction—not only PTSD—such as depression, phobia, social, and personality problems. Gielen, Havermans, Tekelenburg, and Jansen (2012) found that up to 97.4% of patients that presented themselves for addiction treatment had previously experienced DSM-IV criterion-A life events, whereas “only” 36.6% of them had a DSM-IV diagnosis for PTSD. However, obvious the relationship between addiction and trauma exposure may be, it is not self-evident that trauma treatment is necessary or even helpful in these cases. To put it even more strongly, sometimes the therapist and the patient both have the impression that working through the “old stuff” is very useful; the patient may even note that this is “the core of the problem, where it all begun, and what it is all about,” but at the same time, working on these painful memories may also help to avoid an even more difficult or painful part for the addicted person: ceasing the behavior. On the other hand, the approach is obvious: Addiction can be seen as a way to avoid or cope with negative emotions, emotions that are—according to the AIP model—maintained by dysfunctional stored negative learning experiences. As an alternative for affect management and coping skills training—a common element in CBT programs for addiction—one can try to diminish the negative emotions themselves by reducing the impact of the associated memories. Ideally, after TF-EMDR, there is little left that needs to be so vigorously avoided or suppressed. However, the same line of reasoning holds for PTSD in addiction (i.e., the self-medication hypothesis) and treating the PTSD appeared to have disappointing effects on the addiction itself, even if applied alongside an addiction treatment.

Studies that used TF-EMDR in patients without a full PTSD diagnosis are also included in Table 1. The general picture that emerges from these studies is fairly positive, not only regarding trauma symptoms, therapy satisfaction, and treatment completion but also regarding addiction related outcomes, such as craving, time to relapse, and abstinence rates (Brown et al., 2015; Cox & Howard, 2007; Henry, 1995; Marich, 2010; Shapiro et al., 1994; Zweben & Yeary, 2006). Unfortunately, the quality of the research prohibits clear conclusions.

Given the weak empirical evidence, history taking and case conceptualization seem all the more important when indicating TF-EMDR. In the case of PTSD there are good reasons to start with TF treatment as soon as possible. For non-PTSD patients in whom—for example in the behavior analysis—the addictive behavior serves to avoid trauma-related affect, TF-EMDR may also be indicated. That is, alongside AF interventions, as has been done in the majority of the studies on TF-EMDR in non-PTSD patients mentioned in Table 1.

Current Status of Addiction-Focused EMDR

The case conceptualization of the addicted person often demonstrates the significance of specific addiction-related symptoms, emotions, and memories, such as intense craving, fear of relapse, pleasant memories of drug use, or a general sense of helplessness toward the addiction. The reprocessing of addiction-related memory representations has been subject to many attempts to help people to overcome their addiction, the smoking cessation protocol of Popky being the very first publication (Popky, 1992). AF-EMDR protocols have been used as an adjunctive, “add-on” treatment (e.g., Bae, Han, & Kim, 2013; Hase et al., 2008) or as a “stand-alone” addiction treatment (e.g., Bae & Kim, 2012; Miller, 2010, 2012). Most approaches are directed toward mitigating craving; craving defined as an intense desire to consume a substance or to perform a specific behavior. Craving is a key concept in addiction, it might suddenly and unexpectedly be triggered, and it is an important reason for the difficulties that addicted people experience when they try to stop their addictive behavior, how well prepared and motivated they are. It is also considered an important factor in relapse.

Popky (2005, 2010) described his approach in the desensitization of triggers and urge reprocessing (DeTUR) protocol, which he considers as adjunctive to a broader treatment plan for substance use disorders and other problem behaviors such as compulsive eating. For a comprehensive outline of this protocol, see Popky (2010). Popky emphasizes the need to enhance access to a positive internal state by identifying and associating it with a positive treatment goal (PTG) in which abstinence is implied. The DeTUR protocol then focuses on present triggers that induce craving. The DeTUR uses the level of urge (LoU) scale, which represents a Likert-type scale otherwise identical to the Subjective Units of Disturbance (SUD) scale. After the memory representations of the trigger image is fully desensitized (LoU = 0), it is coupled to the positive state of the treatment goal (with the anchor and bilateral stimulation [BLS]), resembling counterconditioning from learning theory. Although several case studies have been published (see Table 1), thus far no controlled research has been done using the DeTUR protocol.

