Phase 2: Preparation

Goals

Client is informed about EMDR therapy
Client is prepared for EMDR therapy
• Ability to self-soothe and tolerate emotion both during and following sessions
• Ability to maintain dual awareness / dual attention / dual focus while processing
• Understands that processing begun in the session may continue between sessions

Considerations

Assess and develop therapeutic rapport, considering:
• Attachment history
• Previous therapeutic relationships
• Client’s core belief system – I can’t trust. I’m not safe. It’s not okay to be myself.
• Physical environment of the therapy room – Does it feel safe and welcoming?
• Does the client have any concerns? – relationship, processing, etc.
Client understanding of:
• EMDR therapy processing and its effects
• Aspects of the memory may be accessed as stored, therefore there may be
• Somatic experiences from the time of the stored experience
• Potential of increased emotional intensity that will require the client’s ability to tolerate it for a period of time
Procedural elements of EMDR:
• Seating arrangement and physical proximity
• Form of dual attention stimulus (DAS) / BLS – eye movement, tactile, auditory
• Importance of accurate and honest observations / reports
• Purpose and use of stop signal
• What does the client need in order to continue?
• Does the client have concerns? Address them
• Does client need to share her/his experience?
• Does the client need a break?
• If the client wants to stop for the day, use resource tool to make sure that s/he is grounded and stable before leaving the office
• A keep going allows the client to communicate without stopping the processing.
Client safety and stability:
• Develop and/or enhance client’s stabilization skills and resources
• Appropriate use of resources such as Container, Happy Place and other resources
Informed consent:
• EMDR is no longer an experimental treatment that requires a special informed consent
• The clinician’s general informed consent regarding the role of therapy in facilitating changes in the client’s life is appropriate
• Additional information specific to EMDR may include
• Sensory input may fade, dissipate, or disappear
• The experience may be very intense for some memories and/or people
• Some people may experience physical sensations associated with the memory being processed
• The client’s emotional disturbance will resolve: they may feel emotion, but will be able to talk about the experience calmly
• Research revealed enhanced retrieval and accuracy of episodic memory
• Effects of DAS / BLS on certain medical issues, e.g., seizure disorders, eye issues

State Change Strategies

Relaxation and stress reduction
• Breathing exercises –
• diaphragmatic breathing
• square breathing
• anchor breathing / roots of a tree
Energy exercises
Aromatherapy
Resource development and enhancement
• Affective
• Behavioral changes (future)
Affect management
• Mindfulness
• Crisis planning (future)
• Challenging distorted thinking
Life management
• Anticipating, planning and/or organizing (future)

Mechanics

Sitting positions – ships passing
Distance – as close as is comfortable for you and the client
DAS/BLS
• Eye movements preferred
• A pass is one complete side-to-side lap, beginning and ending in the center – a round trip (RT)
• The client’s eyes should cross the midline, preferably corner to corner
• Speed of DAS/BLS based on client’s definition of
• A comfortable, relaxing pace for resourcing
• As fast a pace as the client can tolerate/track for reprocessing
Duration of DAS/BLS
• Varies from client to client
• < 30 seconds = explicit / declarative memory
• typically for resourcing or reprocessing with poorly resourced clients
• > 30 seconds = implicit / non-declarative memory
• typically for reprocessing for clients with adequate internal resources
Direction
• Horizontal side-to-side is most common and easiest on the clinician’s arm
• Diagonal – top left to bottom right or top right to bottom left is an alternative
• Contacts or glasses – bifocals / progressives can be problematic for visual BLS
Processing signals
• Stop / time out
• Keep going

Helpful Metaphors for Processing

Movement – train, monorail, limo, movie
Metabolism – digestion vs. disruptions to healthy system
Healing – cuts / breaks
Thawing a turkey, cooking a meal, melting ice
Bank account of positive memory networks to cover the “cost” of processing
Defragging the client’s hard drive
Flowers vs. weeds / weeds and gardening
Peeling an onion / artichoke
Archeological dig
Riding a roller coaster
Mud on the windshield
Dust bunnies
Emotional bucket

Explanation of EMDR

When icky things happen that are too overwhelming for our brains to handle at the time, the memory gets stuck in what we call “state memory.” All the things we experienced with our five senses – sights, sounds, smells, tastes and physical feelings the body had at the time – plus the thoughts, emotions, and body sensations, are stored in unhealthy ways in our brains and bodies. When something comes along that reminds our brain and body of what happened, whether we remember it or not, all that old stuff gets stirred up, plus what just triggered it, and then THAT gets stored in the same way, making the problem worse. When we are in a place of safety and security and use EMDR with side-to-side eye movements, sounds, and/or taps, the brain starts to think about things differently and lets go of things that are disturbing and holds onto the positive things that help us be healthier, happier and
stronger. All you need to do is be curious and occasionally give me brief feedback about what you’re experiencing in that moment. It can be a thought, emotion, body sensation, memory, sound, smell, picture…whatever comes up in your awareness. At some point, you might benefit from a brief phase or word that will help you stay with the processing. For some people it’s “Just notice” or “You’re here with me. You’re safe now.” or “Your brain is processing what it needs to.” Does anything like that work for you? _________________If it ever gets to be too much and you need to take a break,
don’t forget you have your time out signal.

