WHAT IS TRAUMA?

The diagnostic criteria for posttraumatic stress disorder (PTSD; DSM-V, 309.81; ICD-10, F43.10) cited in the Diagnostic and Satistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) is the definition used most frequently to describe acute trauma in adults. This definition describes trauma as an event experienced or witnessed by a person that results in intrusive symptoms, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity (APA, 2013). Flannery describes trauma as

A child who was sexually abused by her older brother may grow up to believe “I am bad” or “The world is unsafe.” When an individual experiences a traumatic event, the event can become entrenched (or fixed) in the form of irrational beliefs, negative emotions, blocked energy, and/or physical symptoms, such as anxieties, phobias, flashbacks, nightmares, and/or fears. Regardless of the magnitude of the trauma, it may have the potential for negatively impacting an individual’s self-confidence and self-efficacy. The event can become locked or “stuck” in the memory network (i.e., “an associated system of information” [Shapiro, 2018, p. 30]) in its original form, causing an array of traumatic or PTSD symptoms. Triggers activate images, physical sensations, tastes, smells, sounds, and beliefs that might echo the experience as though it were the day it originally happened or cause other distortions in perception of current events. Reminders of the event have the potential for triggering an emotional or physical response. By utilizing EMDR therapy, the client can unblock the traumatic information and can fully experience and integrate the trauma toward a healthy resolution.

TYPES OF TRAUMA

Dr. Shapiro (2018) distinguishes between big “T” traumas and other adverse life experiences or disturbing life events (formerly referred to as small “t” traumas). When a person hears the word “trauma,” experiences and images of man-made events such as fires, explosions, automobile accidents, or natural disasters, which include hurricanes, floods, and tornadoes, emerge. Sexual abuse, a massive heart attack, death of a loved one, Hurricane Katrina, and the 9/11 attacks on the World Trade Center by international terrorists are graphic examples of big “T” traumas. Among other descriptors, these types of traumas can be defined as dangerous and life threatening and fit the criteria in the DSM-5 (APA, 2013) as stated previously.

Then there are the traumas Shapiro (2018) has designated as adverse life experiences. These types of events may be subtler and tend to impact one’s beliefs about self, others, and the world. Adverse life experiences are those that can affect our sense of self, self-esteem, self-definition, self-confidence, and optimal behavior. They influence how we see ourselves as a part of the bigger whole. They are often ubiquitous (i.e., constantly encountered) in nature and are stored in state-dependent mode in our memory network. Unless persistent throughout the client’s childhood, adverse life experiences usually do not have much impact on overall development, yet maintain the ability to elicit negative self-attributions and have potential for other long-term negative consequences. The clinical presentations that often signal the presence of past adverse life events may be low self-esteem and anxiety as well as panic disorders and/or phobias, depression, posttraumatic symptoms, and the presence of dissociative disorders. The domains of dysfunction tend to be emotional, somatic, cognitive, and relational.

To illustrate the difference between an adverse life experience and a big “T” trauma, let us consider the case of Rebecca, who grew up as “the minister’s daughter.” As the offspring of a local pastor, Rebecca grew up, figuratively speaking, in a glass house. She believed that her father’s job rested on her behavior inside and outside of her home. In her world, everyone was watching. She was always in the spotlight, and no one seemed to want to share his or her life with her. She went through childhood with few friends. “I remember before and after church, the groups of kids forming. I was the outsider. No one invited me in.” All the kids were afraid that every move they made would be reported to her daddy. Being at home was not much better. Her father was never home. He was always out “tending to his flock” and had little time left for his own family. Her mother was not of much comfort either, because she spent much of her time trying to be perfect as well. Living in a glass house was not easy for any of them, especially Rebecca, the oldest of three. By the time Rebecca entered therapy, she was a wife and mother. She thought she had to be perfect in motherhood and in her marriage as well. She became frustrated, angry, and lonely. She felt misunderstood and neglected by her husband. He was never there. He never listened. She thought she could do nothing right, as hard as she tried.

Probing into Rebecca’s earliest childhood memories, no tragic or traumatic memories (i.e., big “T” traumas) emerged. As she continued to explore her past, the hardships and rigors of living in a glass house as the preacher’s daughter slowly became apparent. The original target that initiated a round of EMDR reprocessing sessions focused on Rebecca “sitting on my hands in church and being a good little girl.” Her negative belief about herself as she focused on this global touchstone event was “I have to be perfect.” She felt isolated, overlooked, and abandoned by her parents and the parishioners of her father’s church. These were undoubtedly adverse life experiences. There was no one single event or series of traumatic events that set her current problem or issue in place. It was her way of life; and how, where, and why she was forced to live as a child caused a specific set of symptoms and interfered with her living happily and successfully in the present.

The differentiation between adverse life experiences and big “T” traumas often appears too simplistic. Another way of discussing the types of trauma is to look at it in terms of shock or developmental trauma.

Shock trauma involves a sudden threat that is perceived by the central nervous system as overwhelming and/or life threatening. It is a single-episode traumatic event. Examples include car accidents, violence, surgery, hurricanes and other natural disasters, rape, battlefield assaults, and war.

Developmental trauma refers to events that occur over time and gradually affect and alter a client’s neurological system to the point that it remains in a traumatic state. This type of trauma may cause interruptions in a child’s natural psychological growth. Examples of developmental trauma are abandonment or long-term separation from a parent, an unstable or unsafe environment, neglect, serious illness, physical or sexual abuse, and betrayal at the hands of a caregiver. This type of trauma can have a negative impact on a child’s sense of safety and security in the world and tends to set the stage for future trauma in adulthood as the sense of fear and helplessness that accompany it goes unresolved.

Table 1.1 outlines more definitely the differences between big “T” traumas and adverse life experiences or disturbing life events (i.e., small “t” traumas).

MODEL—HOW?

The AIP model guides its clinical practice (i.e., case conceptualization and treatment planning) and predicts the EMDR treatment effects, and it is independent from the “why” stated later. It is through the lens of the AIP model that the developmental phenomenon is understood, any clinical phenomena that arise during EMDR processing are interpreted, and successful application and positive treatment outcomes are predicted.

Guided by this information processing model, memory networks are believed to form the basis of clinical symptoms and mental health in general, and “unprocessed memories are considered to be the primary basis of pathology” (Shapiro, 2009–2017a). The important components of the model as outlined by Shapiro (1995, 2001, 2018, 2009–2017a, 2009–2017b) are summarized in Table 1.9.

There is a body of literature, including both research and case reports on a variety of clinical complaints, that illustrates the predictive value of the AIP in terms of body dysmorphic disorder (Brown et al., 1997); generalized anxiety disorder (Gauvreau & Bouchard, 2008); olfactory reference syndrome (McGoldrick et al., 2008); panic disorder with agoraphobia (Fernandez & Faretta, 2007); bonding failures (Madrid et al., 2006); depression (Uribe & Ramirez, 2006); adolescent depression (Bae et al., 2008); PTSD (Mol et al., 2005; Raboni et al., 2006); the role of EMDR therapy in medicine (Shapiro, 2014); dental phobia (Doering et al., 2013); perpetrators with a trauma history (Ricci et al., 2006); adult attachment (Wesselman & Potter, 2009); psychosis (Heins et al., 2011; van den Berg & van den Gaag, 2012; Varese et al., 2012); peer verbal abuse (Teicher et al., 2010); obsessive-compulsive disorder (Nazari et al., 2011); borderline personality disorder (Brown & Shapiro, 2006); phantom limb pain (de Roos et al., 2010; Russell, 2008; Schneider et al., 2007; Schneider et al., 2008; Wilensky, 2006); physical punishment and mental disorders (Afifi et al., 2012); childhood trauma and children’s emerging symptoms (Arseneault et al., 2012); childhood trauma and household dysfunction (Felitti et al., 1998); and biological sensitivity (Obradovic et al., 2010).