Hase (2010) described his approach in what he called the craving extinguished (CravEx) approach. He recognized that trauma is one of several possible routes leading to addiction, but that every addiction has developed a life of its own, with according memory representations. CravEx focuses on this “addiction memory” (Boening, 2001; Müller, 2013), a memory network thought to be composed of addiction-related memories of loss of control and a substance-specific memory representations of the substance. The CravEx protocol follows the three-pronged approach (Shapiro, 2001) whereby past memories of relapse (first, worst, most recent) and craving (first, worst, most recent), present triggers, and future fears are identified and desensitized with EMDR (see Hase, 2010, for the full protocol). A subset of the CravEx protocol (desensitization of memory representations of relapse and intense craving) has been used in a randomized clinical trial (Hase et al., 2008; see Table 1)—thus far the only RCT regarding EMDR in addiction. There were 34 chronic alcohol-dependent patients receiving inpatient, regular TAU participated. They were randomly assigned to TAU only or TAU + two 1-hour sessions of EMDR. Posttreatment and follow-up results were very positive for the EMDR group: they experienced less craving and had lower relapse rates. With only two additional EMDR sessions, these outcomes are almost too good to be true and need replication, especially because the high study and treatment dropout, and the fact that the researcher was also the therapist.

A different approach by Knipe (2010), in his work on dysfunctional positive affect, provides additional strategies when targeting addictions with EMDR therapy. This approach may be particularly useful to target ambivalence regarding treatment goals because positive aspects of the behavior may overshadow the wish for behavioral change. Knipe (2010) uses the Level of Positive Affect scale (a Likert-type scale ranging from 0 to 10) or Level of Positive Affect (LoPA) as a supplement to the SUD scale and LoU scale. Unfortunately, despite several appealing case descriptions (Knipe, 2005), this approach has not been evaluated in research yet.

Miller (2010), likewise, focuses on dysfunctional positive affect in his feeling-state addiction protocol (FSAP). He posits that strong positive experiences can become associated with certain behaviors and that addictions are subsequently driven by the desire to reexperience these positive states by means of reengaging in the addiction behaviors. The FSAP starts with the identification of the most positive aspects of a problematic behavior. Subsequently an affect bridge is used to identify memories that are representative for the coupling of the problem behavior and the underlying healthy need. During desensitization of these memories, associated negative associations that may have contributed to unfulfilled needs or a negative self-image may arise. Emerging negative material can be treated subsequently with the standard EMDR protocol. Miller (2012) has conducted a multiple baseline study in four patients with each at least two treatment-resistant compulsions or behavioral addictions. All four participants demonstrated a significant decrease in the specific behavior that was targeted. Positive results for the FSAP were also published in a Dutch case report of a patient suffering from exhibitionism; the positive feeling state was represented by an image in which a woman startled and the patient was feeling powerful (Ten Hoor, 2014; in Dutch, therefore not included in Table 1). A replication of these findings by others and more controlled research is needed.

Taken together, AF-EMDR protocols (Hase, 2010; Knipe, 2010; Miller, 2010; Popky, 2010) reflect interesting albeit different and sometimes partly overlapping approaches. A few more approaches have been described, but the procedure or case description was not detailed enough to be included in Table 1 (Barbieri, 2008; Omaha, 1998). The current state is that the literature is promising for substance use disorders as well as behavioral addictions (see Table 1). Empirical evidence is weak, however, even though the different protocols exist a while and are widely used. Almost without exception the protocols have been developed by expert clinicians, without much opportunity to initiate research.

On the other hand, a growing body of laboratory research (not mentioned in Table 1) on imagery, craving, and eye movements add to the positive clinical experiences. Well-controlled studies show that eye movements (and other dual tasks) lead to decreases in image vividness and craving in, for example, food-related imagery (Littel, van den Hout, & Engelhard, 2016). In this study, the intervention even affected behavior: subjects in the eye movement’s condition were more inclined to choose healthy over unhealthy snack options. For an overview of relevant experimental research, see Markus, de Weert-van Oene, Woud, Becker, and De Jong (2016).

In conclusion, both clinical and laboratory data suggest that EMDR can be useful to reduce intensity of substance-related imagery and craving and might be a valuable intervention in addiction treatment.