Resources for Phase 2: Preparation & Phase 7: Closure

Purpose

Provide resource management tool to help client manage volume and intensity of material
stored in negative, maladaptive memory networks
Relatively safe and positive way to introduce client to the effects of BLS while accessing
positive networks to build and expand adaptive networks

Uses

Encourage client to use resource tools outside of session to minimize effects of disturbing life experiences or triggered memories
Suggest client use tools to temporarily shift states from upset to calm
• May be used in conjunction with stop signal during processing should client become over-activated

Concepts & Steps

Activate the sensory elements
Enhance the material (notice and tell me…)
Add BLS (may do several sets as long as effects are deepening and client’s experience isstrengthening)

Pair with Cue Word

Self-cue (enhance with slow, short set of BLS)
Cue with disturbance (*may enhance with slow, short set of BLS)
Self-cue with disturbance (*may enhance with slow, short set of BLS)* may activate the recently accessed disturbance in more poorly resourced clients

Practice

You may enhance the experiences with slow, short set of BLS if client has positive experience

Rescript

Think of a time in the last week or two where it would have been helpful to have your Container and Happy Place. [pause] Now I want you to run a movie and see yourself using them. [Pause for the response]

Rehearse

Now you have the tools and know how to use them. Let’s rehearse how you will use them in the future. Imagine a time or situation in the next week where it would be helpful to use them. [Pause for the response] Run the movie and see yourself using them and let me
know what you think. [Pause for the response]

Advanced Resourcing

Identify the needed, existing or desired resource
Stimulate the adaptive memory network
Sensory elements – sight, sound, smell, taste, touch
Positive thoughts / beliefs
Positive emotions
Location of positive body sensations
Enhance the experience with slow, short sets of BLS
• Minimizes potential activation of any negative material
• Repeat sets as long as the effects are strengthening (time permitting), particularly for
more poorly resourced clients
• If negative experience, identify additional resources needed
Use BLS to pair with cue word
Rescript a recent past experience using the resource
• If negative experience, identify additional resources needed
• May use BLS to further enhance positive experience
• Rehearse using the resource with a future experience
• If negative experience, identify additional resources needed
• May use BLS to further enhance positive experience
Possible resource options
• Recalibrating / Resetting / Clearing Emotional Circuits
• Skill (ability to do something well)
• Tool (something for a function)
• Energy
• Breathing and vertical eye movements
• EFT (www.eft-help.com/details/additionaltechniques.htm) (emofree.com)
• Mudras (www.eclecticenergies.com/mudras/)
• Quality / personal attribute – strength, courage, focus, determination, motivation
• Feeling state – relaxed, calm, peaceful
• Behavior – (act or conduct) doing homework, exercising, not yelling at the kids
• Metaphor or symbol
• Slaying the Monster
• Wheel of Fortunate Resources / Support
• Role model / support
• Aromatherapy – olfactory bulb → thalamus → orbitofrontal cortex, hippocampus and amygdala (learning and memory)

Resource Tapping (Parnell, 2008)

Reasons to incorporate Resource Tapping
- People with PTSD have brains that are geared to attend triggering / traumatic stimuli. They are not able to notice neutral/safe stimuli
- Pairing positive imagery with bilateral stimulation helps integrate the information into neuro-networks
Basic principles of Resource Tapping
- We are hard-wired to be healthy and whole, to experience power and joy when given the
  opportunity
- We become unhappy if we are unable to access positive experiences stored in our memory networks or when we are out of balance
- We can access, enhance, and add to positive stored experiences, e.g.,
  - feeling loved and loving, comforted, peaceful, calm, happy, joyful, competent, powerful
- We can access, strengthen and integrate the resources by tapping in our resources by using bilateral tapping
Steps for Tapping-in Resources

Close your eyes and go inside. Bring your attention to a quiet, still place inside yourself.
Bring the resource to mind. It can be a positive memory, a personal attribute or quality, an experience, an important person or an animal.
Imagine the resource as well as you can.
Take all the time you need to enhance this information and develop the resource.
When you have a strong sense of the resource, begin to tap on your knees back and forth, or tap your feet on the floor like you’re walking.
Tap as long as it feels positive. If other memories or resources come to mind that feel good, you can tap them in too.