METHODOLOGY—HOW/WHAT?

EMDR therapy employs an eight-phase integrative treatment approach. Often customized to reflect a client’s clinical diagnosis or individual presentation, EMDR therapy utilizes a distinct set of procedures and protocols to address a client’s presenting issues. BLS is only one component of the methodology that guides this therapeutic practice of EMDR. EMDR therapy is also a three-pronged approach that includes a client’s past experiences, present triggers, and a future template of how the client may want to be or respond in a situation. EMDR therapy is flexible in that it also combines aspects of a clinician’s previous orientations to psychotherapy as part of the process.

For further reading on the “how” and “what” of EMDR therapy, an overview of the model and procedures is elaborated on in Table 1.10.

MECHANISM—WHY?

Over the past 25 years, numerous studies have indicated that eye movements have effects on a client’s memory in terms of vividness, retrieval, emotional arousal, and more. Studies that evaluated EMDR therapy’s mechanism of action are listed in Table 1.11.

PAST, PRESENT, FUTURE

EMDR therapy is a three-pronged treatment approach that focuses on reprocessing of past events, current triggering stimuli, and adaptive rehearsal in future situations (Figure 1.2). This may seem simple, but it is often a concept that escapes many newly trained EMDR therapy clinicians.

Regardless of what you as a participant were taught in the earlier didactic trainings, what you most likely will remember is what was on the instructional sheet that sat on your lap. The first question that you asked the client was, “What old issue or old memory would you like to focus on today?” It is important to note that this question was only used in the training exercises and not in daily clinical practice. Fortunately, this teaching method has changed as the training focus now is to establish a more formalized plan that attempts to identify past events (and a touchstone event, if available), present triggers, and a future template, and to encourage the participant to process in this order. Shapiro (2006) referred to this strategy as the Treatment Planning Guide (TPG).

Figure 1.2

Self-actualization: EMDR therapy and the three-pronged hierarchy.

To completely resolve a client’s issue and achieve adaptive resolution, EMDR therapy is designed to (a) address a client’s past events, (b) clean out related current stimuli that might trigger distress in the client and/or reprocess difficult present experiences, and (c) prepare the client for future situations involving the same kind of circumstances (or reaction). The concept of the three-pronged approach is so important that an entire chapter in this Primer has been devoted to it (Chapter 4).

THREE-PRONGED TARGETS—EXPERIENTIAL CONTRIBUTORS TO PRESENT-DAY PROBLEMS

The order of the processing is important. First, it is necessary to strive to adaptively resolve past traumas, then process current stimuli that trigger distress, and finally do a future template on the present trigger. See Exhibit 1.3 for a breakdown of what is identified and processed under each prong of the EMDR approach.

The clinician may want to consider targeting the memories that lay the groundwork for any present problems and/or issues first. It may be a single traumatic event or what is called a touchstone event, a primary and self-defining event in the client’s life. In AIP language, Dr. Shapiro refers to the touchstone memory as a node to which similar events will attach in the continuous formation of a “neuro” or memory network that is critical to the client’s sense of self. It is a portal into the memory network as different associations may arise (2018; see Exhibit 1.4A and 1.4B).

Once all presently charged past events are processed (i.e., after the touchstone event is processed), other past events may or may not have a cognitive or affective charge remaining. The clinician may want to consider processing those that have a “charge” before continuing to recent events. Then any recent events, circumstances, situations, stressors, or other triggers that might elicit a disturbance are targeted. After the past events and present disturbances have been identified and reprocessed, focus on the future desired behavior and the client’s ability to make better choices or cope more effectively. This entails education, modeling, and targeting what Dr. Shapiro calls a future or positive template (2018). It is important for the client to appropriately and properly assimilate the new information gained through the previous prongs (i.e., past, present, and future) by providing them with experiences that ensure future successes.

EXHIBIT 1.3 Three-Pronged Targets: Order of Reprocessing

During recent EMDR trainings, the order of processing the three prongs (i.e., past, present, and future) and strategically identifying the touchstone event, if any, have been emphasized more dramatically. If trained in EMDR prior to 2008, the clinician needs to pay particular attention to Chapters 3 and 4 of this Primer.

Although the standard EMDR therapy protocol prescribes the order of processing as past, present, and future, this is not always practical or effective. Symptoms, circumstances, and other variables may indicate future, present, past (e.g., Inverted; Hofmann, 2005 or Reverse; Adler-Tapia, 2015 protocols) or present (e.g., recent events). The client’s goals for therapy and presenting issue should determine the order of processing and the clinician should be prepared to direct the client where they need to go for a positive treatment outcome.

EXHIBIT 1.4 (A) Targets or nodes and (B) targets or nodes with examples.

The Importance of Past, Present, and Future in EMDR Therapy

The foundation of the three-pronged protocol postulates that earlier memories are processed before current events, and current events are processed before future events. Why is it so important to process these events in this order? What is the effect on the overall treatment result if it is not processed in order of past, present, and future? Earlier life experiences set the groundwork for present events and triggers. Hence, it is useful to reprocess as many of the historical associations with the triggers as possible. Once these associations have been transformed, some, if not many, present triggers will dissipate. There may, however, still be current triggers that exist outside of these channels of association that will need to be targeted and processed independently. Or there may be unprocessed material that surfaces when processing these triggers. These triggers will be the next targets to be processed.

The focus on the future template provides the client an opportunity to imaginally rehearse future circumstances and desired responses. This is yet another opening for unprocessed material to surface. The use of the future template provides the client a means of resolving any anticipatory anxiety that they may still experience in similar future situations. The three-pronged approach appears to be a bottom-up process in that the future is subsumed by the present and the present is subsumed by the past. It has been suggested that bypassing the three-pronged approach as part of the full EMDR treatment means obtaining only a fraction of the full treatment effect. If one does not complete the full protocol and believes that the material is resolved because the past has been successfully reprocessed, the client may remain unprepared for being triggered in the present and may still hold anxieties about the future.

TARGETS MAY ARISE IN ANY PART OF THE EMDR THERAPY PROCESS

When a clinician instructs a client to focus on a target in EMDR reprocessing, they are asking the client to tune into a specific memory, image, person, or event or the most disturbing part of it. The target or node then becomes the pivotal point of entry into the associated psychologically stored material. If Raymond’s presenting issue relates to the way he responds to his mother-in-law when she first sees him, the target he selects may be the image of her hugging and kissing him as a form of greeting. Because the target image has a constellation of associated experiences around it, Shapiro (2018) calls it a node.

Throughout Dr. Shapiro’s clinical books (2006, 2018), she refers to several different targets that may arise in certain parts of the process. The past, present, and future targets referred to earlier are the primary focus in the EMDR therapy training. Her text also introduces the reader to other associated words, such as node, channel, cluster, and progression. Exhibit 1.5 attempts to provide a better understanding of the relationship between these types of targets from a more visual perspective.

EXHIBIT 1.5 Three-Pronged Targets: Types of Targets

TARGETS FROM THE PAST

TARGETS FROM THE PRESENT

TARGETS FROM THE FUTURE

OTHER POTENTIAL TARGETS

WHAT DOES IT DO?

BLS, along with dual attention (i.e., simultaneous awareness of the traumatic memory and the present) and the eight-phase, three-pronged protocol, are the core components of EMDR therapy. Research has validated that BLS makes a unique and effective contribution. The client simultaneously focuses on a negative aspect of an internal experience (e.g., image, thought, emotion, physical sensation) while experiencing rapid, alternating external stimuli (e.g., eye movements, taps, tones).

