What to expect in EMDR therapy.

Eye Movement Desensitization and reprocessing (EMDR) is a bottom-up therapy rather than top-down. This means that EMDR therapy works more with the subconscious, nervous system and body rather than exclusively with the pre-frontal cortex executive functioning as is done in more cognitive, in other words more top-down, approaches. EMDR does this with an eight phase protocol that addresses trauma with a three pronged approach; 1) memories of past trauma, 2) present day disturbance, and 3) creating future templates for desired outcomes. Following is a description of each phase in the traditional EMDR protocol.

First phase is information gathering:

During this phase the therapist explains the dynamics of EMDR to the client, answers questions and takes the client’s history.

Second phase is  preparation:

During the EMDR preparation phase the therapist will guide the client in skills needed to both focus on the trauma memory and, at the same time, keep the body calm. Typically, recalling the trauma will rouse the brain’s fight or flight response causing major changes in brain functioning. When the brain’s threat system is activated, one’s attention narrows to focus only on the perceived threat with certainty that the threat is real. In a truly dangerous situation these responses ensure survival. If one is endangered, it is essential that the brain focuses on nothing else with unwavering certitude that defensive response is necessary right now. The part of the brain responsible for the flight or fight response cannot differentiate between past and present threats and instinctively prepares the body to fight or flee for survival when a trauma memory is activated.

However, in EMDR dual awareness is practiced. This means that the client learns to think about the memory while maintaining awareness that he or she is safe. That was then, this is now. Dual awareness during EMDR is often achieved by grounding to the present using the five senses.   If a client’s fight or flight response is activated in the therapist’s office, the client is not in the present, instead he or she is reacting mentally and physically to a past threat, unaware of the actual safety of the present environment. Conversely, traumatic memories can also trigger the freeze response, especially if the client was unable to fight for flee during the actual trauma, such as in childhood trauma. Either way, the client is outside the Window of Tolerance.

The Window of Tolerance is a term used to describe the state of arousal that the brain is in

One can only change what one is aware of. However, the brain automatically tries to repress upsetting experiences in order to “protect”, tucking the memories of trauma deep into the subconscious. Even purposefully trying to recall the memory causes varying degrees of abreaction or disassociation, deflecting awareness away from the memory.

Third phase is setting a target:

Trauma is stored in the brain with at least four components;

1) Negative cognition (usually having to do with a sense of one’s worth, safety, control or responsibility)

2) Emotions

3) A bodily felt sense of that emotion, and

4) Sensory data, usually an image but it could be sound, smell, tactile sense, or taste.

These components are stored in a self-enclosed memory system, your brain’s way of allowing you to function without having to focus on the trauma 24/7. Without this isolation, your brain would automatically keep your mind and body on a threat response until the trauma has been processed, but processing the trauma is not always possible immediately after its occurrence, many times not until much later.

Unfortunately, that same encapsulated detachment from everyday thinking causes that trauma to be frozen in the brain. While the rest of the brain integrates current material, the self-enclosed trauma memory takes in no new information and is stuck with the self-perceptions, fight or flight response, emotions and sensory input that were wired into the brain at the time of the trauma. Thus, when the trauma is triggered, or that self-enclosed memory system is accessed, it is experienced in the same way as when the trauma actually occurred, again, and again, and again, through re-experiencing episodes, nightmares, intrusive thoughts, and  inexplicable emotional reactions,

The brain is excellent at keeping you from thinking about the trauma. So in EMDR, the trauma components of negative cognition, emotion (as well as the emotion’s intensity on the Subjective Units of Disturbance Scale, i.e. SUDS), sensory data (such as image, sound, tactile, olfactory, or taste),  and body sensation are specifically named and set up as a target of focus to direct the brain to that memory in order for it to be processed.

Fourth phase is processing a target:

After setting up the target trauma memory by naming the four components, negative cognition, emotion, body sense, and sensory data, some form of bilateral stimulation (BLS) is used to process the memory. This is the essence of EMDR processing and it imitates the brains natural processing ability that occurs in the Rapid Eye Movement (REM) phase of sleep. Everyone experiences REM sleep, even if they do not remember their dreams. During REM sleep actual physiological brain connections are formed, which is why difficult problems often benefit from “sleeping on it.” In fact, there have been scientific breakthroughs, such as ascertaining the structure of the atom, that have been the result of dreams.  The mind synthesizes and integrates the available knowledge during REM sleep, putting it together in ways that make sense, driven by the individuals will to resolve the problem, and resulting in a big picture solution.

EMDR utilizes this ability of the brain to process problems by using bilateral stimulation (BLS), activating the brain in the same way REM sleep does. With BLS first one side of the brain is stimulated, then the other creating connections that result in processing. This bilateral stimulation done inn EMDR can be induced various ways such as the therapist tapping on one knee then the other, following a moving light bar with one’s eyes, holding tappers that buzz alternately right and left, or visually following the therapists hand as it waves back and forth.

In this forth phase of EMDR, the client is asked to think about the four components of the stored trauma memory while engaging in some sort of BLS. Thus, connections are made and the enclosed memory is no longer isolated physiologically, nor perceptually stuck in the past.

Fifth phase is installing a positive cognition:

During this phase the client chooses a preferred, positive self-definition as an alternative to the negative cognition that was generated during the trauma and stored within the memory thereafter.  This positive cognition has to do with the client’s sense of responsibility for the trauma, a sense of inherent goodness, wellness and worth, a sense of current safety, or a sense of his or her ability to make choices and/or have control over his or her life. The positive cognition is then evaluated as to how true the statement feels to the client. Bilateral Stimulation (BLS) is used to install a positive cognition until it is firmly held. Ideally the client should reach a seven on the one to seven scale of Validity of Cognition (VOC). If this does not happen there may be a blocking belief which may be ecologically sound such as the belief that it is sad that children are abused, or it may indicate a need for more adaptive information. It may also indicate a need to set a new target for an associated memory.

Sixth phase is body scan: 

During this phase the client is asked to think of both the memory of the trauma along with the positive cognition while doing a mental scan of their body to notice any tension, tightness, or unusual sensation. If the body is not totally relaxed it probably indicates a bodily rejection of the positive self-definition.  Sometimes the brain completely accepts the positive self-statement as true, but the body does not. The body memory of the trauma remains. This may happen for various reasons, such as the client may subconsciously hang on to one aspect of the trauma for defense reasons or that one part of the trauma was not completely processed.

Seventh phase is closure:

This is a debriefing for the EMDR session in which the client may name what he or she learned from the processing with a positive emphasis. Closure is a time for the therapist to evaluate the client’s stability before the client leaves the office and it can also be utilized as a transition time between focused processing and orienting toward returning to daily living. The therapist will warn the client that as the traumatic memory has been activated during the session, the client may notice new insights, thoughts, physical sensations or dreams associated with that memory and be reminded of the calming techniques learned in Phase two. The therapist may or may not give the client homework at this time

Eighth phase is reevaluation:

This phase is a follow-up on the previous session done at the beginning of the next session. It addresses any disturbing material that may have come up since the last EMDR session as a result of processing, and evaluating the need for more processing of that target. Life experiences and dreaming both can contribute to further opening up of a self-enclosed memory system that holds the trauma. An expanded phase eight is done before termination of therapy to evaluate complete processing of traumatic memories.