Clinically Researched Uses of EMDR

* You should be experienced in working with each of the populations before integrating EMDR into the treatment

Children

What to expect
- Children tend to process much more quickly than adults
  - Fewer experiences and complex memories = simpler memory networks
  - Even newborns respond to BLS
- Sessions tend to be shorter, e.g., 20-30 minutes, based on attention spans
- Greater generalization effects
- Standard EMDR procedures may require developmentally appropriate modifications
  - May incorporate art, sand tray or play therapy in all phases
  - Be faithful to the concepts but use creativity to engage the child and facilitate processing
Phase 2: Preparation
- BLS modified to hold child’s attention
  - Eye movement – finger puppets, wand, light saber
  - Children under 4 are not capable of tracking across the midline
  - Tactile – drumming, koosh ball, butterfly / angel hug
  - Auditory – music or tones
  - Combinations – e.g., scratching out or erasing a picture, apps for iPad, buzzies
- Container and Happy Place may be real objects or imaginary
Phase 1: History
- Consult with adult caregiver(s) for history without the child present
  - Child is more externally locused
- Adult present during child’s interview?
  - Meet with child with (and without) the adult caregiver(s) present if it facilitates child’s sense of safety and comfort
  - Adult has to be able to be calm, grounded and present during child’s processing
- Developmental modifications for child’s history, e.g., creating a story book, sand tray, puppets
Phase 3: Assessment
- Image (worst part) – developmentally appropriate
- Cognitions / beliefs are often thoughts or statements about their experience
  - www.judycab.com/#!cognition-cards/c1ew5
  - Kid friendly labels on index cards (you can find them on the cloud)
- Emotions – often useful to have emotional faces chart available
- VoC & SUD – use hand gestures or objects of graduated sizes
- Magnifying glass may be used as “feeling detector” to identify body location
Phase 4: Desensitization
- Sets tend to be shorter
- May involve story telling or games
  - www.emdrjourneygame.com
  - www.drrobbie.org – My EMDR Workbook
- Prepare the caregiver(s) that emotion(s) may manifest in acting out and that it is part of the processing
  - Work with the child to develop tools to help them deal with the emotional disturbance
Phase 5: Installation, Phase 6: Body Scan, Phase 7: Closure, and Phase 8: Reevaluation
- Use developmentally appropriate language
Interventions that may be used in groups (directions are on the cloud)
- Happy Place and Container
- Slaying the Monster
- Wheel of Resources
- Drawing Technique – Janero
Dissociative elements may manifest in a range of behaviors
- Not all dissociation is the result of a pathology or trauma – consider the history
- Even young children dissociate under nontraumatic conditions
  - Staring off in a fixed gaze
  - Rocking and singing to self
  - Engaging in fantasy play and invisible friends
- For children who have experienced severe / complex trauma, more extreme forms of dissociation may manifest, including DID