When Dr. Shapiro was in the early stages of developing the theory, procedures, and protocol behind EMDR therapy, she thought that it was the saccadic eye movements or eye tracking that helped to activate the information processing system, which processes the dysfunctionally stored material around a traumatic event. Alternating bilateral hand taps and auditory tones may also be utilized. The type of BLS utilized is important in terms of what the client can best tolerate while facilitating dual attention. A person with an eye disorder obviously might not be able to track a clinician’s fingers well. Someone who does not like to be touched may not be able to tolerate being tapped by the clinician or the proximity of the clinician to them. The type of stimulation chosen depends on the client. Although eye movements are the preferred form of BLS, it is important to be able to offer alternative types of BLS to accommodate the client’s needs.

A client’s preferred means of BLS is not always the most effective. De Jongh et al.’s (2013) discrepant findings “suggest that patients are not the ones that should choose or decide which modality is best for them when they request EMDR therapy.” Shapiro (2014) recommends eye movements as the preferred method of BLS, but also suggests that clients be offered tactile or tones when deemed necessary.

If the information during reprocessing is not moving or becomes stuck, it is important to have the client agree beforehand on two preferred directions (i.e., back and forth, up and down, or diagonal) or two types of modalities (i.e., eye movements, audio, tapping) from which the client can choose. Thus, if a need for change in direction or modality occurs, the client has agreed to their preferences in advance. Any time a change in BLS is indicated, the clinician should check with or inform the client that a change is being made before implementing the change.

EXHIBIT 1.7 Three-Pronged Targets: Types of Targets With Examples

PREFERRED MEANS OF BILATERAL STIMULATION

Shapiro’s (2018) preferred means of BLS is eye movement. All the research involved in establishing the efficacy of EMDR therapy was conducted utilizing eye movements. This type of stimulation also supports dual attention, whereby the client can attend to both internal and external stimuli. The client processes using eye movements with their eyes open so that they remain aware of their present environment.

Many studies have focused on investigating the role of eye movements in EMDR to date (Acierno et al., 1994; Andrade et al., 1997; Barrowcliff et al., 2003, 2004; Boudewyns & Hyer, 1996; Chemtob et al., 2000; Christman et al., 2003; Christman et al., 2006; Davidson & Parker, 2001; de Jongh et al., 2013; Devilly et al., 1998; Engelhard et al., 2010a; Engelhard et al., 2010b; Engelhard et al., 2011; Gunter & Bodner, 2008; Homer et al., 2016; Kavanagh et al., 2001; Kearns and Engelhard, 2015; Kuiken et al., 2002; Kuiken et al., 2010; Lee & Drummond, 2008; Lohr et al., 1995; Lohr et al., 1996; MacCulloch, 2006; Maxfield et al., 2008; Nieuwenhuis et al., 2013; Parker & Dagnall, 2007; Parker et al., 2008; Parker et al., 2009; Patel & McDowall, 2016; Pitman et al., 1996; Propper & Christman, 2008; Renfrey & Spates, 1994; Rimini et al., 2016; Sack et al., 2016; Samara et al., 2011; Sanderson & Carpenter, 1992; Schubert et al., 2011; Servan-Schreiber et al., 2006; Sharpley et al., 1996; Smeets et al., 2012; Solomon et al., 1992; van den Hout et al., 2001; van den Hout et al., 2011, 2012; van Etten & Taylor, 1998; van Veen et al., 2015; Wilson et al., 1996; Zarghi, 2015).

Two dominant theories have emerged as a result of these research studies about the effects of eye movement during EMDR: (a) eye movements have a tendency to interfere with working memory by reducing emotionality and vividness of autobiographical memories (Andrade et al., 1997; Barrowcliff et al., 2003; Barrowcliff et al., 2004; Engelhard et al., 2010a, 2010b, 2011; Gunter & Bodner, 2008; Kavanagh et al., 2001; Maxfield et al., 2008; Schubert et al., 2011; van den Hout et al., 2001) and (b) eye movements are linked into the same processes as rapid eye movement (REM) sleep (Barrowcliff et al., 2004; Christman et al., 2003; Christman et al., 2006; Elofsson et al., 2008; Kuiken et al., 2002, 2010; Parker & Dagnall, 2007; Parker et al., 2008, 2009; Sack et al., 2008; Schubert et al., 2011; Stickgold, 2002, 2008). Stickgold (2002) proposed that “the repetitive redirecting of attention in EMDR induces a neurobiological state, like that of REM sleep” (i.e., the effect of BLS is related to REM in a waking state).

Studies suggest that eye movements are superior to tones (van den Hout et al., 2012) and saccadic eye movements are superior on all parameters in all conditions to vertical eye movements (Parker et al., 2008). One study found that eye movements increased the true memory of an event (Parker et al., 2009). No research presently exists to support having the client process with his eyes closed. Lee and Cuijpers (2013) reported positive effects of eye movements in their meta-analysis.

Table 1.12 outlines the randomized studies of hypotheses regarding eye movements in EMDR reprocessing.

SHORTER OR LONGER? SLOWER OR FASTER?

During the Preparation Phase, BLS is originally introduced with the safe (calm) place and any other resource enhancement or stabilization exercises deemed appropriate by the clinician prior to using EMDR reprocessing and, then again, during reprocessing in the Desensitization, Installation, and Body Scan Phases. There is a difference in the speed and number of BLS passes used. A single pass in terms of BLS is a “round trip” from center to right, then to left, and back to center again. A series of passes make up a “set.” The recommended rate of speed is slower, and the number of round-trip passes is fewer (i.e., 4–6 round trips) when using BLS with resource, coping, relaxation, and stress reduction exercises and strategies. Slower and shorter sets are utilized in stabilization efforts to not activate any disturbing material prior to actual reprocessing.

While using BLS when reprocessing, including installation and, when necessary, the body scan, the speed is tolerably comfortable (i.e., much faster) for the client and number of passes is increased (i.e., from 20 to 24 round trips to start, lengthen to 36 to 40 as needed during the reprocessing phases). The number of sets of BLS is determined by attention to the client’s response and is customized to the needs of the client. Faster and longer sets of BLS are more likely to activate linkages to other memory networks and trigger associated channels of information. The longer and faster the eye movement, the faster the associative linkages occur. Always increase the speed of BLS with caution because, if associative linkages come too fast for a client’s window of tolerance, it can lead to a loss of dual awareness. Faster BLS may impede effective processing and consequently lead to slower reprocessing. On the other hand, if a client is trying to “think” rather than just observe during reprocessing, faster eye movements can help move him into actual reprocessing.

During the Desensitization Phase, the suggested average number of BLS sets (i.e., 20–24 longer, faster sets, then lengthen to 36–40 or as needed by the client) is only a starting point for the client’s processing. As the clinician wants to avoid sets that are too long or too short, it is suggested that she begin with 20 or more passes and watch the client’s facial expressions and body language to determine the best length for any set. After this initial set, the clinician may customize the number of sets according to the client’s need or response.

Some clients may require shorter or longer and/or slower or faster sets. For instance, clients who are anxious and/or unsure of the process may require longer sets of BLS. In addition, some clients need more time to shift from an external (outward) to an internal (inward) focus. The longer sets of BLS create adequate time for the client’s processing to unfold and increase the likelihood of the client experiencing success with reprocessing. If a clinician watches eyes and other body language, clues will usually arise that indicate the appropriate pace and number of BLS sets. It is always appropriate to ask the client for feedback as well.

In terms of desensitization and speed, eye movements (or passes) that are too slow tend to stimulate a relaxation response and may not facilitate sufficient dual attention. Therefore, it is imperative for optimal processing that the clinician facilitates the passes as fast as the client can comfortably tolerate. In addition, the clinician should avoid long pauses between sets without a specific reason (e.g., the client feels the need for clinician connection). The client is discouraged from talking at any length between sets. It is suggested that the clinician minimally or nonverbally acknowledge what the client has reported and say, “Notice that” or “Go with that.”

