Eye Movement Desensitization and Reprocessing (EMDR) Therapy

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EMDR Therapy 101: Treatment Process & How to Get Started

Eye Movement Desensitization and Reprocessing Therapy, or EMDR, is an eight-step neurological treatment utilized in a therapeutic setting to identify, challenge, and reprocess negative core beliefs. Francine Shapiro developed this neurological approach in the late 1980s while completing her dissertation. It was initially named EMD, or Eye Movement Desensitization. Shapiro utilized this technique for her dissertation on a sample of twenty-two individuals, including Vietnam veterans and survivors of sexual and physical abuse. During this study, she realized there was an opportunity to take EMD a step further by desensitizing memories and triggers. The addition of reprocessing enabled her clients to create new, more adaptive core beliefs and memories instead of only calming their nervous systems. Since its creation, EMDR has grown from a research/theoretical perspective and in a practical capacity within the mental healthcare field. 

EMDR is unique in its foundations. Because it’s a neurological treatment more reminiscent of Brain-Spotting and Biofeedback, it exists within a different sphere of treatments than traditional talk therapy approaches such as Cognitive Behavioral Therapy, psychoanalysis, or Acceptance and Commitment Therapy. In EMDR, the therapist does not question or analyze what comes up in the process. It’s a more “free form” type of therapy that relies on the client’s nervous system to guide treatment. Despite this “free form” nature, EMDR follows a strict protocol to keep clients in a processing space. The protocol is in place to keep the client and the clinician safe and reduce potentially harmful effects from the intense neurological processing occurring in sessions. There is room for adaptation within the protocol to work with each client where they are instead of a “one-size-fits-all” approach.

How Does EMDR Work?

EMDR is an eight-step protocol. It relies on “bilateral stimulation” to challenge different parts of the brain. Because each client and nervous system is unique, bilateral stimulation is adaptable and comes in many forms. As stated in the name of the treatment, eye movement is one type of stimulation. Visual bilateral stimulation includes a light bar, following the clinician’s finger or pencil tip, and moving the eyes back and forth between two points in the room.

Auditory and physical stimulation are additional methods used in EMDR treatment. Auditory stimulation utilizes modified songs or beeping that moves between headphones. Physical stimulation typically involves tapping. Clients can either tap themselves or have the clinician tap somewhere on their body where the client feels comfortable. One of the most common touch-based bilateral stimuli is the “butterfly hug,” where clients put their right hand on their left shoulder and vice versa before beginning to tap. A therapist may also have “tappers” where clients hold one tapper in each hand while the therapist controls the stimulation moving between two tappers.

The Eight-Step Process

While EMDR appears to be a linear process at first glance, clients may need to repeat specific steps before moving forward. The process moves at each client’s unique pace. Some clients will need multiple target plans, sessions, etc., while others may require fewer sessions.

Step 1: History & Treatment Plan

During the first step of EMDR, the clinician needs to get an accurate and detailed client history. The intake process can be a traditional session with questions about what’s bringing the client to therapy, what they want to get out of it, current symptoms, their childhood, school, occupational history, etc. A biopsychological approach, however, is best suited for EMDR intake. This involves understanding biological, psychological, and social mechanisms impacting the client in the past or present. A clinician should also seek any present triggers and how they affect the client and their life. 

Another part of this first step is target planning. In target planning, the clinician identifies doorways, or triggers, from the past, present, and future that bring significant adverse nervous system reactions. Clinicians will then help a client identify a negative core belief associated with that feeling. Negative core beliefs are interpretations of the self, not just descriptors. For example, “I’m a bad employee” is a description, while “I’m incompetent” is a negative core belief. Various situations often activate these negative core beliefs. This is why a comprehensive target plan centered around the client’s core belief system is crucial. A target plan will also include a new, more adaptive belief the client wishes they could believe but currently can’t. Going off the example above, a challenge to “I’m incompetent” could be something like “I can learn from my mistakes.”

Step 2: Preparing For Processing

There are many steps to prepare clients for EMDR therapy, including: 

  • Identify a form of bilateral stimulation that works best for the client.
  • Strengthen or reinforce positive resources or nervous regulation skills. This approach includes slow, bilateral stimulation to help get the client used to the stimulation. 
  • Provide psychoeducation on what the EMDR process will look like and how it works. Informed consent is key in a treatment like EMDR.
  • Develop a stop signal that immediately stops EMDR therapy regardless of progress for the day. 
  • Review grounding/affect management skills. 
  • Work to “secure the space.” This could mean changing the lighting in the room, moving to a new seat, removing something that is obstructive or triggering, or bringing in items that help the client feel secure. Typical items include specific pieces of clothing, stuffed animals, pillows, blankets, and trinkets. Anything and everything is welcome, though some clinicians may have more guidelines than others depending on the office space or their boundaries. 
  • Prompt the client about difficult topics. Clients can set as many boundaries as needed, and remember that some things only need to be processed once! Starting low and slow is an acceptable and encouraged way to go.

Step 3: Assessment

During Step Three, the clinician will review the selected target agreed upon by the client and clinician. The clinician will explore the significance of this target, which may include the level of distress, the impact in a specific area of life, and associated sensory information (images, smells, sounds, tastes, physical sensations). Then, the clinician will walk through the negative core belief identified with the target and confirm that it still feels true to the client. The clinician will then repeat the desired adaptive belief and prompt the client to determine how true it feels on a scale of 1 (Totally False) to 7 (Totally True). After identifying negative feelings still associated with the target, the clinician will prompt the client to assess how disturbing/distressing the target feels on a scale of 0 (No Disturbance) to 10 (Highest Disturbance).