New Possibilities in Addiction-Focused EMDR

In recent years, an increasing number of studies have been published in favor of the working memory theory (Andrade, Kavanagh, & Baddeley, 1997). At this moment, it seems to provide the best explanation for the effects of eye movements in desensitizing and reprocessing negative memories. Other mechanisms may add to the effects of eye movements, but the empirical evidence for other possible working mechanisms is much smaller and the contribution (explained variance) to the effectiveness is probably much lower as well. We will briefly summarize the working memory theory, including its significance for EMDR, because it generates several new possibilities for EMDR, not least for AF-EMDR. The theory and the new possibilities have already been described for Dutch therapists (Hornsveld & Markus, 2016a) and are included in the list of potential EMDR interventions (Table 2).

The theory underpinning the working memory model states that recalling a memory taxes working memory capacity, which in itself is limited (Baddeley, 2012). Because a traumatic memory is inherently intense, vivid, and emotionally charged, it loads particularly strong on the working memory when recalled. So if a concurrent task loads on working memory (such as eye movements; Gunter & Bodner, 2008) is executed during recall, it competes for resources with the recalled memory representation. As a result, the vividness and emotionality of the memory is reduced (e.g., Andrade et al., 1997; de Jongh, Ernst, Marques & Hornsveld, 2013; Gunter & Bodner, 2008; Maxfield, Melnyk, & Hayman, 2008). The desensitized and reprocessed memory representation is then reconsolidated in long-term memory, in a less disturbing format.

Consistent with this theory, memories have been found to becoming less disturbing, and less vivid, not only during execution of bilateral eye movements (e.g., Gunter & Bodner, 2008) but also during a range of other nonbilateral working memory taxing tasks (for an overview, see van den Hout & Engelhard, 2012). Four main clinical implications derive from this line of research: regarding positive memories, negative flash-forwards, positive flash-forwards, and resource installation procedures.

Module 1: Safe Place Procedure and Resource Development Installation

The SPP (Shapiro, 2001) and RDI (Korn & Leeds, 2002; Leeds & Shapiro, 2000) hardly need explanation. When needed, these interventions can be used at any time and in any disorder, including addiction disorders, for example, resourcing firmness to remain steadfast in a difficult (trigger-)situation, between sessions or to bring oneself in a desired state of mind (e.g., relaxed, calm) that otherwise is pursued by using a substance or demonstrating the addictive behavior. As explained in the preceding text, we recommend very slow eye movements or another low-taxing dual task in this case.

Module 2: Installation of a Positive Treatment Goal

“Installing” a PTG (Popky, 2010) seems especially valuable in patients whose life has become governed by the addiction. These patients are motivated to “stop” and “get rid of the negative consequences” but have little idea how life can be without addiction; they do not have a dot on the horizon to focus on. A middle-aged woman, for example, pictured herself in a zoo with her grandchildren, who were not allowed to stay with her as long as she could not abstain from alcohol. This clear, feasible, attractive image and associated positive state helped her to keep motivated. In line with Popky (2010), the positive state was subsequently linked to desensitized trigger situations to further increase feelings of mastery.

Experts differ in the importance given to resource building in addiction (Modules 1 and 2). Popky (2010), in his latest version of DeTUR, places strong emphasis on positive and empowering interventions, especially in the first phase of therapy. He starts with the question “What do you like and do best?” (installing the answer with eye movements) and continues with physically anchoring a true “positive treatment goal.” He then moves on with the identification and desensitization of triggers for urge. He only works with the past “when it opens up.” His idea is that with the desensitization of triggers and installation of the positive, the patient’s ego strength grows to “a point where threads open leading back to core issues, if they arise . . . ” (p. 490). Other experts tend to indicate using TF-EMDR and in an earlier stage, especially with comorbid PTSD.

