EMDR for Professionals Hospice of Volusia/Flagler Lynda Majure Ruf, EdS, LMFT, LMHC August 3, 2007

1. EMDR for Professionals Hospice of Volusia/Flagler Lynda Majure Ruf, EdS, LMFT, LMHC August 3, 2007

2. What is EMDR? • EMDR is a psychological method for treating emotional difficulties caused by disturbing events. • EMDR brings together elements from well-established clinical theoretical orientations. For many clients, EMDR provides more rapid relief from emotional distress than conventional therapies.

3. What is the origin of EMDR? • In 1987, psychologist Francine Shapiro discovered that voluntary eye movements reduced the intensity of disturbing thoughts. • Although EMDR was originally developed by Dr. Shapiro with lateral eye movements as a core feature of its methodology, alternate forms of bilateral stimulation are now being used, such as alternate right-left auditory tones and taps on the client’s hands.

4. Traumatization is a disruption of the inherent information processing system that normally leads to integration and adaptive resolution following upsetting experiences (van der Kolk & Fisler, 1995). Under normal circumstances, this information processing may occur during thinking, talking, expressive/artistic activities, and/or dreaming. In trauma, however, a malfunction of this natural information processing system occurs such that the experience of the trauma remains “frozen”, manifesting in persistent intrusive thoughts, negative emotions and self-referenced beliefs, and unpleasant body sensations. EMDR: An Adaptive Information Processing Model

5. Components of Traumatic Memory TRIGGERS PICTURES EMOTIONS TRAUMA BELIEFS SENSATIONS

6. EMDR: An Adaptive Information Processing Model • All humans are understood to have a physiologically-based information processing system. This can be compared to other body systems, such as digestion in which the body extracts nutrients for health and survival. The information processing system processes the multiple elements of our experiences and stores memories in an accessible and useful form. Memories are linked in networks that contain related thoughts, images, emotions, and sensations. Learning occurs when new associations are forged with material already stored in memory.

7. EMDR: An Adaptive Information Processing Model (cont) When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks. For example, a rape survivor may “know” that rapists are responsible for their crimes, but this information does not connect with her feeling that she is to blame for the attack. The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed. When the individual thinks about the trauma, or when the memory is triggered by similar situations, the person may feel like s/he is reliving it, or may experience strong emotions and physical sensations. A prime example is the intrusive thoughts, emotional disturbance, and negative self-referencing beliefs of posttraumatic stress disorder (PTSD).

8. EMDR: An Adaptive Information Processing Model (cont) • It is not only major traumatic events, or “big-T Traumas” that can cause psychological disturbance. Sometimes a relatively minor event from childhood, such as being teased by one’s peers or disparaged by one’s parent, may not be adequately processed. Such “little-t traumas” can result in personality problems and become the basis of current dysfunctional reactions.

9. EMDR: An Adaptive Information Processing Model (cont) • Shapiro proposes that EMDR can assist to successfully alleviate clinical complaints by processing the components of the contributing distressing memories. These can be memories of either little-t or big-T traumas. Information processing is thought to occur when the targeted memory is linked with other more adaptive information. Learning then takes place, and the experience is stored with appropriate emotions, able to appropriately guide the person in the future. A variety of neurobiological contributors have been proposed 4,5,6,7,8 • EMDR specifically targets traumatic material and appears to restart “stalled” information processing, facilitating the resolution of the traumatic memories through the activation of neurophysiological networks in which appropriate and positive information is stored.

10. What Happens during EMDR? During EMDR, the clinician works with the client to identify the specific problem that will be the focus of treatment. Utilizing a structured protocol, the practitioner guides the client through a description of a disturbing event related to his or her presenting problem(s). The practitioner asks the client to identify and focus on the image, cognitions, emotions, and somatic distress associated with the traumatic memory. While the client is engaged in eye movements or some other form of bilateral stimulation, s/he is experiencing various aspects of the initial memory or other related memories. The practitioner pauses with the eye movements or bilateral stimulation at regular intervals to ensure that the client is processing adequately on his or her own.