Step 4: Desensitization

Step Four is when EMDR therapy begins. The clinician will prompt the client to pull the negative feeling through the target and start with fast, bilateral stimulation. To begin, these sets usually last anywhere from 15 to 30 seconds. After each set, the clinician will prompt the client to take a breath, return to the room, and verbalize what they noticed. The goal is to repeat this step until the disturbance, rated on a scale of 0 to 10, is as low as it can go or remains stable.

Step 5: Installation

During Step Five, Installation, the therapist will call the client back to the room and have them simultaneously hold both the target and the new adaptive belief. The therapist will repeat sets of bilateral stimulation and assess how true the new, adaptive belief feels when paired with the target. The goal is to get the belief feeling as accurate as possible, rated on a scale of 1 to 7, or until it remains stable.

Step 6: Body Scan

The therapist will prompt the client to hold the initial target and new adaptive belief together and “scan” their body. The goal is to identify any negative feelings in the body. If the body has negative emotions, the therapist will utilize short sets of bilateral stimulation until the client experiences an overall calm or neutral feeling.

Step 7: Closure

Step Seven is the final active processing session. In this step, the therapist will cease processing and help the client return to the room. The therapist and client will use small grounding/stabilization skills as needed until the client feels centered and present. They will then verbally discuss thoughts, feelings, and observations from the processing session. The therapist will remind the client that processing may continue once the client leaves the session. Clients may experience several negative symptoms due to the neurological processing that occurs and continues to occur within the client’s mind. Common symptoms of continued processing include nightmares or flashbacks, exhaustion, irritability, sadness, and anxiety. The therapist may plan out coping mechanisms with their client to help regulate responses outside of therapy sessions. 

Step 8: Reevaluation

Clients explore what they noticed between sessions (both positive and negative) with a therapist during follow-up sessions. Suppose the client was struggling with a particular symptom. In that case, the therapist may have to go back to Step 2 to help strengthen or reinforce the client’s regulation/grounding techniques, depending on the level of distress and impairment. The therapist will also look for any new issues that may have come up between sessions. If a client still feels pain toward the target from the processing session, EMDR therapy will continue to focus on the singular target until the distress level is 0. Once this level is achieved, the therapist and client can use a different target from the plan drafted in Step 3. Adjustments can also be made to target plans as needed. EMDR is a process that requires maximum flexibility to meet client needs appropriately. 

The Science Behind EMDR

There are many theories for when EMDR therapy works. The leading therapy, the Adaptive Information Processing (AIP) model, was created by Francine Shapiro. AIP is a neurological process of constantly updating, learning, and consolidating memories into memory networks. 

AIP asserts that individuals emotionally encode events based on their significance. This emotional encoding affects individuals’ perceptions, attitudes, and behaviors and includes both positive and negative experiences. These experiences create positive and negative encoding within the brain and nervous system. “Codes” form based on sensory information, emotions, and cognitions associated with the event. The stronger the emotional encoding, the more influential those past experiences and encoding are on present situations. In most cases, the earlier the event, the stronger the dynamic encoding. 

Shapiro identified the term “cognitions” as emotionally encoded beliefs in the AIP model. As stated previously, beliefs are interpretations, not merely descriptors. Because the brain has neurological plasticity (it can change and update its neural networks throughout life), its goal is to keep the helpful and adaptive changes and let go of unnecessary ones. According to the AIP model, psychological problems are hostile emotional neural networks that cannot link, blend, or consolidate with functional, adaptive neural networks. In a way, they are “frozen.” Perceived trauma overwhelms the nervous system, which triggers a brain’s “life or death” emotions. This flood of life-or-death emotions stops the system from updating and encodes a fight-flight-freeze-numb-collapse-dissociate response to the event. Thus, adaptive neural networks are locked out.

Through AIP, the ultimate goal is memory reconsolidation, which has three main steps. The first step is to access, activate, and attach opposing memory networks. This is achieved through activating their sensations, emotions, and beliefs while identifying the mismatch (EMDR Steps 3 and 4). The second step is stimulation. By stimulating the mismatched neural networks in a safe environment using bilateral stimulation, the goal is to “update” the “frozen” neural networks by pairing them and installing a new, adaptive belief to a triggering target. The new, adaptive belief is identified through the target planning process and then “installed” (Step 5 of EMDR). Finally, the third step of memory reconsolidation is solidifying and integrating the consolidated memory networks. Future-oriented EMDR creates this by identifying and desensitizing potential triggers or events. This update allows “frozen” networks to become active, adapt, and learn instead of remaining stagnant.

Who Are Candidates For EMDR Therapy?

Almost anyone! EMDR is not limited to clients with Post-Traumatic Stress Disorder. People from all walks of life, ages, races, religions, and diagnoses can utilize and benefit from it. There are a few instances when EMDR would not be recommended. These include: 

  • Individuals using heavy benzodiazepines. These medications affect the brain’s ability to process specialized treatments like EMDR.
  • Clients who struggle to regulate themselves
  • Clients who are in acute distress 

Therapists spend a lot of time focusing on the first two steps of EMDR to ensure clients have adequate regulation skills and can utilize dual awareness. Dual awareness is the ability to be present in the room and feel negative emotions/sensations without becoming overwhelmed and shutting down. 

How To Get Started

WMPS has EMDR therapists ready and available to meet your needs. Once we verify your insurance and all intake paperwork is complete, an EMDR therapist will contact you with availability and appointment timelines. In the meantime, don’t be afraid to do your research on EMDR therapy. Because EMDR therapy is a highly specialized treatment, it can be challenging to find the right therapist. Finding the right match for you and your needs is essential! A great resource to start with is Francine Shapiro’s book Getting Past Your Past, which breaks down EMDR therapy and provides simple, easy exercises you can do at home to understand yourself and begin to change your life.

This blog was written with the help of WMPS Therapist Erika Katt, MS, TLLP.