Module 3: Trauma-Focused EMDR for Comorbid Posttraumatic Stress Disorder

We recommend using TF-EMDR when the presenting addiction is comorbid with PTSD (see Figure 1). PTSD and other comorbidities in addiction are easily overlooked (Gielen et al., 2012) or can only manifest during the recovery, making assessment in addiction a continuous process. In patients with comorbid PTSD, the approach is essentially standard EMDR therapy as early as possible. The aim is not to reduce the addiction in the first place, but to treat the PTSD, preferably alongside or integrated with addiction treatment. Substance use is no longer considered an absolute contraindication for TF-treatment (Van Minnen et al., 2012); only a factor to be taken into account and requiring good cooperation with the patient and expertise of the therapist in both addiction and trauma. The idea that trauma-work should be postponed until patients are stable and have reached a considerable period of abstinence is often not feasible, and is now outdated.

Module 4: Trauma-Focused EMDR for Emotional Problems in Patients With Addiction and Without Posttraumatic Stress Disorder

This module pertains to standard TF-EMDR therapy with respect to negative life experiences (ACEs, t-traumas) that are thought to have contributed to present emotional problems (e.g., anxiety, depression), but not directly to PTSD. EMDR will only have an effect on the addictive behavior itself, if these traumatic experiences are still fueling the emotional instability of the patient and if this instability is supposed to maintain the addictive behavior. In other words, the treatment plan is based on the self-medication hypothesis (Khantzian, 1985). Brown’s findings (Brown et al., 2015) are positive for TF-EMDR in patients with a history of trauma exposure, both on the addiction as well as on the comorbid emotional problems. Individual therapist can include this module in their treatment plan, when the behavioral analysis of the addiction predicts that the addiction serves to regulate emotional problems and that this can be repaired by TF-EMDR.

Module 5: Trauma-Focused EMDR for Patients With Debilitating Negative Core Beliefs

This module describes a method called “from core-beliefs to targets” (de Jongh, ten Broeke, & Meijer, 2010), for complex case conceptualizations. It assists in identifying relevant targets for EMDR, especially when there seem to be too many traumatic memories from which to select targets. Which ones are the most relevant? The method provides a reasonable alternative when the methods of “affect-scan” or “floatback” seem to get a bit random. It is especially indicated when the symptom pattern of the addicted person seems to be driven by a negative core belief: a dominant belief about how the world works and who he or she is, rather than by specific emotional problems. Core beliefs generate affective and behavioral responses, which in turn contribute to new experiences that appear to confirm the cognitive bias: a vicious circle, hard to escape from. In addicted patients, low self-efficacy is known to be a significant predictor for relapse and usage (Adamson, Sellman, & Frampton, 2009); self-efficacy being defined as the extent or strength of one’s belief in one’s own ability to perform a certain behavior in specific circumstances sometime in the near future (e.g., to be able to refuse a drink when offered). Low self-efficacy is self-perpetuating: it contributes to relapse, while relapse itself contributes to a further decrease in self-efficacy. The relevant core belief that accompanies a low self-efficacy might be formulated by the individual as “I am incompetent,” “I am weak,” or “I am powerless.” Often times, these core beliefs existed before onset of the addiction; they actually seem to have added to the development of the addiction. Learning theory and the AIP model (Shapiro, 2001) assume that dysfunctional beliefs about oneself (e.g., “I am a bad person”), or the world (“The world is a dangerous place”), or the capacity to handle difficult situations (“I am a weak person”) are the resultant of multiple negative events. People are not born with negative core beliefs or a low self-efficacy. Because of the quantity of events that have contributed to a dysfunctional belief, it may be efficient to use the core belief to identify the most relevant memories to be processed with EMDR (de Jongh et al., 2010). In short, this method involves the following: (a) identifying the dysfunctional belief that is consistent with the patient’s problems. The dominant and most relevant core belief in addiction is often the one that contributes most to the low self-efficacy although other core-beliefs might be identified as more relevant to the maintenance of the addiction, (b) identifying experiences that have led to the formation of and perpetuation of this belief and (therefore)—so to speak—“prove” that the belief is true, and (c) “discredit” this “evidence” with EMDR. For a full understanding and description of this method see de Jongh et al., 2010, and see PEIA; Hornsveld and Markus, 2016b, for this procedure tailored to addiction.

The method “from core-beliefs to targets” is primarily used to treat more severe forms of pathology, such as severe social phobia, complex PTSD, and/or personality disorders. The method is not evidence based for addiction, nor for other disorders, but clinical practice seems promising.