Although the purpose of the Installation Phase is to fully integrate a positive self-assessment with the targeted information, there is still the possibility that other associations could emerge that may need to be addressed. The faster, longer sets of BLS facilitate the emergence of any lingering disturbing material related to the original targeted event. Remember, a completely successful treatment of the original target memory cannot be attained until the early memories that caused the blocking belief are reprocessed. There is little research regarding this widely practiced distinction in the speed and number of sets of BLS. However, it is considered a guideline by many EMDR trainers, consultants, facilitators, and clinicians.

Except for the reprocessing phases of treatment, shorter, slower sets of BLS (approximately 4–6) are used to reinforce and strengthen the client’s positive networks. The clinician wants to ensure that the client’s brain is not activated in such a way as to associate the positive networks with maladaptive experiences. Especially with more complex cases, the client may not possess sufficient adaptive memory networks; and the client must have access to adaptive memory networks for reprocessing to occur. During the Installation Phase, the sets of BLS should be longer and faster (i.e., 20–24 to start, lengthen to 36–40 as needed) because the client is strengthening the connection between the newly processed memory and its connection to other existing adaptive information networks and/or continued reprocessing of associated negative networks as well. Therefore, when a clinician wants to manage a client’s response, use slow, shorts sets; when a clinician wants to allow a client’s associations to roam freely, use longer, faster sets. Table 1.13 demonstrates when to use long or short and slow or fast sets of BLS.

Note: If a positive association occurs during reprocessing, do not slow the speed of the BLS or decrease the number of sets. During Phases 3 to 6, the sets of BLS are faster and longer as there is always the possibility of negative associations emerging at any phase.

CONTINUOUS BILATERAL STIMULATION

Although there may be clinicians who administer one continuous sequence of BLS throughout the Desensitization, Installation, and Body Scan Phases, Shapiro (2018) clearly outlines the reasons for breaking the stimulation into sets (Table 1.14).

Note: If a clinician uses continuous BLS during the reprocessing phases 3 through 6, it should not be called EMDR therapy.

Table 1.15 lists what can happen if BLS (i.e., in terms of speed and number of sets) is used inappropriately.

HOW TO DO EYE MOVEMENTS

Table 1.16 outlines the specific criteria outlined by Shapiro (2018) on the proper and acceptable way to facilitate eye movements in terms of preference, duration, speed, distance, height, and more.

IS BILATERAL STIMULATION EMDR THERAPY?

BLS is but one component of EMDR therapy. Stimuli, such as directed and accelerated eye movements, are used to activate the client’s information processing system as they focus on a past trauma, present-day trigger, or future event. Over the years, many beginning students of EMDR therapy, consultees, and even seasoned veterans have referred to BLS as EMDR. BLS is used when facilitating the sacred space, safe (calm) place, and resource development exercises (Chapter 8). When coupled solely with BLS, does this mean that sacred space, safe (calm) place, resource installation, or even the reprocessing phases are EMDR therapy? EMDR therapy is clearly identified as an eight-phase, three-pronged process. If one of the phases is eliminated or substituted with something else, it can no longer be called EMDR therapy.

MEMORY NETWORK ASSOCIATIONS

No one knows what a memory network looks like, but these networks represent the basis of the AIP model. Metaphorically, Dr. Shapiro pictures these networks as a series of channels “where related memories, thoughts, images, emotions, and sensations are stored and linked to one another” (Shapiro, 2018). The negative memory network associations may consist of a series of memories linked to a person (e.g., critical mother); auditory, tactile, or other sensory stimuli (e.g., the sound of a car backfiring); events (e.g., automobile accident, plane crash, tornado); physical sensations (e.g., chest or leg pain); emotions (e.g., fear, sadness); or beliefs (e.g., I am unlovable). The goal is to assist the client’s progression through these memory networks and toward an adaptive resolution.

STOP SIGNAL

It is important to heed a client’s wishes to ensure a sense of safety in the therapeutic environment. EMDR treatment is a choice, and the desire to stop or continue in whatever context is a choice as well. It is one a clinician should always respect. It is imperative a client always feels that the process is a choice and not an imposition or demand. So, if a client asks to stop reprocessing, the clinician should stop immediately.

In the Preparation Phase, the client is asked to provide the clinician with a cue that indicates they want to stop the processing. It may be a hand, finger, or body gesture. The client may simply just turn away or hold their arms up in the air. Whatever the cue is, the processing should be discontinued immediately when used. This allows the client to maintain an ongoing sense of comfort, safety, and control. When this cue to stop is utilized, the clinician assists the client in accessing whatever is needed to stabilize the client and to proceed with the processing. Discontinue all BLS until the client is willing and able to continue reprocessing. The clinician may explore what is needed in order that reprocessing may resume. The clinician should inquire of a client, “What happened? Why do you want to stop?” “Do you need to slow down or just take a break?” Perhaps a client needs to take a break because they are confused or overwhelmed, or they simply want to share concerns about the processing itself. The clinician may ask, “Why did you stop?” (i.e., “What stopped the train?”) and address any concerns the client may have. And then, “What is it you need to continue processing?” (i.e., What does the client need in order to get back on the train?). The clinician also needs to ensure the client has what they need before continuing processing. If a client still insists that they do not want to continue, a clinician should respectfully use the procedures for closing down an incomplete session and only return to processing when a client is ready (Shapiro, 2009–2017a, 2009–2017b). The clinician may ask the client at this point to access their safe (calm) place, use a container strategy, or do some other stabilization exercise to help them to ground, to bring energy back into the body, or bring them into the present moment. The clinician should explore what the client needs to be in place in order to resume processing in the session or at the next session. If a client does not want to continue, do not implement BLS as it may reactivate the processing. Table 1.17 demonstrates some appropriate ways for a client to indicate they want to discontinue or pause the process.

It is important not to accept words for stop signals (e.g., “Stop,” “No more,” “I can’t do this,” “I want to throw in the towel,” or “Whoa!”) as it may be confused with what is going on in the processing.

The stop signal is tantamount to having a cord on a train the passenger can pull to indicate to the engineer that they want the train to stop for some reason. For instance, the client may need an added rest before the next stop or may want to get off the train. Ultimately, it is the engineer (i.e., clinician) who stops the train when signaled by the client in some way to stop.

At the beginning of each session, the clinician may remind the client of the chosen stop signal by saying, “If at any time you feel you have to stop, raise your hand (i.e., remind client of desired stop signal).”

Table 1.17

Stop Signals

“If at any time you feel you have to stop, (remind the client of chosen stop signal).” “Is this a comfortable distance and speed?”

Hand gestures

Hand Signal Time-Out Signal

Body gestures

Standing up Crossing arms or knees Putting hands over mouth, ears, or eyes Cyclist stop signal

EMDR Therapy Is Not Hypnosis

A frequent question asked by clients is, “Is EMDR hypnosis?” When this question is asked, the clinician may want to spend some time with the client explaining the basic differences between the two. Clients may be concerned that EMDR reprocessing will induce a deep trance state where they may lack control. Unlike hypnosis, EMDR reprocessing causes a state of heightened emotional arousal. This is an important distinction for the clinician to make when this question arises.

The differences between hypnosis and EMDR therapy are summarized in Table 1.18.

WHAT ONCE WAS ADAPTIVE BECOMES MALADAPTIVE

Some behaviors are learned. Some serve us well and others do not. Some serve us for a period in our life and eventually become a nuisance. For example, a client who was repeatedly sexually molested by a relative as a young child may have learned to dissociate during the molestation. This was their automatic coping response to the fear and pain of the trauma at the time of the abuse. Years later, as an adult, they may still find themself dissociating during stressful situations in their work and life. As a child, dissociation was the only response available and allowed them to cope; it worked well at the time. As a maturing adult, the dissociation begins to cause problems at home, at school, and/or at work.