11. What Happens during EMDR? The practitioner guides the process, making clinical decisions about the direction of the intervention. The client may process at cognitive, affective, and/or somatic levels over the course of a given session. The goal is the client's rapid processing of information about the negative experience, bringing it to an "adaptive resolution." In Shapiro's words, this means a reduction in the symptomatology, a shift in the negative belief to the client's new positive belief, and the prospect of functioning more optimally.

12. What Happens during EMDR? (cont) The comprehensive "three-pronged approach" employed in the EMDR method addresses: 1) earlier life experience; 2) present-day stressors; and 3) desired thoughts and actions for the future. EMDR treatment may last from 1-3 sessions to 1 year or longer for complex problems.

13. Why Do Clients Seem to Respond Well to EMDR? • EMDR is a client-centered approach that allows the clinician to facilitate the mobilization of the client's inherent healing mechanism. • EMDR targets the physiological components of emotional difficulties, along with negative beliefs, emotional states, and other disturbing symptoms.

14. Why and how does EMDR work? Hypothesized Mechanisms • Many hypotheses have been put forth to explain the possible mechanism of change related to EMDR, but a definitive explanation has not been confirmed. • “Fortunately we do not have to know why a demonstrably effective treatment works before using it.” (Shapiro, 1995)

15. EMDR: Hypothesized Mechanisms • One hypothesis was proposed by Harvard Medical School sleep researcher Robert Stickgold, Ph.D. at the 1998 EMDRIA Annual Conference:

16. EMDR: Hypothesized Mechanisms "Several lines of evidence suggest that EMDR may help in the treatment of PTSD by turning on memory processing systems normally activated during Rapid Eye Movement (REM) sleep but dysfunctional in the PTSD patient. Two separate memory systems store information in the brain. One, located in the hippocampus, stores 'episodic' memories, the memories of actual events in our lives. The second, located in the neocortex, stores general information and associations.”

17. EMDR: Hypothesized Mechanisms Stickgold proposed that recovery from trauma depends the processing of traumatic memories in their episodic form into general semantic memories. Literature that suggests that this normally occurs during REM sleep but is prevented from occurring for people who have PTSD. In particular the arousal associated with PTSD results in associations between the trauma event and other related events failing to develop.

18. EMDR: Hypothesized Mechanisms • Bessel van der Kolk, M.D. of Boston University School of Medicine states (Boston Globe, 1998): “In a recent EMDR study, in collaboration with the New England Deaconess/Beth Israel Neuroimaging Laboratory, brain scans were used to measure how brain activity changes after effective treatment.” • During EMDR two areas of the brain had increased activation: the anterior cingulate gyrus and the left frontal lobe. It is tempting to say that these changes reflect an increased ability to differentiate between exposure to a real traumatic event and confrontation with a mere reminder of a shocking event that occurred many years ago.

19. EMDR: Hypothesized Mechanisms • EMDR through the repetitive redirecting of attention, activates brain systems normally present during REM sleep. Any alternating, lateralized stimulation regimen, whether eye movements, tapping, or binaural sound, could activate these systems by forcing the brain to constantly re-orient to new locations in space. In this manner, EMDR can 'push-start' the broken-down REM machinery that is required for the brain to effectively process traumatic memories.”

20. Treatment elements of EMDR • Treatment elements enhance the processing and assimilation needed for adaptive resolution. These include: • Linking of memory components. • Mindfulness. • Free association. • Repeated access and dismissal of traumatic imagery. • 5) Eye movements and other dual attention stimuli.

21. Treatment elements ofEMDR • 1) Linking of memory components. • The client’s simultaneous focus on the image of the event, the associated negative belief, and the attendant physical sensations, may serve to forge initial connections among various elements of the traumatic memory, thus initiating information processing.

22. Treatment elements ofEMDR • 2) Mindfulness. • Mindfulness is encouraged by instructing clients to “just notice” and to “let whatever happens, happen.” This cultivation of a stabilized observer stance in EMDR appears similar to processes advocated by Teasdale (1999) as facilitating emotional processing.

23. Treatment elements of EMDR • 3) Free association. • During processing, clients are asked to report on any new insights, associations, emotions, sensations, images, that emerge into consciousness. This non-directive free association method may create associative links between the original targeted trauma and other related experiences and information, thus contributing to processing of the traumatic material (see Rogers & Silver, 2002).