Most commonly used resources
- Container – a virtual “storage facility” to safely hold all the disturbing experiences until client is ready to process them
- Happy place — neutral, safe, secure, peaceful, serene, tranquil, sanctuary
  - Can use pictures or art to enhance
  - Be cautious of how you define it — “safe” may be triggering
  - Sacred place / sanctuary
  - The heart as a safe refuge
  - Neutral, grounded place in the body
  - Positive memories
    - The idea may be triggering for poorly resourced clients who DON’T have positive
      memories they can access
  - Imaginal nature setting
- Aromatherapy and/or breathing
- Nurturing figures
  - Real or imaginary people who have a nurturing, supporting, uplifting quality
    - May be someone from media or life
    - Don’t have to imagine the figure nurturing them
    - Be cautious — no relationship has been 100% perfect!
  - Spiritual figure
  - Adult, competent, caring, loving self
    - Can be used to assess whether the adult can be a resource to the child self (use
      pictures)
    - Important for adults abused as children
  - Ideal parent
    - May be difficult or triggering for more traumatized clients
- Protector Figures
  - Real or imaginary people from past or present
    - Books, movies, TV
      - Transformers, X-Men, Wonder Woman
  - Angels / spirit guides
  - Animals, e.g., bear, wolf, buffalo, lion
  - Spiritual figure
    - Can be same as nurturing figure
- Adult, protective self
  - Important for adults abused as children
Circle of Protection / Circle of Support / Wheel of Resources / Daisy Flower
- Bring in all allies or resources for protection or support
  - Animals, e.g., bear, wolf, buffalo, lion
  - Spiritual figure / Ideal parent / caregiver
  - Adult, protective self
  - Angels & spirit guides
Inner Wisdom figures
- Wise figures
  - historical figures, books, movies,
  - ancestors, family
  - spiritual figures
- Inner wise self or advisor
Resources for Attachment Repair
- Therapeutic relationship
- Experiences of healthy relationships & relating
  - Times the client felt acknowledged, cared for, nurtured, and/or loved
  - Current experiences of healthy, adaptive connection
- Healthy boundaries
- Visuals of healthy relating from movies, tv, or YouTube
Resources for Different Attachment Styles
- Identify client’s needs to develop healthy way to connect
- Use resources to fill in the voids or gaps
  - Calming resources?
  - Experiences of connection?
  - May be imaginal or real experiences
- Enhance any resource with slow bilateral tapping
Additional Resource Options
- Peace and calm
- Person, nature, memories
- Empowerment
  - Memories of being powerful or overcoming problems
    - experiencing core inner strength
  - Uplifting experiences or resources
    - beauty, wonder, awe, or creativity
    - joy, laughter, playfulness
  - Spiritual resources
  - Any additional resource to facilitate healing and recovery
  - Resource development and enhancement
  - Affective
  - Behavioral changes (future)
  - Affect management
  - Mindfulness
  - Crisis planning (future)
  - Challenging distorted thinking
  - Life management
  - Anticipating, planning and/or organizing (future)

Recalibrating / Resetting / Clearing Emotional Circuits – Katie O’Shea

Before we get too far into your history or processing, let’s make sure your emotions are operating at maximum efficiency and you’re able to feel the emotions without becoming overwhelmed. We are hardwired to feel emotions and research shows that those experiences are encoded in our brains from six months in utero and that basic brain development continues to about age 25. Along the way, we have
experiences that can influence the development of those emotional circuits and how we react to emotional triggers. Some people learn to shut down or disconnect from emotions for survival, others learned that it’s not okay to feel feelings, and others may become so overwhelmed by them that they go numb. The end result is that some people may feel shame for feeling any of their emotions.

We now know how important it is to be able to feel and express our feelings, hence the recalibration. Let’s start by putting all the feelings in your container and remind yourself that “It’s okay to feel safe when I am safe and nothing bad is happening.” We’ll take one emotion at a time and all you need to do is notice what the feeling looks like and watch with curiosity.

For some people it’s easier to imagine a picture on the wall with a label naming the emotion and see what the picture is in the frame. Once we start the BLS, as long as the picture is changing, we’ll keep going. When the picture stops changing, let me know what you see and we’ll start the BLS again. We’ll continue this way until the picture stops changing completely.

The picture may become positive, neutral, or just stops changing. Once it stops, we’ll go on to the next emotion. If you start to feel any of the emotions, let me know and I’ll have you put them in the container so you are just focusing on the picture that represents the emotion.