DEVELOPING AND ENHANCING ADAPTIVE NETWORKS OF ASSOCIATION

Before processing of the negative networks may begin, clients with more complex cases may need to access, strengthen, and reinforce positive life experiences and adaptive memories (e.g., positive resources and behaviors, learning, self-esteem). It is possible to access these positive experiences by developing new and enhancing existing positive networks described as follows.

STATE VERSUS TRAIT CHANGE

Shapiro (2008) differentiated between state and trait change. She defined a state change as momentary or transitory, whereas a trait change reflected a permanent change. A state change is a change of mind. It instills a sense of hope in the client. A state change also requires the use of coping mechanisms to continue the change, whereas a trait change no longer requires the same. With a trait change, the client changes how they see or view the event and, as a result, can experience it differently.

When a client changes their perspective about a previous traumatic event and has the needed skills, they can function more appropriately. An example of a state change is the client saying, “I am able to soothe myself by breathing and using my safe (calm) place when my boss asks me to come to his office. I feel much calmer.” A trait change may be, “I am no longer triggered when my boss asks me to come to his office.” To simplify, “states are weather” whereas “traits are climate.” “All traits are states” but “not all states are traits” (Shapiro, 2006). See Table 1.19 for a better understanding of the differences between the two.

DUAL AWARENESS—INTERNAL/EXTERNAL BALANCE

Dual awareness or mindfulness, or what Dr. Shapiro calls “dual focus of attention” (2018), allows the client to maintain a sense of present awareness and for the client’s internal processes to function without interference during reprocessing. It allows the client to be a nonevaluative observer with respect to whatever emerges during a reprocessing session. It helps the client keep “one foot in the past and one foot in the present.” The client is on the “train” watching the scenery go by.

One of the primary reasons to teach a client grounding and breathing skills and anchoring them in the present is to help them learn to keep one foot in the present while reprocessing something traumatic from their past. This provides them with a dual focus of attention and reduces the possibility or risk of a client dissociating, blanking out, becoming overwhelmed, and/or resisting. Teaching them these skills prior to the reprocessing will help facilitate a smoother therapeutic experience. It also allows the client to maintain a sense of safety in the present while accessing and stimulating negative information from the past. The clinician can solidify the client’s connection to the present by utilizing verbal reassurances, such as “Good,” “You’re doing fine,” “It’s over,” or “You’re safe now.” The clinician may also stop and change the direction or speed of the BLS. When a client is in an abreactive state, these types of clinical strategies are particularly important to help the client maintain an external focus (Shapiro, 2018).

ECOLOGICAL VALIDITY (I.E., SOUNDNESS)

In attempting to discern whether a client’s target has been resolved, look at what resolution of this traumatic event would look like in the real world given the individual, the timing, and the situation. To what degree does the current situation “fit” the circumstances? Ask yourself, “If a client was processing a rape that occurred months before and the rapist was still on the loose, would it be appropriate for them to continue to feel fear and demonstrate vigilance around this event?” The answer depends on how their information processing system works. Is there a reason they may be or may think they are still in danger? Is their sense of vigilance and fear around the rapist emotionally appropriate under the circumstances?

How does one recognize ecological validity? And how do you work with it within the EMDR therapy framework? First, use Wolpe’s SUD scale (Wolpe, 1990; Exhibit 1.8).

EXHIBIT 1.8 Subjective Units of Disturbance Scale

Developed by Joseph Wolpe in 1969, the modified SUD scale is an 11-point Likert scale utilized to measure the subjective units of disturbance being experienced and reported by a client at a given time.

Abbreviation: SUD, Subjective Units of Disturbance.

The SUD scale is an 11-point Likert scale utilized to rate the anxiety level of a memory being accessed by a client in the present. When you ask the client during the Desensitization Phase to focus on the original event (incident, experience) and again ask, on a scale from 0 to 10, “How disturbing does it feel now?” and the client says a 1, the clinician needs to check out what is blocking (i.e., blocking belief) desensitization of the original target by: (a) having the client focus on where they feel it in their body; and by asking (b) “What keeps it a 1 (or .5 or 2)?”; or (c) “What keeps it from being a 0?” In the case of a rapist, the client might respond, “He’s still out there.” Ask the client to “go with that” and continue to process to a more complete resolution. Do not assume that the client has reached the end of the channel just yet. Continue to process and check the SUD again before proceeding to the Installation Phase.

If the client still clings to the 1 (or .5 or 2) and “he’s still out there,” you can consider this to be ecologically valid. Ecological validity is one of the reasons the clinician should go directly to the Installation Phase without the client’s SUD level getting down to a 0. The SUD scale will be discussed in more depth in Chapters 2 and 3.

A blocking belief may also arise in the Installation Phase when evaluating the VoC, a 7-point semantic differential scale that measures the validity (i.e., felt sense of the trueness or falseness) of the client’s stated PC. If the client reports a VoC of 6 or 6.5, use the same questioning mentioned earlier when the SUD does not equal 0 (i.e., focus on where the client feels it in their body, “What keeps it a 6.5?” “What prevents it from being a 7?”) to discern if there is: (a) a blocking belief, (b) feeder memory, or (c) ecological validity.

Dr. Shapiro has been known to say, “Forgiveness is like rain—it may or may not happen.” If a client forgives someone who has hurt them, it does not mean they use poor judgment with respect to that individual (e.g., they will never leave their children with a past abuser). However, clients often arrive at forgiveness or compassion more quickly and more completely than they might with other forms of therapy. A clinician must be alert to not use their own experiences or experiences of their other clients to determine “ecological validity” for any specific client. If processing stops at a certain place, first attempt to remove the block by changing the direction or modality of the BLS. Always get the client’s permission before doing so. Then do a couple more sets of BLS before determining if it is ecologically valid for the person to move further toward forgiveness or compassion.

SIDE BENEFITS OF EMDR THERAPY

The primary goal of EMDR therapy is to reprocess any irrational, negative cognitions; emotions; sensory stimuli (e.g., images, sounds, smells, tastes); and physical sensations associated with a trauma. It does not, however, remove or eliminate any irrational, negative sensations and cognitions related to a traumatic event. In the rape example mentioned earlier, it may be ecologically appropriate that the client maintain a healthy sense of fear and an appropriate level of vigilance until the rapist has been caught and their physical safety is ensured. It does not change the client’s negative thoughts and feelings about the rapist and what they did to them.

Reprocessing will not eliminate any negative thoughts, emotions, or physical sensations that are appropriate to the situation. For example, a client may experience hate toward their abusive, neglectful, and distant mother. In response to ongoing experiences, the client may have developed low levels of self-esteem and confidence. Reprocessing may be successful in improving the client’s self-esteem and other issues, but the client may or may not still feel hatred toward their mother.

EMDR therapy does not have the potential for making one fall back in love with their significant other if one does not love them, secure a raise at their job if one does not deserve one, believe that their abusiveness to another was acceptable, or make one the next race car champion of the Indy 500 if one does not have the ability to drive a race car. It cannot make the true untrue or the untrue true. It only can decompress the negative thoughts, feelings, and physical sensations from the client’s internal system so that natural healing can take place. In the process of EMDR therapy, new insights may occur; behavior, perceptions, and attitudes can shift; and physical and emotional responses can change.

HOLISTIC NATURE OF THE APPROACH

Even though it has been around for more than 30 years, EMDR is very much a “cutting edge” therapy. One of the reasons that it continues to be cutting edge is that it appears to be a permanent means of flushing traumatic memories with the accompanying negative cognitions, emotions, and physical sensations from the client’s system in a way that seems unique. It is a whole-system approach. It can reach down into the depths of a client’s despair, attach itself to every negative element connected to a traumatic event, and then flush it out.