24. Treatment elements ofEMDR • 4) Repeated access and dismissal of traumatic imagery. • The brief exposures of EMDR provide clients with repeated practice in controlling and dismissing disturbing internal stimuli. This may provide clients with a sense of mastery, contributing to treatment effects by increasing their ability to reduce or manage negative interpretations and ruminations.

25. Treatment elements of EMDR • 5) Eye movements and other dual attention stimuli. • There are many theories about how and why eye movements may contribute to information processing.

26. The Eight Phases of EMDR Treatment The eight phases of the EMDR protocol represent a comprehensive treatment approach incorporating many well-established elements of psychotherapy and the novel element of bilateral stimulation. 1. Client History and Treatment Planning 2. Client Preparation 3. Assessment 4. Desensitization 5. Installation 6. Body Scan 7. Closure 8. Reevaluation

27. The Core of EMDR Treatment ASSESSMENT PHASE DESENSITIZATI0N PHASE INSTALLATI0N PHASE

28. The Core of EMDR Treatment • ASSESSMENT PHASE • Presenting Issue • Picture • Negative Cognition (NC) • Positive Cognition (PC) • Validity of Cognition (VOC) • Emotions/Feelings • Subjective Units of Distress (SUDS) • Location of Body Sensation

29. The Core of EMDR Treatment • DESENSITIZATION PHASE • Potential Responses: Pictorial Processing, • Cognitive Processing, Emotional Processing, Sensory Processing • Associative Links and Feeder Memories • Informational Plateaus: • Responsibility, Safety, and Choices • INSTALLATION PHASE • Integration of Positive Cognition with • Targeted Information and VOC Check

30. Examples of Cognition Negative Cognitions I am a bad person. I am worthless (inadequate). I am shameful. I deserve only bad things. I cannot trust my judgment. I cannot succeed. I am not in control. I am powerless. I am weak. I cannot protect myself. I am stupid. I am Insignificant (unimportant). I am a disappointment. I deserve to die. I deserve to be miserable. I cannot get what I want. I am a failure (will fail). I have to be perfect (please everyone). I am permanently damaged. Positive Cognitions I am a good person. I am worthy; I am worthwhile. I am honorable. I deserve good things. I can trust my judgment. I can succeed. I am now In control. I now have choices. I am strong. I can (learn to) take care of myself. I have intelligence. I am significant (important). I am okay just the way I am. I deserve to live. I deserve to be happy. I can get what I want. I can succeed. I can be myself (make mistakes). I am (can be) healthy. Reprinted with permission of the EMDR Institute, Inc.

31. Childhood Trauma Case Example • Client • A 35-year-old woman reports that she was sexually abused as a child by her alcoholic father. • Presenting Problems: Nightmares, flashbacks, avoidance of trauma-related trigger situations, hypervigilence, guilt, self-hatred, mistrust of others, and a sense of hopelessness and helplessness. • Negative Cognitions: It was my fault. I'm bad. I'm always vulnerable and in danger. I have no control. • Positive Cognitions: I did the best I could. I'm a good person. It's over. I'm safe now. I have choices and a reasonable degree of control now. • Assessment Components • Picture: My father appears at the bedroom door late at night and tells me to take off my clothes. I'm about 5 years old. He smells of alcohol. • Negative Cognition: I'm in danger. • Positive Cognition: I'm safe now. • VOC=2 • Emotions/Feelings: Fear, sadness, anxiety • SUDS=8 • Location of Body Sensation: Tension in the neck and shoulders, knots in stomach, palpitations in chest.