Module 6: Addiction-Focused EMDR on Negative Flash-Forwards of Prolonged Abstinence

One of the first goals in AF-EMDR is to reduce the impact of change-blocking fears or beliefs. Two fears are typically reported in addiction: the fear for prolonged abstinence (this module) and the fear for relapse when abstinent (next module). When these fears seem to hinder progress, they can best be tackled at an early stage of therapy.

It is not uncommon that patients—also when they are motivated to stop—have strong negative associations with abstinence. They fear for example, that they will experience a boring life without thrills, constantly fighting cravings, losing their friends, and struggling to avoid temptations. That perspective is not only discouraging; it is also not realistic in that extent; it sometimes seems to have developed during the addiction to justify one’s behavior.

Because a flash-forward refers—by definition—to an overvalued image of the future, the negative self-referring cognition is something like, “I can’t stand it,” “I don’t want to look at it,” or “It is unbearable to think of.” The desired positive change and ultimate statements (PCs) go—as a consequence—something like, “I can handle it,” “I can look at this doom scenario since it is not realistic,” “I am the one to make sure that this will not happen,” or “I am in control of my life.” Often, we observe that the original flash-forward fades out, to make room for a more realistic picture of the future.

Asking for the negative cognition (NC) as it is done in the standard EMDR protocol, “What words go best with the picture that express your negative belief about yourself now?” is often confusing or is not very helpful to activate the full impact of the flash-forward. We therefore ask, “Which statement about yourself or about your life with respect to this negative future scenario bothers you the most/is most repulsive?” (SUD-augmenting statement) this reveals answers such as “My life is boring without alcohol,” “I will lose all my friends,” and so forth.

People differ in the extent to which they have and are aware of the presence of their doomsday scenarios. The clinician should ask for it with some persistence, and not be afraid to trigger these fantasies. The higher the SUD of these flash-forwards, the more valuable it seems to confront the addicted patient with his or her feared visions and help him or her to learn to reevaluate it in a realistic and empowering way, especially combined with Module 3 (PTG). When people say that they are not afraid of abstinence because their aim is controlled use (or behavior), they are often not aware that their wish for controlled use is motivated by a negative image of abstinence. In accordance, our clinical experience is that many patients with a stated goal of controlled use shift to at least a period of full abstinence during AF-EMDR. So searching for a relevant flash-forward is still valuable despite intentions to pursue controlled use. Examples of negative images about abstinence are “alone and bored at the kitchen table,” “ridiculed by my friends at a party” and “old and still craving.”

Module 7: Addiction-Focused EMDR on Negative Flash-Forwards of Relapse

This module is aimed at reducing the fear of a relapse. This may sound counterintuitive for two reasons. First, the fear of a relapse seems to be a healthy fear without the necessity to be reduced. Secondly, relapses are not unrealistic or irrational, they happen more often than not in the course of addiction treatment. However, the underlying catastrophic aspects of how the person visualizes a relapse is often a question of all or nothing, for example, “all will be lost,” “then I’ll end in the gutter,” “I am a total failure,” “I have gone back to day one,” and so forth. If a person imagines the outcome of a possible relapse as very negative and highly probable, he or she will be hampered to try or actual give up after a setback. Desensitizing and reevaluating these catastrophic images can help the person to gain a more realistic image of a possible slip or relapse; as an experience to learn from and not to be paralyzed by.

The NC is usually “I cannot handle (the image of) relapsing” and corresponding positive cognitions (PCs) are “I can handle this catastrophic image” (because it is not realistic to think that everything is lost after a slip) or “I am in control.” Good questioning is essential to activate flash-forwards that the person is often not fully aware of. During EMDR on a flash-forward of relapse, past memories of relapses can arise, especially when not already treated with Module 8. Earlier relapses are reprocessed when these memories arise, in the chain of associations.

Our experience is that flash-forwards quickly lose their frightening features. Patients start to see nuances in their all-or-nothing image of a relapse. They feel empowered when they realize that—even when there will be a relapse—the present situation is different from the catastrophic image in their head, or in the past. Spontaneous rescripting is the rule rather than the exception. The judgment of the own abilities to handle the situation has increased.