COOKIE-CUTTER APPROACH

EMDR therapy is not a one-size-fits-all approach. It is neither mechanistic nor cookie-cutter. Clients are as different as night and day and sessions can vary from simple to complex depending on a client’s trauma history. Each client is approached individually in terms of history-taking, treatment planning, preparation, and target focus. Some clients will benefit from eye movements while others may do better with other forms of BLS. The speed and the length of the set will vary from client to client. Some will need more and different forms of preparation. Not only do clinicians approach each client differently, each client responds differently to EMDR treatment as well. EMDR therapy is not simply a matter of a clinician waving their fingers in front of a client’s eyes as they focus on a trauma. From beginning to end, each client is treated as unique and special as the clinician helps them to navigate his way through his trauma to adaptive resolution.

TRAIN METAPHOR

While no longer a major form of transportation in America and the experience of riding a train is unfamiliar to many, the use of the train metaphor continues to be Shapiro’s primary means of explaining the intricate principles, protocols, and procedures inherent in EMDR therapy.

Dr. Shapiro prescribes the use of a train metaphor to help clients move along their processing “tracks.” Reference to and use of this metaphor will be utilized frequently throughout this Primer. During the Desensitization Phase, this metaphor can be applied as a means of noticing yet distancing the client from fear of the trauma. Dr. Shapiro favors this metaphor because it conveys a sense of movement and safety (Shapiro, 2006). The train metaphor may be used throughout the reprocessing as needed. It goes like this: “In order to help you just notice the experience, imagine riding on a train and the feelings, thoughts, etc., are just scenery going by” (Shapiro, 2018).

During the reprocessing, the image of the train going down the track is also used to encourage the client to continue. The passenger is the client, and the scenery represents the dysfunctional information that they are reprocessing. The clinician might say, “It’s just old scenery. Just watch it go by.” This metaphor is a reminder to the client that the train passes the scenery as quickly as it appears.

Dr. Shapiro describes the processing as “metaphorically like moving down a train track” (Shapiro, 2006). From the point of origination to the destination, there are freight depot stops where useless cargo (i.e., dysfunctional information) is unloaded and new, useful cargo (i.e., adaptive information) is loaded (i.e., adaptive resolution). In between stops, resources may need to be loaded for the client to continue the trip down the track, debris may need to be cleared from the track, and/or linkages to adaptive networks can occur. See Exhibit 1.9 for a pictorial rendition of this metaphor. Again, the damaged material is unloaded and discarded at the freight depots found along the track during the stopping and starting of the BLS. It is also at this freight depot where adaptive information is loaded. When the train reaches its final destination, the client has reached adaptive resolution. Metaphorically, the processing stimulated by the assessment questions and BLS move the train down the track toward adaptive resolution.

Whether suggesting the train or another example, the metaphor is an option being offered to a client if the trauma becomes too much to bear and distancing from it will allow reprocessing to continue. Installation of the metaphor is unnecessary.

During an abreaction, the train metaphor is a useful strategy for supportively assisting a client to allow movement down the tracks. The clinician can assist by saying, “It’s just old information. Watch it like scenery going by.”

Dr. Shapiro also uses the train metaphor to describe information that moves adaptively from dysfunctional to functional. It is a common experience for a client’s once-vivid negative images, affect, and cognitions to become less vivid and less valid while the opposite happens to the positive images, affect, and cognitions. Can you visualize a train traveling down its track? Each time the dysfunctional information is stimulated or when accelerated processing takes place, the train moves down the track and stops. At each stop, the client unloads dysfunctional information and loads more functional or adaptive information. The train continues on this route until it reaches its final destination (i.e., adaptive resolution). One of the important elements of this journey that should not escape the client is that the choice to make a return trip down the same track and revisit the scenery that emerged is optional.

EXHIBIT 1.9 Adaptive Information Processing Model—Metaphoric Train Moving Down the Track Toward a More Adaptive, Functional Resolution

TABLE 1.20

Distancing Metaphors

Although seemingly archaic, the use of the train metaphor versus others (i.e., movie theater, river) makes more sense for several reasons. It conveys the sense of movement and safety that Shapiro emphasizes (2018). It is a distancing metaphor. First, the train moves forward at a rapid rate of speed as it distances the client from the trauma while the scenery recedes in the distance at the same rate of speed. In addition, there is a visual barrier between the client who sits on the train and the scenery passing by outside the train. The protective barrier between the client and trauma helps to create a greater sense of safety. See a representation of this idea by the comparison with the other distancing metaphors in Table 1.20.

TUNNEL METAPHOR

Another metaphor used by Shapiro (2018) is driving a car through a tunnel. To get through the tunnel as quickly as possible, the driver will need to increase their pressure on the accelerator (i.e., “You are in a tunnel. Just keep your foot on the pedal and keep moving.”). In EMDR reprocessing, the eye movements or other BLS act as the accelerator (i.e., the processing of the dysfunctional information is accelerated by the speed and length of the BLS). This metaphor is utilized to encourage the client to pass through the tunnel as fast as possible (i.e., keep moving his eyes quickly). If they ease up on the accelerator or choose to stop during transit, the car moves slower; and it takes much longer to get through the tunnel. Or they are left in the midst of unprocessed material.

HAND METAPHORS

Using the hand as her prop, Shapiro explained two different aspects of the treatment process by using a metaphor. When she was training clinicians in EMDR therapy, Dr. Shapiro often used a hand metaphor to emphasize and explain the progression of the treatment effects through the memory network. With the back of her hand facing outward and her fingers pointing downward, she would explain the processing of an identified traumatic memory. The top part of the hand represented the target or node (i.e., the traumatic event or some aspect of it, such as thought, belief, body sensation) and her fingers the different channels of association that the client had to progress through to achieve adaptive resolution.

With the palm facing outward and fingers pointing downward, Dr. Shapiro would use another hand metaphor to demonstrate the different components of a memory. The top part of the hand represented the memory and the fingers the different aspects of the memory network—sensory (e.g., visual, auditory, olfactory, tactile, gustatory), thoughts, emotions, body sensations, and thoughts and beliefs (see Figure 1.1).

SECONDARY GAINS

Secondary-gain issues tend to obstruct or stall processing. Therefore, it is advisable for a clinician to attempt to ferret these out prior to any actual processing taking place. In the History-Taking Phase and Treatment Planning Phase, the clinician may investigate the presence of these gains by asking the client if they are aware of any reasons why processing might be unsuccessful. Is there something a client may be uncomfortable giving up to help resolve the issues they bring to therapy? What other issues are served by the presenting complaint, such as positive consequences (e.g., pension checks); needs (e.g., fear of dishonoring the dead by getting better and moving on; fear of bears may keep a wife from going on camping trips with her husband); or identity issues (e.g., fear of loss of professional or social identity)? Identify what feeds these secondary gains (e.g., low self-esteem, irrational fears, boundary issues, lack of assertiveness). Whatever the issues are, these fears need to be resolved before a successful therapeutic outcome can be expected or maintained. A clinician also needs to ensure that a client has the stability and resources available, which assists them in giving up the gains. Noncompliance may also be related to other fears (e.g., fear of success, fear of terminating therapy, fear of failure). When this occurs, the clinician may ask the client, “What is the worst that could happen?” or “What would change if you were successful?” The secondary-gain issues and fears may need to be addressed before any successful processing can occur.

BLOCKING BELIEFS

Blocking beliefs generally arise during EMDR processing toward the end of the Desensitization, Installation, and Body Scan phases. They become evident when a client’s SUD level does not lower to a 0, VoC does not rise to a 7, or a clear body scan is not achieved.