32. Childhood Trauma Case Example TRIGGERS • Watching a “sexual scene” in a movie • Smell of alcohol • Husband expressing desire for intimacy • Excessive demands from boss PICTURES EMOTIONS Traumatic Memory Age 5 Sexual Abuse by Alcoholic Father My father at my bedroom door telling me to take off my clothes Fear, sadness, anxiety BELIEFS SENSATIONS • It was my fault • I’m bad • I am always vulnerable and in danger • I have no control • Tension in neck and shoulders • Knots in stomach • Palpitations in chest

33. Childhood Trauma Case Example • Possible Information Processing Shifts Related to Concepts of Responsibility, Safety, and Choices: • Responsibility: • Client recognizes that she was an innocent child betrayed by the person who was supposed to love and protect her. • She mourns the loss of her "innocence" and expresses anger toward her father for the first time. • She experiences a greater sense of compassion for herself and an increased sense of self-respect as a survivor. • Safety: • Client experiences a dramatic increase in her distress level as her memories of abuse are desensitized and reprocessed. • She recognizes (at a cognitive, affective, and somatic level) that the abuse is truly over and that her father can no longer hurt her.

34. Childhood Trauma Case Example • Possible Information Processing Shifts Related to Concepts of Responsibility, Safety, and Choices (cont): • Choices: • Client begins to acknowledge the choices she has made in her adult life (establishing boundaries with her family of origin, connections with supportive people, a commitment to therapy). • She begins to consider new possibilities for the future. • She expresses a desire to initiate new friendships and activities and acknowledges a renewed sense of hope and confidence.

35. Work-Related Case Example • Client • A 40-year-old man who was laid off during the 'downsizing' of his company. • Presenting Problem: Sleep-onset insomnia, loss of appetite, self-medicating with alcohol, irritable, worried about the future, "paralyzed" in efforts to seek other work, fighting with his children and sometimes with his wife. • Negative Cognitions: I'm not worthwhile enough to retain at my company so they let me go. I'm worthless. • Positive Cognition: I have value to offer and can find an organization that recognizes this about me and is a 'good fit' with my skills and who I am. • Assessment Components • Picture: The Human Resources Director comes into my cubicle and tells me that I have 10 minutes to clear out my desk and download my computer files before my exit interview. • Negative Cognition: I'm worthless. • Positive Cognition: I have value. • VOC=3 • Emotions/Feelings: Irritable, worried • SUDS=7 • Location of Body Sensation: nausea, tightness in chest, tingling in arms

36. Work-Related Case Example TRIGGERS • Friends who are still employed calling to ask how things are going • wife asking how the job search is proceeding • kids wanting more allowance PICTURES EMOTIONS BEING LAID OFF AT HIS COMPANY The Human Resources Director comes into my office and tells me I have 10 minutes to clear out my desk... Irritable, worried BELIEFS SENSATIONS I’m worthless. Nausea, tightness in chest, tingling in arms.

37. Work-Related Case Example • Possible Information Processing Shifts related to Concepts of Responsibility, Safety, and Choices: • Responsibility: • Client considers whether he is at “fault”, for being on the list for layoffs. Practitioner and client explore client's history of performance reviews and note that all were average or above average. • Client comes to understand that he is not at "fault." He recognizes that this layoff had more to do with the company's economic pressures than his worth. • The client acknowledges that he has performed well, as evidenced by his written reviews, but nevertheless, he has been let go.

38. Work-Related Case Example • Possible Information Processing Shifts related to Concepts of Responsibility, Safety, and Choices: • Safety/Survival: • Client explores the question, "Will I be okay?" • In assessing his strengths, he arrives at the idea, "I will find another position because of the skills and work experiences I have accumulated. And I do have the financial resources to last 6 months while I search for another position. I can borrow money from my brother if I have to.”

39. Work-Related Case Example • Possible Information Processing Shifts related to Concepts of Responsibility, Safety, and Choices: • Choices: • Client at first confronts his fear of "having no choices." He questions whether he must remain in the same industry and concludes that he can look at other industries hiring people with his skill set. • At this point, he assesses the time and costs needed to change careers and decides that he will stay in the same line of work but search within several different industries. • He feels more encouraged for having arrived at this greater sense of choice.

40. Efficacy and Endorsement of EMDR?

41. International Treatment GuidelinesRecommending EMDR International Treatment Guidelines • American Psychiatric Association (2004).  Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder.  Arlington, VA: American Psychiatric Association Practice Guidelines • EMDR given the highest level of recommendation (category for robust empirical support and demonstrated effectiveness) in the treatment of trauma. • Bleich, A., Kotler, M., Kutz, I., & Shalev, A.  (2002). A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel. •  EMDR is one of only three methods recommended for treatment of terror victims.