Module 8: Addiction-Focused EMDR for Memories of Relapse

Modules 8 and 9 are AF-EMDR modules based on the concept of the addiction memory (Boening, 2001) as described earlier. Modules 8 and 9 are also key features of the CravEx approach of Hase (2010).¹

In Module 8, past memories (first, worst, most recent) of relapse are identified and reprocessed (see Hase, 2010, and Hornsveld & Markus, 2016b, for a comprehensive description of the procedure). Reprocessing memories of relapse serves two aims according to Hase (2010): first, to reprocess the maladaptive memories of the addiction memory by AIP model, and second, to reduce levels of craving. Hase in his description (no verbatim or case descriptions available) of the procedure seems to focus on the second objective, reducing the level of craving, measured by the LoU. However, we observed that retrieving memories of relapse activate a sense of powerlessness that is highly maladaptive, as demonstrated by NCs such as “I am weak,” “I cannot cope,” “I am a slave of my behavior,” and so forth.² Craving may be low, whereas SUD may be high. We recommend, therefore, to enquire about the SUD as well, next to the LoU. Reprocessing these memories seems especially healing when the patient is able to shake of this paralyzing feeling through EMDR therapy, by reevaluating feelings of powerlessness, self-worth, and mastery.

To make sure that all relevant debilitating memories are considered, we not only ask for memories of relapse but also for other relevant memories of lack of control, “What other memories do you have whereby you clearly lost control over using/doing [name substance or behavior]? and “What other experiences provide the strongest ‘proof’ that you cannot handle using/doing [name substance or behavior]? In response to this last question, for example, an alcoholic father mentioned that he was drunk at the wedding of his daughter. It was not a relapse, but a painful demonstration that he has no guts and will never have. After reprocessing this memory, he decided to apologize to his daughter, took the responsibility and felt more decided and powerful than a long time before. Hase (2010) starts with the most recent memories, using the argument that they are easier to access and evaluate, but starting with the most salient, most significant, agreed upon targets is well defendable.

Module 9: Addiction-Focused EMDR for Memories of Craving

In this module past memories (first, worst, and most recent) of craving are identified and treated with EMDR (for a full description, see Hase, 2010, and Hornsveld & Markus, 2016b). The reprocessing of memories of craving is almost always included in an AF-EMDR treatment plan. Indeed, in the case conceptualization or behavioral analyses of many patients, craving—a resultant of the triggering the addiction memory—is an important maintaining factor.

Measures are the Level of Urge (LoU and/or the LoPA). Aim is to reach a maximum reduction, preferably 0, before switching to installation of a PC. However, LoU and LoPA may still be rated 1–2 after successful and prolonged processing. We feel this is acceptable because the real aim is to maximize experienced control over craving. In a GHB case study (Qurishi et al., 2016), reducing the level of daily life craving was the main objective, and Module 9 was chosen to start with. Three “craving memories” were identified, the first being “alone at home, dosing a GHB-fix.” Retrieval of these memories led to acute craving levels of 8–10 LoU. To maximize LoU and LoPA the therapist asked for a threshold-lowering statement instead of the NC, “When I use GHB, my life is much more fun.”

To start reprocessing when the LoU is as high as possible, we ask for a craving-augmenting-, or threshold (for subsequent use)-lowering statement, which often is a statement to give in to their desire (e.g., “just one time”). Key question is “What words do increase your urge to perform the behavior?” Craving is increased more by these statements than by asking for an NC (“What words best go with the picture that express your negative belief about yourself now?”). In our experience, this latter question usually leads to a decrease in craving. See Hase (2010) for a full description of this procedure, and see Hornsveld and Markus (2016b) for the variant with the craving-augmenting statement.

Module 10: EMDR on Positive Memories

Since the last publication on CravEx (Hase, 2010), Müller (2013) described the significance of positive episodic memories (e.g., the vivid memory of a first shot of heroin, or the positive memory of being one of the boys while drinking) in experiencing and anticipating drug use. Thus, not only memories of relapse and craving are powerful forces to keep someone addicted but positive memories as well. We already stated that EMDR on positive touchstone memories could be a promising adjunct to current treatment options. In this module, the first, most pleasant and most recent positive memories are selected and reprocessed. The attractiveness of the positive memory can best be expressed by either the LoU (Popky, 2010) or LoPA (Knipe, 2010).