SUBJECTIVE UNITS OF DISTURBANCE AND THE EMERGENCE OF BLOCKING BELIEFS

If, after repeated applications of different directions and types of BLS, the client cannot attain a 0 for a SUD level, the clinician may ask the client to: (a) focus on where they feel it in their body. If it still does not lower, the clinician is directed to look for the presence of a dysfunctional blocking belief by asking (b) “What keeps it a 1 (or .5 or 2)?” or (c) “What prevents it from being a 0?” If a benign or nonproblematic blocking belief (e.g., “I don’t believe in absolutes”) arises, the clinician should ask the client to “Just notice that,” and add another set of BLS. Sometimes this allows the SUD to drop to 0. If not, then proceed to the Installation Phase.

To probe further for a blocking belief, the clinician may ask the client, “Is there a part of you that might have concerns about getting over this problem?” or “What would happen if you were to completely get over this problem?” and initiate one of more sets of BLS in order to bring forth the concern or an association to the client’s consciousness. Examples of responses that may emerge are, “It’s not safe to get over this problem,” I don’t deserve to get over this problem,” or “If I feel better, I will forget about what happened.”

If a dysfunctional blocking belief surfaces and, after successive sets of BLS, it does not remit, the clinician should target it with full reprocessing (i.e., Phases 3–6). This means that processing of the original target should be stopped until the blocking belief has been identified, targeted, and reprocessed. After a blocking belief has been successfully processed, the clinician should reevaluate the original targeted event and then complete the Desensitization Phase and proceed to the Installation Phase.

VALIDITY OF COGNITION AND THE EMERGENCE OF BLOCKING BELIEFS

Except for the wording, the same procedures cited earlier for blocking beliefs and the SUD level apply to blocking beliefs and the VoC. For assessing a blocking belief at the Installation Phase, the clinician asks the client: (a) to focus on where they feel it in their body; (b) “What keeps it a 6.5?”; or (c) “What prevents it from being a 7?” When assessing a client’s level of validity, ecological validity should be taken into consideration by the clinician. What current life circumstances may keep a client’s VoC from rising to a 7? If a client is processing a rape and their PC is, “I am safe,” her 7 level may not be realistic or possible for them if their rapist is still at large. If blocking beliefs are revealed during the Installation Phase, they need to be fully processed using phases 3 through 6. Once it has been reprocessed, the clinician should reevaluate the original targeted event and then complete the Desensitization Phase and proceed to the Body Scan Phase.

BODY SCAN AND THE EMERGENCE OF BLOCKING BELIEFS

Blocking beliefs can emerge anywhere during EMDR treatment, including the body scan. If a blocking belief emerges during this phase and it appears more dysfunctional than innocuous, it should be targeted and processed with full reprocessing (i.e., Phases 3–6). Once resolved, the original target should be accessed, processed, and completed at the Body Scan Phase.

FEEDER MEMORIES

When Shapiro (2018) first began developing and implementing eye movement desensitization (EMD) in 1989, she started by targeting a client’s current dysfunction. The result was that, when a client focused on their negative reaction to present stimuli, they would become more anxious and processing remained blocked. What she readily discovered was after several sets of BLS and often earlier, related memories would spontaneously emerge; and the client would get better once the processing of them was complete. It was then that Dr. Shapiro developed and introduced the three-pronged protocol—past, present, and future—whereby her first area of focus changed from a client’s presenting issue to the precipitating event that fueled their current dysfunction.

At this stage of development, Dr. Shapiro also began asking a client to focus on a presently held negative belief and scan back in the past for an earlier time they may have had this negative belief about themself. Because of these changes, Shapiro (2018) wrote, “The theoretical assumption of EMDR treatment is that any current dysfunctional reaction (with the exception of organically or chemically based pathologies) is always the result of a previous experience, although, of course, not necessarily one from childhood” (p. 181).

The earlier untapped memories that may emerge and appear to continue to feed a client’s current dysfunction and block successful processing are called feeder memories and may arise in any of the three stages of the EMDR approach. Clinicians are now encouraged to initially treat the earlier memories with the standard protocol, followed by the present triggers and desired future outcome.

There are several ways to elicit the existence of feeder memories from a client: (a) direct questioning, (b) floatback, and (c) affect scan. If a feeder memory surfaces during the processing of another related event, these strategies may be utilized to ascertain the existence of a feeder memory within the reprocessing session or may be targeted later.

In addition to ancillary targets, there are other client obstacles that may obstruct reprocessing. In these cases, the clinician will need to determine the cause and rectify to initiate or continue processing. The obstacles highlighted in Table 1.21 were adapted from Dr. Shapiro’s work (2009–2017a, 2009–2017b).

ASSESSMENT PHASE

DESENSITIZATION PHASE

The clinician continues to install the PC as long as the reprocessing keeps becoming more and more adaptive. If the reported VoC does not increase to 7, the clinician will check for ecological appropriateness. The existence of blocking beliefs should be considered.

Continue to the Closure phase. See Chapter 6 for a complete transcript using EMD with a client. Please note that a Body Scan is not initiated using EMD as the clinician does not want to run the risk of opening up associative links.

PRACTICE, PRACTICE, PRACTICE

Practice, practice, practice is this Primer’s mantra. In the EMDR Weekend 1 and 2 Trainings you were introduced to EMDR therapy—but, because of time limitations, you may not have fully integrated its substance and protocol into your own therapeutic paradigm. Learning EMDR therapy comes from the actual doing of it. Even skilled clinicians who have conducted hundreds of sessions have the potential for learning something new every time they execute the process with a client. It is only from practicing EMDR that excellence and expertise can be derived; so, the mantra practice, practice, practice cannot be overly emphasized.

FOLLOW THE SCRIPT VERBATIM

Newly trained EMDR therapy clinicians are strongly encouraged to follow Dr. Francine Shapiro’s script verbatim in the Assessment Phase. Dr. Shapiro has chosen every word for a specific reason, and these words have been tested and validated repeatedly in one context or another in session after session with clients presenting various mental health issues. It is important for the clinician to understand the intent and implications of the wording of the well-researched protocol before implementing individual styles of eliciting the same information. In addition, it is highly beneficial for clinicians to follow the scripts provided for Phases 4 through 6. Clinicians who learned the script in the early days of EMDR therapy may notice how it has been refined throughout the past 30 years.

If you have been recently trained or have decided to finally put your EMDR training to use, sit with a copy of the standard protocol in your lap as you implement the Assessment Phase with clients (see Chapter 3). Reading the script verbatim may feel unnatural at first, but you can expect to feel more at ease as you learn the procedural steps. Sitting with the pages in your lap and reading the script as it is written can also serve as good modeling for your client as they watch you work with something new on their behalf. As they become more familiar with the protocol and what words are required in each part, the clinician will most likely develop their own style for setting up the EMDR protocol. The words in the Assessment Phase necessary to optimize receiving the desired processing outcome have been underlined in this chapter and in subsequent ones for your recognition and convenience.

The EMDR Fidelity Rating Scale (EFRS) was developed by van der Kolk et al. (2007) to evaluate adherence to EMDR therapy’s eight phases of treatment (i.e., Phases 1–8) and three-pronged protocol (i.e., past, present, future). The EFRS can help a clinician evaluate use of the standard EMDR therapy protocol with memories associated with adverse life events or current triggers. A modified version of this scale (Korn et al., 2018) can be found on the EMDR Research Foundation website (see https://emdrfoundation.org/research-grants/emdr-fidelity-rating-scale/). Clinicians are strongly encouraged to become familiar with this helpful scale. The more fidelity a clinician demonstrates, the better treatment outcome for the client.