Addictions & Impulse Control Disorders

AIP-informed approach
- Trauma results from
  - Adverse childhood experiences
  - Active addiction
  - Relapses, treatment failures and their consequences
- Positive and negative feeling states can be associated with the maladaptive behaviors
- Addiction exacerbates the negative beliefs about self and identity that were internalized as a result of the earlier trauma(s)
- The goal is to create a life worth staying straight and sober for
  - Accomplished by desensitizing the addiction memory networks and “deactivating relapse triggers”
Processing Choice points
- Client’s available internal resources
  - Building adaptive networks and/or creating positive resources and coping skills
- Trauma vs. addiction
  - Trauma is what fuels the addictive behaviors
    - Process the traumas and the addictive behaviors are no longer needed
  - Addictive behaviors are maladaptive coping strategies
    - A way to self-soothe and state change from disturbed state
      - Calm down, relieve stress, sleep without nightmares, reduce depression, anxiety and feelings of helplessness
    - Can be a way for client to feel a sense of “belonging” or “fitting in” with friends / family
    - “Protector” parts / ego states use it to cope
- Abstinence vs. active use
  - Active use can inhibit / block effective processing
  - Client needs to be “straight” enough to connect with affective elements of processing
Phase 1: History
- Assess for
  - Detoxification
  - Client’s ability to report impulses and behaviors HONESTLY
  - Patterns of use
  - Triggers
  - Maladaptive positive feelings
  - Red flags
    - Suicidal / homicidal ideation or self-harm behaviors
    - Lethal substance use
    - Medical or safety concerns
    - Psychiatric instability
    - Dissociation
Phase 2: Preparation
- Client must be completely honest in reporting all impulsive behaviors
- Clarify potential of consequences of reporting, e.g., legal or DCF involvement
- If client struggles to remain substance free, schedule sessions at times that make this a possibility
- Use traditional state change tools: Container, Happy Place, and stop signal
- Enhance and install more resources from times client felt resourceful, powerful, or in control
- When there is a positive affect / experience, resource it with slow, short sets of BLS
- Common resourcing needs
  - Ability to ask for and use help
  - Avoidance of responsibility
  - Determination
  - Willingness
  - Over-responsibility
  - Avoidance of emotion
- Client MUST demonstrate adequate stability before moving to reprocessing phases
- Identify commitment to change
  - How committed are you to making this change on a scale of 0-10?
    - If not a 10, what would it take or what would you need to make it a 10?
- Desensitizing Protocols enhance stabilization
  - Future template to “practice” / enhance use of healthier coping skills
    - Identify alternate adaptive behaviors you’d like to do / use instead of _____.
    - Run a Future Template seeing yourself using the adaptive behavior.
    - Imagine waking up tomorrow and the issues are completely resolved. (FT)
  - Resource times when client felt resourceful, powerful, or in control
  - Two-handed Interweave – Robin Shapiro
    - One hand – motivated, invested in change and healthy behaviors
    - Other hand – unmotivated, invested in dysfunctional behaviors
  - CravEX – Michael Hase (2008, 2010)
    - How would you feel if you used your addiction of choice?
    - Has there been a time when you experienced this feeling in a healthier way?
      - Resource it
  - Reverse Protocol – Robbie Adler-Tapia
    - Invert the three prongs, future, present, past
      - This builds up positive / resource networks
  - DeTUR – AJ Popky (2005) www.ajpopky.emdrcounselingteam.com
    - Targets triggers and urges
      - Measures LOU (level of urge)
    - Extensive resourcing
    - Inverted protocol, using future to resource adaptive alternatives to using
    - Target triggered urges beginning with least first – 1 on 0-10 scale
      - Target traumas in each of the three prongs beginning with the least disturbing, working up to the most disturbing experiences
    - Feeling State – Robert Miller (2012) http://www.imttherapy.com/
      - Targets maladaptively encoded Positive Feeling States (PFS)
        
        Feeling State (state dependent memory) = Fixation of [Feeling + Behavior]
        
        Goal is to no longer want to do the addictive behavior
        
        Once PFS has been processed, underlying trauma will be the next target
    - Four Elements – Elan Shaprio
      - Earth – grounding, safety in present
      - Air – breathing for centering, balance and strength
      - Water – calm, focused and in control
        