42. International Treatment GuidelinesRecommending EMDR • Chambless, D.L. et al. (1998).  Update of empirically validated therapies, II. The Clinical Psychologist, 51, 3-16. • According to a taskforce of the Clinical Division of the American Psychological Association, the only methods empirically supported for the treatment of any post-traumatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy. • CREST (2003). The management of post traumatic stress disorder in adults.  A publication of the Clinical Resource Efficiency Support Team of the Northern Ireland Department of Health, Social Services and Public Safety, Belfast. • Of all the psychotherapies, EMDR and CBT were stated to be the treatments of choice.

43. International Treatment GuidelinesRecommending EMDR • Department of Veterans Affairs  & Department of Defense (2004). VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC.http://www.oqp.med.va.gov/cpg/PTSD/PTSD_cpg/frameset.htm •  EMDR was placed in the "A" category as “strongly recommended” for the treatment of trauma. • Dutch National Steering Committee Guidelines Mental Health Care (2003). Multidisciplinary Guideline Anxiety Disorders. Quality Institute Heath Care CBO/Trimbos Intitute. Utrecht, Netherlands. • EMDR and CBT are both treatments of choice for PTSD • Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press. • In the Practice Guidelines of the International Society for Traumatic Stress Studies, EMDR was listed as an efficacious treatment for PTSD. • INSERM (2004). Psychotherapy: An evaluation of three approaches. French National Institute of Health and Medical Research, Paris, France. • Of the different psychotherapies, EMDR and CBT were stated to be the treatments of choice for trauma victims.

44. International Treatment GuidelinesRecommending EMDR • National Institute for Clinical Excellence (2005). Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care. London: NICE Guidelines. • Trauma-focused CBT and EMDR were stated to be empirically supported  treatments for choice for adult PTSD • Sjöblom, P.O., Andréewitch, S .  Bejerot,  S.,   Mörtberg, E. ,  Brinck, U., Ruck, C., &  Körlin, D. (2003). Regional treatment recommendation for anxiety  disorders.  Stockholm: Medical Program Committee/Stockholm City Council, Sweden. • Of all psychotherapies CBT and EMDR are recommended as treatments of choice for PTSD. • Therapy Advisor (2004): http://www.therapyadvisor.com • An NIMH sponsored website listing empirically supported methods for a variety of disorders.  EMDR is one of three treatments listed for PTSD. • United Kingdom Department of Health (2001).  Treatment choice in psychological therapies and counselling evidence based clinical practice guideline. London, England. • Best evidence of efficacy was reported for EMDR, exposure, and stress inoculation

45. Research: Efficacy of EMDR • Civilian & Combat-related PTSD • Meta-analysis of Treatments for PTSD • Panic Disorder & Phobias • Somatoform Disorders • Symptoms arising after a natural catastrophe • Trauma in children, conduct disorders • Test Anxiety • Crisis Intervention • Grief • Substance abuse and addictions • Performance enhancement • Dissociative Disorders

46. EMDR Research • There is much research in progress. Over 125 publications to date. • See “Efficacy of EMDR,” updated yearly by the EMDR Institute. • www.emdr.com • www.emdria.org

47. EMDRIA & EMDR-HAP • EMDRIA is the professional organization that operates independently of the Institute • Governs training • Organizes annual conference • HAP – Humanitarian Assistance Programs • The mental health equivalent of Doctors Without Borders • Primary focus is on training local therapists within crisis or underserved communities • Provides low cost basic training in EMDR

48. HAP Training • Affordable, high-quality, local training • $300 per person per Part (total $600) • Commercial trainings average $1600 • Two, three day weekends • Friday – Sunday, eight hours each day • 10 hours of didactic + 10 hours of supervised practice • Average of three months apart • 10 hours of case consultation • Sponsoring agency’s role: • Supply participants (minimum 18) • Furnish appropriate location and A/V supports • Manage registration and payment of fees • Light refreshments (optional) • May provide 20 CEUs per part (not offered by HAP) • Participant requirements: • Masters level mental health clinician with valid licensure • Full time clinical work (30 hrs/wk) in a non-profit setting