Consider logging onto the Trauma Recovery/EMDR Humanitarian Assistance Programs (TR/EMDR-HAP) website to contribute to a worthy cause. You may want to consider purchasing the laminated SUD/VoC Scale Chart or the EMDR Progress Notepad. These items may be purchased online at the TR/EMDR-HAP website (https://www.emdrhap.org/content/). The worksheets can assist you in being more consistent and successful from client to client. The laminated chart may save time and help the client to distinguish a belief from a feeling and to select a negative belief appropriate to their situation. It is not an uncommon reaction for a client to look like a deer caught in the headlights when asked, “What words go best with the picture that express your negative belief about yourself now?” Having said this, use this placard sparingly. In all cases, it is imperative that the client be given ample opportunity to provide the clinician with a negative and positive cognitions on their own. When a client seemingly does not understand what is being asked for, the clinician should be knowledgeable and skilled in ways to tease these cognitions out before handing them the placard.

KNOW YOUR CLIENT

Before you begin using the reprocessing phases, it is important that you know your client well. Know their strengths and weaknesses. Know their abilities and their limitations. Know their ego deficits. Know their coping mechanisms and strategies. Know their support system—or lack of it. Some clients may not be appropriate or ready for EMDR trauma processing. There could be situations, however, in which you will not have the luxury of waiting weeks to know your client before beginning reprocessing. Then it becomes imperative that you gain as much information as you can about your client in a brief period, particularly when situations or circumstances indicate a necessity of serious caution.

STAY OFF THE TRACKS

The hallmark of EMDR reprocessing is facilitating a client’s flow of association and allowing the client to get to the end of the “track” on their own. After completion of the Assessment Phase, the clinician is encouraged to be very limited in what they say, such as “Take a breath. (Pause.) Let it go.” “What are you noticing now?” “Good.” “Go with that.” “Notice that.” The clinician does not say much of anything else unless the client appears stuck in the process.

The most appropriate and easiest method to stay out of the way is by consistently maintaining a position of quiet neutrality. During the process, the clinician encourages the client by saying “Good” or “You’re doing fine.” Beyond this, the clinician must be careful not to physically or verbally express what they believe or think about a client’s responses between sets of BLS. It is imperative that the clinician allow the client to own the reprocessing of their traumatic event and not be encumbered by the clinician’s interventions, comments, or questions. Remember, the clinician is not the agent of change: the client is.

TRACKING THE CLIENT

It is important for the clinician to write down as much as possible of what the client says during the Assessment Phase, especially the exact wording of the client’s negative and positive cognitions and key words from their descriptions of traumatic events. Why? Because it is important to use exact wording when activating what the client says. If a client provides a negative cognition, such as “It’s my fault,” and a clinician reframes it as “I’m responsible,” the clinician may have inadvertently distorted what the client originally meant. In doing so, the clinician has also placed themself in the client’s process. Because the clinician reframed it that way, the client may begin to interpret it as “I’m responsible,” simply because the clinician said it. “It’s my fault” and “I am responsible” may or may not mean the same to the client. To the degree that it does not, it can alter the direction of processing. During the remaining reprocessing Phases 4 through 6, clinicians often find it helpful to write down what the client says. However, if writing down what the client says during reprocessing slows, interrupts, or hinders in any way the client’s flow, stop writing and opt to listen and observe more closely what the client is experiencing in the moment.

KEEP IT SIMPLE

In the early days of your EMDR experience as a clinician, try to keep it simple. Do not go straight from the training to your office and select the most challenging client to conduct your first reprocessing session. Select someone with a less complex trauma, such as a client who presents with a single-event trauma. Maybe someone has recently been involved in an automobile accident that relates to no other traumatic event in their life. As will be described in Chapter 4, when the three-pronged approach is discussed, multiple-event traumas are more comprehensive, will take a longer time frame to deal with, and require more skill than a client who presents with a single event. As a new EMDR clinician, you may not yet have the skill level required to deal with multiple-event traumas.

POWER OF NOW

One of the most emphasized words in the EMDR protocols is “now.” Why? Because we are asking the client what they believe negatively about themself, what they want to believe positively about themself, and what are the negative emotions and physical sensations that go with the event they are focusing on “now.” How are they being affected in the present by something that happened to them 2 months, 2 years, or 20 years ago? How are they being affected now?

The clinician may need to repeat the “now” over and over to a client. The client may get confused between how they felt “then” about an incident and how they feel “now” and ask questions that indicate their confusion. “Do you mean then or now?” And they could say, “Then it felt awful, but now it does not feel so bad.” If this happens during the Assessment Phase, the clinician may need to reevaluate whether the client has chosen an appropriate target. Remember, the clinician is looking to relieve the client of a memory that is charged with negativity. Use Exhibit 1.10 to help remember this important point.

EXHIBIT 1.10 Past, Present, Future

ONE MORE TIME

A good rule to remember during EMDR reprocessing with a client is that any time something is positively reinforced with BLS, it strengthens the focus of reinforcement. So, when a client reports a positive direction in the reprocessing, say “Go with that” just one more time before returning to target. After the client reaches the SUD of 0, VoC of 7, and a clear Body Scan, say “Go with that” one or more times to reinforce the positive treatment effect and/or to allow deepening of the PC (Shapiro, 2018, 2009–2017a, 2009–2017b). If the clinician is consistent with this rule, the success of the EMDR will be enhanced. In any case, it is important to continue BLS if positive material continues to emerge or strengthen in any part of the client’s reprocessing experience.

When reinforcing a positive effect during the Desensitization, Installation, and Body Scan Phases, the BLS will be faster and the length of the sets longer (i.e., 20–24 round-trip passes to start, lengthen to 30–40 as needed) than during the Preparation Phase, when using the safe (calm) place and other resource-building exercises (i.e., slower 4–6 round-trip passes). As indicated earlier, slower and shorter sets are utilized in stabilization efforts to not activate any disturbing material prior to actual reprocessing with EMDR. The primary reason for utilizing faster, longer sets during Phases 3 through 6 is that negative associations may emerge at any phase. Faster, longer sets facilitate the resolution of the negative material, adaptive resolution, and generalization.

SOLO RUN

Client selection is always an important part of the EMDR therapy process, but more so when a clinician is choosing clients for a first solo run. Clinicians may want to select clients with whom they have a strong client–clinician relationship. Pick the less complicated cases. Think of a client’s trauma as an onion. How many layers are there? How thick? How thin? So, when looking at the onion, look for the one- or thin-layered skins. And go slowly.

If you are new to EMDR therapy, select a client with more strengths than weaknesses, adequate coping mechanisms, and a supportive network of family and friends. Initially, you may also want to consider working with a client’s lesser issues to build up your experience and the client’s confidence in AIP during your learning process. For example, Sharon entered therapy 3 weeks prior. She had been sexually abused over a long period of time by an older brother who had an intellectual disability. Because Sharon was new to therapy and the clinician was new to EMDR, it was decided that her first reprocessing session would focus on her fear of dogs. It turned out that Sharon had been bitten by a stray dog at the age of 5 years. Because the session was so successful, they were able to continue using the process on the sexual abuse she experienced at the hands of her older brother.

Dr. Shapiro suggests first identifying the “touchstone” event when there may be one (2008). Before proceeding in this direction, however, one must carefully discern whether it is possible for the client to attain successful processing of a touchstone event. This means that the client must be able to tolerate any level of disturbance that may arise. If the touchstone event is chosen for processing and the client becomes too overwhelmed by the experience, much time could be lost by having to “undo” the client’s newly created fear of the process. On the other hand, if you do not target the touchstone event and it arises as a feeder memory, it has the potential to be even more disturbing. The significance of completing a comprehensive history and obtaining informed consent becomes clearer here; that is, it is important for the client to be informed of the potential for accessing feeder memories during the reprocessing of any chosen target.

In this chapter, an attempt has been made to help refamiliarize the reader with basic concepts inherent in EMDR and/or to provide valuable updates to EMDR therapy. Throughout subsequent chapters, case examples will be provided along with teaching points that attempt to explain the clinician’s strategies or to point out techniques prescribed by Dr. Shapiro during reprocessing.