        saliva requires switch from sympathetic to parasympathetic system
      - Fire – fire up imagination to bring in a resource needed in the moment
- Clearing Affective Circuits (Recalibrating Emotional Circuits) – Katie O’Shea
- Flash Technique – Phil Manfield
Processing approaches
- AIP is the theoretical framework for the following approaches
  - It explains symptoms
  - Guides case conceptualization and treatment planning
  - Predicts outcomes
  - All target specific maladaptively encoded memories associated with addictive / compulsive behavior(s) or avoidance
    - Reveals disturbing affect underlying the maladaptive behaviors
  - Desensitizing urges means creating adaptive coping skills before and during processing
    - What trigger, urge, or craving would you like to work on?
      - Bring up the trigger with any words, tastes, smells, sensations that go with it. What’s the level of urge on a scale of 0-10? Notice where you feel the urges in
        your body when you think about the trigger and notice.
      - Add long, fast sets of BLS until LOU is 0
      - Contain traumatic material that urges
    - Cue with Positive Treatment Goal – Bring up the trigger, your goal, a cue word and pair them together
    - Future Template – Imagine a time in the future when you will experience that trigger. Notice the LOU. Notice where you feel it in your body. Use your cue word and notice what happens. Add fast sets of BLS until it becomes neutral
CravEX – Michael Hase (2008, 2010)
- Targets cravings, loss of control, and relapse (positive and negative aspects)
  - Measures LOU
Targeting Positive Affect & Level of Urge to Avoid (LOU-A) – Jim Knipe (2010)
- Targets maladaptive positive (idealized) memory or avoidance
Measures Level of Positive Affect (LOPA) or Level of Urge to Avoid
- What do you gain from (using)?
- What do you lose from (using)?
- What is your greatest fear if you (use)?
- What is your greatest fear if you don’t (use)?
Choose an avoidance target
- Focus on the desire to avoid and notice any emotions, thoughts, sensations you’re having
- Notice how strongly you want to avoid on a scale of 0-10
  - Add fast sets of BLS, asking What are you noticing now? And How strong is the avoidance now?
- Contain any emerging traumatic material
- Continue with BLS until urge to avoid = 0
- Do a FT, See yourself doing what you’d like to do instead of avoiding and run the movie. Add BLS until client can imagine doing the behavior without avoiding.
Payson & Becker’s Unified Protocol approach (2014-19)
- * based on the work of Hope Payson & Kate Becker – https://hopepayson.com/
- Uses any “doorway” into maladaptive network as the target
  - May be traumas, triggers, urges, positive feeling states, euphoric recall, idealized relationships or behaviors, cognitions, emotions, sensations, relapses, obsessions or rituals
  - Allows more flexible movement between protocols
- Where to start in the treatment plan
  - Further stabilize client by desensitizing positive feeling states and triggers connected to addictions
    - Increases self-confidence, ego strength, safety and therapeutic rapport
  - Target specific trauma with direct connection to addiction
    - ACES that push the addiction
    - Processing underlying trauma reduces pressure, but only IF the client has resources to tolerate the processing and stay safe and abstinent
- Targeting Maladaptive Positive Affect Protocol
  - Choose a maladaptive positive feeling
  - Focus on positive emotions, images, thoughts and sensations
    - Is there a positive statement that describes what you’re feeling? “I am….”
    - How strong is the positive feeling on a scale of 0-10? Focus on those intense positive sensations and notice.
      - Add fast sets of BLS, returning to target after three sets
    - What are you noticing now? How intense does it feel now?
      - Continue sets of BLS and checking target until intensity = 0
      - Contain any new traumatic material
  - Level of Urge to Avoid Protocol
    - Choose an avoidance target
    - Focus on the desire to avoid and notice any emotions, images, thoughts and sensations you are having.
    - Notice how strongly you want to avoid on a scale of 0-10
    - Add fast sets of BLS, asking, What are you noticing now? And, How strong is the avoidance now?
    - Contain and note any emerging traumatic material
    - Continue with fast sets of BLS until urge to avoid is 0
    - Do a FT, See yourself doing what you would like to do instead of avoiding.
    - Add fast sets of BLS until they can imagine doing the behavior without avoiding.
- Common NC/PC – I can’t handle…àI can (learn / find ways to) handle…
  - Screw it (I don’t matter)
  - I deserve this (I don’t deserve good things)
  - I can handle it (I’m powerless, I don’t have control, I can’t let go, I want to be like “everyone else”)
  - It will be different this time (I can have control, otherwise I’m weak)
  - Behaviors, cognitions and / or situations that trigger impulsivity
  - Barriers to abstinence or acquiring adaptive coping skills
  - Memories associated with relapse due to impulsive behaviors
  - Negative sense of self due to addiction
Phase 7: Closure
- End all sessions
  - Make sure you have enough time to decrease a strong craving
  - Contain remaining negative material
  - Access resources, rehearsing their use in the time between sessions
EMDR & Eating Disorders – Marnie Davis, https://www.marniedavislmhc.com
Dissociative elements
- Clarify the difference between “black outs” from substance use and “black holes” of dissociation
- Identify ego states – Part of me wants to get sober and part of me doesn’t

