After the therapist and client agree that EMDR therapy is a good fit, the beginning sessions will involve discussing what the client wants to work on and improving the client's ability to manage distress.
When ready for the next phases of EMDR therapy, the client will be asked to focus on a specific event. Attention will be given to a negative image, belief, emotion, and body feeling related to this event, and then to a positive belief that would indicate the issue was resolved.
While the client focuses on the upsetting event, the therapist will begin sets of side-to-side eye movements, sounds, or taps. The client will be guided to notice what comes to mind after each set. They may experience shifts in insight or changes in images, feelings, or beliefs regarding the event.
The client has full control to stop the therapist at any point if needed. The sets of eye movements, sounds, or taps are repeated until the event becomes less disturbing.
A typical EMDR therapy session lasts from 60-90 minutes. EMDR therapy may be used within a standard talking therapy, as an adjunctive therapy with a separate therapist, or as a treatment all by itself.
There are eight phases to EMDR therapy: initial history discovery and treatment planning, preparation, assessment, desensitization, installation, body scan, closure, and then reevaluation.
Eight Phases of EMDR Therapy Treatment
The amount of time the complete treatment will take depends upon the history of the client. Complete treatment of the targets involves a three pronged protocol to alleviate the symptoms and address the complete clinical picture:
- past memories
- present disturbance
- future actions
The goal of EMDR therapy is to process completely the experiences that are causing problems, and to include new ones that are needed for full health.
"Processing" does not mean talking about it. "Processing" means setting up a learning state that will allow experiences that are causing problems to be "digested" and stored appropriately in your brain. That means that what is useful to you from an experience will be learned, and stored with appropriate emotions in your brain, and be able to guide you in positive ways in the future.
The inappropriate emotions, beliefs, and body sensations will be discarded. Negative emotions, feelings and behaviors are generally caused by unresolved earlier experiences that are pushing you in the wrong directions. The goal of EMDR therapy is to leave you with the emotions, understanding, and perspectives that will lead to healthy and useful behaviors and interactions.
Although EMDR therapy may produce results more rapidly than previous forms of therapy, speed is not the issue and it is important to remember that every client has different needs. For instance, one client may take weeks to establish sufficient feelings of trust (Phase 2), while another may proceed quickly through the first six phases of treatment only to reveal something even more important that needs treatment.
Phase 1: History and Treatment Planning
This phase generally takes 1-2 sessions at the beginning of therapy, and can continue throughout the therapy, especially if new problems are revealed. In the first phase of EMDR treatment, the therapist takes a thorough history of the client and develops a treatment plan. This phase will include a discussion of the specific problem that has brought him or her into therapy, the behaviors and symptoms stemming from that problem. With this information, the therapist will develop a treatment plan that defines the specific targets on which to use EMDR:
- the event(s) from the past that created the problem
- the present situations that cause distress
- the key skills or behaviors the client needs to learn for his future well-being
One of the unusual features of EMDR is that the person seeking treatment does not have to discuss any of his or her disturbing memories in detail. So while some individuals are comfortable, and even prefer, giving specifics, other people may present more of a general picture or outline. When the therapist asks, for example, "What event do you remember that made you feel worthless and useless?" the person may say, "It was something my brother did to me." That is all the information the therapist needs to identify and target the event with EMDR.
Phase 2: Preparation
For most clients this phase will take between 1-4 sessions. For others, with a very traumatized background, or with certain diagnoses, a longer time may be necessary. In this phase, the therapist will teach you some specific techniques so you can rapidly deal with any emotional disturbance that may arise. If you can do that, you are generally able to proceed to the next phase.
One of the primary goals of the preparation phase is to establish a relationship of trust between the client and the therapist. While the person does not have to go into great detail about his disturbing memories, if the EMDR client does not trust his or her therapist, he or she may not accurately report what is felt and what changes he or she is (or isn't) experiencing during the eye movements. If the client just wants to please the therapist and says they feel better when they don't, no therapy in the world will resolve that client's trauma.