It is a typical observation that after a few sets of positive associations, the person starts to see the negative aspects of the target situation, for example, the social consequences or the hangover. Just like positive associations appear in trauma treatment, as soon as the person is no longer overwhelmed by the intrusive, emotional image, an overly positive memory turns into a realistic, adaptive version before it is “resaved” (reconsolidated) in long-term memory. Of course, on a rational level, the information about the negative consequences was already available, but here it is adaptively connected to the addiction memory.

From a theoretical viewpoint (learning theory) and validated by our clinical observations, three kinds of negative aspects may appear in the association chain of the addictive patient: (a) the presence of negative consequences, for example, hangover, shame, physical symptoms; (b) the absence of positive consequences, for example., no interesting job, no healthy friendship (of course, a and b are two sides of the same coin); and (c) the function of the addiction becomes painfully accessible, what they are looking for and what they are trying to avoid, for example, “I now realize that I am not drinking because I like to get drunk, but I want to get free, I am afraid for all those responsibilities.”

To illustrate an experience we have had with this module, a patient with binge eating disorder recalled a positive memory of eating large amounts of chocolate on the coach before the TV, her craving-augmenting statement being “chocolate is my best friend.” After initial associations on the sweetness of the chocolate and the sense of comfort (positive associations), she realized the negative feelings afterward and her overweight (negative consequences) and that her friends were probably elsewhere, having fun without her (absence of positive consequences). After a while, she became sad and stated, “It is not about the chocolate, I hate it, I just want to have something for myself, to feel connected . . . ” (function of the addiction). The therapist knew the issues of loneliness and feelings of abandonment; they were part of the treatment plan but decided to continue reprocessing this memory by going back to target until the sweetness of the chocolate was almost gone. If new material had come up, the therapist would probably have allowed more associations, but in this module, the main aim is to reduce the attractiveness of the chocolate by AIP. At follow-up the patient said, “I still like chocolate, but the craving has gone, I now feel that it is a surrogate. You took away my best friend.”

Module 11: EMDR on Feeling States and “Linking Memories”

This module is based on the work of Miller (2010) and is a nice variant of the previous module. Miller’s starting point is the function of the addictive behavior; he emphasizes that every unhealthy behavior (substance use or behavioral addiction) is linked with an underlying healthy psychological desire. According to Miller (2010), focusing on the urge does not automatically reveal this actual psychological need (e.g., longing for approval, bonding, or competence). For both the patient and the therapist, it is not directly clear which part of the behavior is rewarding, and which need is satisfied, so this needs to be investigated first. In the earlier case of the patient with binge eating disorder, the answer could be “the most intense feeling is the very start of the binge, it gives me a feeling of warmth and belonging.” Miller would then ask, “When you let yourself remember that event of starting the binge, how intensely do you feel that you belong?” With the floatback technique, Miller (2010) would then try to identify memories representing this linkage. He assumes that strong positive memories are formed within emotionally deprived persons: the more the need for a specific feeling, the stronger reaction will be when the healthy desire is satisfied. The chocolate eating woman, for example, could have retrieved that she often went to her neighbor when her parents were arguing, and that she was welcomed with nice words and sweets and had experienced a feeling of belonging. The starting memory for reprocessing may be this older memory or the most recent; whatever is most potent (more examples in Miller, 2012).

From a learning-theory perspective, this module is interesting because it directly addresses memory representations which are rewarding because they either fulfill a psychological need or because they help to avoid negative feelings. For a full description of the FSAP, see Miller (2010) and Hornsveld and Markus (2016b).

Module 12: EMDR on Positive Flash-Forwards of the Behavior (“Dry Use”)

This module is based on the literature of desire thinking (Caselli & Spada, 2015), flash-forwards (Logie & de Jongh, 2014), and our clinical application of the procedure. Two appetitive flash-forwards are typically reported in addiction: flash-forwards of performing the behavior (this module) and flash-forwards of the desired results of the behavior (next module). Vivid, intrusive imagery and perseverative thoughts regarding the behavior or use of the drug is a common feature in addiction and is called “desire thinking” (Caselli & Spada, 2015) or “dry use.” It is known to escalate craving and drive to subsequent use. The corresponding memory representation can be conceptualized as a flash-forward of imminent use (seeing oneself sitting on the bench and eating chocolate, tonight). Given its appetitive nature, we use the LoPA or LoU scale to rate its attractiveness, whatever is most prominent. We also use a craving or attractiveness-augmenting statement, for example, “I’m on top of the world!” or “I need this.” As with all dysfunctional positive memories, we frequently observe that strong bodily sensations arise. As soon as they decrease, more adaptive associations arise, especially when a person is highly motivated. Healthy alternative scenarios appear as soon as the overwhelming desire has decreased.