Anxiety & Phobia

Not all anxieties are associated with a major trauma
Phase 2: Preparation considerations
- Psychoeducation concerning physiological symptoms of anxiety
- Build / enhance client state-change / self-control resources
- Understand client’s dissociative elements
- Consider and address issues of secondary gain and second-order conditioning
Phase 1: History
- Identify the anxiety and the cause or touchstone memory
  - May use float back
- Identify client’s desired responses
- Establish order of three-pronged reprocessing
  - Earliest memory of experiencing the fear / anxiety
  - Most disturbing representative experience
  - Most recent example of anxiety producing situation
  - Future templates of desired behavioral and emotional responses in similar situations
- Consider processing the “fear of the fear (symptoms)” first, using Kiessling’s Wedging
  script
Phase 8: Reevaluation
- Resource positive experiences
- Target additional / subsequent disturbances for reprocessing that may have emerged from in-vivo exposure
Additional notes on phobias
- Identify and process
  - Antecedent / ancillary events that may be contributory
  - Specific external stimuli
  - Any physical sensations / stimuli associated with the phobic response
- Create contract for action
- Run a mental movie of phobic experiences, reprocessing any disturbance
- No failure, only feedback if there is residual anxiety. Target and reprocess
- Ad de Jongh http://www.emdrnorge.com/styled/styled-2/deJong.html
Dissociative elements
- Difficulty grounding and changing states

Couples

EMDR is used to facilitate integration of new behaviors and perspectives within the relationship
- Follow EMDR standard procedures and protocols (eight phases and three prongs) unless specific modifications are indicated
Follow accepted interview approaches for working with couples, identifying
- Treatment goals
  - How they would like to feel, behave and communicate
- Communication styles
- Major problem areas
  - Previous experiences that contribute to present triggers
Considerations
- Systemic changes occur as a result
- Individual processing sessions or joint?
  - Safety in the relationship – emotional and physical
  - Commitment to relationship by both partners
  - Early sexual abuse of a partner
    - Would the partner be a supportive witness-bearer or disinterested / use session material as a weapon against the survivor?
  - Refer one or work individually with both?
    - Systemic approach
    - Safety and trust
Dissociative elements
- AIP – present “issues” or situations activate maladaptive memory networks
  - Childlike behaviors, thoughts, language (ego states)
  - “I don’t want to talk about it” – Gottman’s “stonewalling”
    - Over accessing results in under accessing / shutting down