Paul Eckman’s Atlas of Emotions – Resource on emotions and how they are experienced: http://atlasofemotions.org

Troubleshooting Recalibration of Emotions

Flash Technique (Manfield & Engel, 2017)

www.emdrvideo.com & https://flashtechnique.com/wp/

Uses in trauma work
• Assessment for readiness
• Helps clients integrate positive experience of using EMDR
• Prepares clients to do trauma processing by reducing the SUD without requiring
exposure to intense emotions
Use with clients who are:
• Defended
• Avoidant
• Major intellectualizers
• Moderately dissociative
• Afraid to feel emotion associated with a specific memory
Applications
• Regulate affect intensity
• Reduce anxiety
• Enhance ego strength
Examples: anything referenced in the Adverse Childhood Events scale; incident involving major shame, guilt, fear, sadness, sibling relationship rupture, or separation; relationship loss or rejection (If no feeder); loss/death, person or animal; betrayal, helplessness; loving as child; loss of friends, new school/house; getting lost; changing jobs, separation from colleagues; assaults or violence (witnessing or experiencing); hospitalizations, injuries or anything involving intense pain; natural or man-made disaster; nightmares; a failure; scene from movie; legal conflict.

Flash Technique Procedure

Basic client instruction:
- Before we start, I’d like you to think of a disturbing /upsetting memory or image from your life, one that still bothers you now. Please choose a memory that has a disturbance level of at least 6 on a zero – 10 scale, where 0 is nothing or neutral and 10 is the worst you can imagine. If you can’t think of a memory, try a scene from a movie is disturbing. Once you’ve done that, put it into your container. I do NOT want you to continue to think about it, or tell me about it just yet.
  - Avoid a memory where the disturbance is related to feeder memories.
  - Do not discuss or elaborate on the memory.
Positive Engaging Focus: Have the client bring up a positive engaging focus. Strengthen this positive memory or image with a couple of short slow sets of eye movements or taps.
- Instead, I’d like you to find a positive, engaging focus (PEF). It may be a person, special place, enjoyable activities, favorite music, or imagined experiences. We want it to be strong enough to hold your attention so you don’t think of disturbing things. Focus on that positive experience and tap back and forth on your thighs as I tap on mine. (Tap back and forth 4 times)
- Was it easy to stay connected to your positive focus? (If so, proceed)
- Basic client instruction:
  - We’ll be doing the same thing again, but this time, I’ll say “flash/blink” and I want you
    to quickly blink your eyes once. (If so…)
  - This time, I’d like you to rapidly blink three times each time I say “flash/blink.”
    - Repeat the triple flash set five times, with 4-5 passes of BLS between each triple.
  - Zero to ten, where’s your disturbance now?
    - If SUD = 0, check the SUD of the disturbing memory.
    - After feedback, if the disturbance isn’t zero, place the disturbance in the container, resume focus on PEF, and continue with additional sets of five triple blinks.
    - Check the SUD at the end of each group of five triple blinks.
    - If the disturbance isn’t dropping, check to see if there is any intrusion from the disturbing memory during the flashes.
    - If so, place the disturbing memory in the container and continue five sets of tripleflashes/blinks until the SUD is 0 or > 3 and not dropping by at least two points after a set of 5 triples (in this case, move on to Phase 3 of EMDR).
    - Once the SUD = 0, check the SUD of the identified disturbing memory / experience. If it is greater than 0, have the client place it in the container, focus on the PEF and do another set of five triple blinks.
    - Continue checking the SUD after each set of five triple blinks
    - If the difficulty continues to be more than slight, go back to single flashes / blinks until the client is ready for triples. If the client has difficulty returning to a resourced state rapidly enough between the three flashes, they can return to a calm /neutral state or being present in the room between flashes.

Troubleshooting the Flash Technique

When the flash doesn’t work, it’s usually because the client is connecting with the trauma in a way that is activating.

If SUD doesn’t drop and there’s no apparent reason, try, Pretend this blank piece of paper has your disturbing memory on the underside. Before each triple blink, glance rapidly at the piece of paper. If that doesn’t cause a shift, move to Phases 3-6.
If client doesn’t think it’s working, they’re probably accessing the memory to evaluate. This prevents Flash from working. Make sure they understand that once they identified the memory and rated it on the SUD scale, while they’re doing the slow BLS, and blinking when instructed, you DON’T want them to think about it. They are to access it only when asked.
If the client isn’t “rehearsing,” instruct the client to trust that the brain will go where it needs to.
Make sure the client isn’t talking.
Client may need help identifying a strong “positive engaging focus” (PEF).

Experiencing Emotion Can be a Good Thing

Emotion = information is being released and processed
There is a beginning, middle and end to the emotional roller coaster ride
This may be the first time the client is able to experience and process emotion
There may be an emotion that’s been camouflaging the underlying, more primitive emotion
Continue BLS until the intensity of the client’s emotional response has shifted
Maintain a stance of detached compassion while being mindful of client’s attachment history
Use your tone of voice and energy to help ground the client and maintain dual awareness

Window of Tolerance

adapted from Ogden, Minton & Pain; Corrigan, Fisher & Nutt

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