Module 13: Addiction-Focused EMDR on Positive Flash-Forwards About the Desired Goal

In this module, EMDR is used to desensitize appetitive flash-forwards of desired goals that a patient tries to achieve with the addictive behavior (e.g., “winning the jackpot” or “having a ball with friends getting hammered this weekend”). The patient visualizes not the behavior itself, as in Module 12, but the desired outcome of the behavior. For example, for a shopping-addicted patient, the shopping itself was not rewarding but showing off new possessions was. A recurrent flash-forward was the image of herself in an expensive wedding dress, watched by admiring family members.

Other examples from our caseload are (a) a woman who was stalking her ex-boyfriend had a flash-forward that she was lying in his arms again. Desensitizing this memory was far more effective than any other intervention because she realized during reprocessing that this coveted state was never going to happen, something she rationally already knew; (b) a convicted thief in a forensic setting had a positive flash-forward of himself sitting in a white limousine, a fantasy he already had as a child. After reprocessing this flash-forward with EMDR, the limousine was less attractive, a change that may have contributed to his progress.

We again use the LoPA and LoU scales to rate the attractiveness; we also use a craving or attractiveness-augmenting statement instead of a NC. The PC in flash-forwards is always “I can handle (this image).”

Module 14: Addiction-Focused EMDR on Triggers

The desensitization of urge triggers is central in both Popky’s (2010) DeTUR as well as Hase’s (2010) CravEx approach. For the addicted person, daily life is full of risks, situations that may evoke strong urges or even relapses. Self-control procedures generally consist of mapping these situations and making plans (or learning new ways) to deal with these situations. Avoiding is one of the most effective strategies, but this is not always possible or desirable; an ex-alcoholic will inevitably visit parties where alcoholic drinks are offered. In this module, AF-EMDR is applied to reduce craving in these situations. The procedure starts with the identification of urge triggers, and then starting to desensitize them one by one, starting with the weakest trigger (Popky, 2010) or with the one of choice by the patient (Hase, 2010; Hornsveld & Markus, 2016b). Reprocessing is often very rapid, especially when memories of craving have already been desensitized in Module 9. Another observation is the frequent rescripting during reprocessing: for example, a son, for whom it is difficult to visit his father, because his father usually insists on drinking large quantities of good wine at dinner. During reprocessing, the son is determined to call his father and to tell him in advance that he is not drinking any more, and that he will refuse any offer. The image of father offering a wine lost its attractiveness and tension (LoU = 0, Validity of Cognition [VOC] = 7, “I can handle this”).

If a patient reports a lapse or relapse between sessions, this module can be applied to the triggers that brought up the urge to use.

Module 15: Future Templates, Imaginal Rehearsal, and Behavioral Experiments

The installation of future templates, as described in the EMDR standard protocol (Shapiro, 2001, 2010) is always important to obtain stable treatment effects. Difficult situations that the patient would like to cope with are mostly the same as the “trigger situations” of the previous module. The alternative scenarios that emerge during spontaneous rescripting in Module 14 can often be the future templates of Module 15. Both modules may be offered in an integrated way.

Future templates are—by definition—images or snapshots of effective coping. The next stage is to ask the patient to play a movie in their mind about future coping, with a beginning, middle, and end. If tension is felt, or blocks are hit, the patient is asked to open the eyes and follow the fingers of the therapist. Therapists can make some suggestions to help inoculate their patients against future problems. If necessary, education on social skills and customs is provided first. Resourcing (Modules 1 and 2) can also be helpful to prepare the patient for difficult situations. Good worksheets for future templates can be found in Shapiro (2010). Imaginal rehearsing can by continued in the form of homework. The next stage is performing behavioral experiments (e.g., demonstrating adequate coping behavior in a trigger situation to see whether the patient can handle the associated stress). In the subsequent discussion of the experiments, new triggers and future templates may emerge that need some attention.