Illness & Somatic Disorders

May be caused by chronic illness or catastrophic illness
- Psychological disorders, e.g., ADHD, schizophrenia, bipolar disorder
- Physical conditions, e.g., cancer, Crohn’s, Parkinson’s, autoimmune disorders
- Chronic pain & phantom limb pain
Manifestations may be psychological and/or physical
Consider any secondary gains that might potentially block / hinder adaptive processing
Follow EMDR standard procedures and protocols to process experiential contributors
- Enhanced / extended resourcing
- Three-pronged targeting
  - Typically, devise an action plan to address current needs first, then address psychological needs
    - Exception – primary intrusions must be addressed (“mud on the windshield”) can block creation of adaptive action plan
  - Personal or physical constraints
  - Relevant memories
    - e.g., medical experiences – procedures and interactions with personnel
  - Present situations, e.g., feeling helpless and hopeless
  - Social issues
  - Fears regarding the future
    - EMDR will not eliminate fears / anxieties that should be addressed with psychoeducation or action
Reprocess all identified targets
- The incident or learning of the diagnosis
- The aftermath
- The consequences of the incident or diagnosis
Useful to employ imagery and visualization as targets
- Psychoeducation
- Run movie of the next 1-5 years
- Guided imagery, e.g., Simonton method
For future template work, identify fitting positive cognition, linking it with the image
- “It’s not what happens to you but how you deal with it that matters.” Ronald A Martinez
- Emphasis is on improving the client’s quality of life
- Process any negative emotions associated with client’s desire to live (or die)
Consider processing family members empowering them to provide optimum support
- If not possible, process with client to accept reality of family as they are
Dissociative elements
- Difficulty grounding
- Hyper-focus on physical symptoms

Grief & Mourning

Grief is a natural emotional, behavioral, social, and physical reaction / response to loss
- Loss isn’t limited to death e.g., relationships, jobs, opportunities
- It’s the beginning part of mourning
- Follows a common pattern of emotion, e.g., shock, confusion, denial, anger, sadness, rage, depression, isolation
- The brain’s way of dealing with a fact it can’t completely comprehend in the moment
- Worse if death was sudden or unexpected
Mourning is the process of adapting to the changes created by the loss
EMDR does not exclude experiencing appropriate, healthy emotions
- EMDR does not take away the normative pain of loss. It takes the knife out of the client’s heart
- By processing any obstacles to healthy grief and mourning, EMDR allows the client to experience a greater sense of inner peace and acceptance
- Allows the client to access positive memory networks
Follow EMDR standard procedures and protocols to process experiential contributors
- Actual events
- Intrusive images
- Nightmares
- Present triggers
- Issues of guilt and personal responsibility, and mortality
- Safety and control issues
- Change in role or identity due to loss
- Other losses
Future targets
- Firsts and anniversary dates
- Future life experiences without…
- Fantasies of what might have been
Potential blocks to processing
- What is the client willing to let go of or what does s/he want to hold on to?
- What is s/he afraid of? (e.g., losing memory of dead or dishonoring by letting go of pain of loss)
- Unspoken words
- Unprocessed feeder memories of other losses
Dissociative elements
- Difficulty grounding, lack of awareness of surroundings, people and events
- Outside the window of affective tolerance
- Hyper-focus on loss

Complex PTSD, DESNOS (Disorders of Extreme Stress) (DDNOS & DID)

Alterations in
- Regulation of affective impulses, including difficulty with modulation of anger and being self-destructive
  - Persistent sadness, suicidal thoughts, explosive / inhibited anger
- Attention and consciousness, leading to amnesias and dissociative and depersonalization episodes
  - Forgetting / reliving traumatic events, feeling detached from body
- Self-perception, such as a chronic sense of guilt and responsibility, and chronically feeling ashamed
  - Helplessness, shame, guilt, stigma, feeling completely different from others
- Distorted perceptions of the perpetrator
  - Attributing total power to the perpetrator or preoccupied with revenge
- Relationships with others
  - Inability to be intimate, isolation, distrust, or repeated search for a rescuer
- Systems of meaning (loss of meaning or distorted beliefs)
  - Loss of faith or sense of hopelessness and despair
Somatization of the problem, feeling symptoms on a somatic level when medical explanations can’t be found
Examples of client experiences
- Sexual abuse survivors
- Prisoners of war
- Victims of sex trafficking
- Long-term domestic violence
- Long-term child abuse (physical and/or sexual)
- Prisoners of criminal justice system
Special considerations
- Important to have adequate state-change mechanisms and adequate resources in place before initiating processing
- May need to titrate history-taking due to complexity of trauma and/or inadequate resources
- May need to use Recent Event and / or EMD approach to processing
- Will likely require additional processing in future related to life changes

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