During the Preparation Phase, the therapist will explain the theory of EMDR, how it is done, and what the person can expect during and after treatment. Finally, the therapist will teach the client a variety of relaxation techniques for calming him or herself in the face of any emotional disturbance that may arise during or after a session.
In any form of therapy it is best to look at the therapist as a facilitator, or guide, who needs to hear of any hurt, need, or disappointments in order to help achieve the common goal. EMDR therapy is a great deal more than just eye movements, and the therapist needs to know when to employ any of the needed procedures to keep the processing going. Learning these tools is an important aid for anyone. The happiest people on the planet have ways of relaxing themselves and decompressing from life's inevitable, and often unsuspected, stress. One goal of EMDR therapy is to make sure that the client can take care of him or herself.
Phase 3: Assessment
In this phase, the client will be prompted to access each target in a controlled and standardized way so it can be effectively processed. Processing does not mean talking about it. (See the Reprocessing sections below.) The EMDR therapist identifies different parts of the target to be processed.
The first step is for the client to select a specific image or mental picture from the target event (which was identified during Phase One) that best represents the memory. Then he or she chooses a statement that expresses a negative self-belief associated with the event. Even if the client intellectually knows that the statement is false, it is important that he or she focus on it. These negative beliefs are actually verbalizations of the disturbing emotions that still exist. Common negative cognitions include statements such as "I am helpless," "I am worthless," "I am unlovable," "I am dirty," "I am bad," etc.
The client then picks a positive self-statement that he would rather believe. This statement should incorporate an internal sense of control such as "I am worthwhile/lovable/a good person/in control" or "I can succeed." Sometimes, when the primary emotion is fear, such as in the aftermath of a natural disaster, the negative cognition can be, "I am in danger" and the positive cognition can be, "I am safe now." "I am in danger" can be considered a negative cognition, because the fear is inappropriate -- it is locked in the nervous system, but the danger is actually past. The positive cognition should reflect what is actually appropriate in the present.
At this point, the therapist will ask the person to estimate how true a positive belief feels using the 1-to-7 Validity of Cognition (VOC) scale. "1" equals "completely false," and " 7" equals "completely true." It is important to give a score that reflects how the person "feels," not " thinks." We may logically "know" that something is wrong, but we are most driven by how it " feels."
Also, during the Assessment Phase, the person identifies the negative emotions (fear, anger) and physical sensations (tightness in the stomach, cold hands) he or she associates with the target. The client also rates the negative belief, but uses a different scale called the Subjective Units of Disturbance (SUD) scale. This scale rates the feeling from 0 (no disturbance) to 10 (worst) and is used to assess the disturbance that the client feels.
The goal of EMDR treatment, in the following phases, is for SUD scores of disturbance to decrease while the VOC scores of positive belief increase.
Reprocessing. For a single trauma reprocessing is generally accomplished within 3 sessions. If it takes longer, you should see some improvement within that amount of time. Phases One through Three lay the groundwork for the comprehensive treatment and reprocessing of the specific targeted events. Although the eye movements (or taps, or tones) are used during the following three phases, they are only one component of a complex therapy. The use of the step-by-step eight-phase approach allows the experienced, trained EMDR therapist to maximize the treatment effects for the client in a logical and standardized fashion. It also allows both the client and the therapist to monitor the progress during every treatment session.
Phase 4: Desensitization
This phase focuses on the client's disturbing emotions and sensations as they are measured by the SUDs rating. This phase deals with all of the person's responses (including other memories, insights and associations that may arise) as the targeted event changes and its disturbing elements are resolved. This phase gives the opportunity to identify and resolve similar events that may have occurred and are associated with the target. That way, a client can actually surpass his or her initial goals and heal beyond his or her expectations.
During desensitization, the therapist leads the person in sets of eye movements, sounds, or taps with appropriate shifts and changes of focus until his or her SUD-scale levels are reduced to zero (or 1 or 2 if this is more appropriate). Starting with the main target, the different associations to the memory are followed. For instance, a person may start with a horrific event and soon have other associations to it. The therapist will guide the client to a complete resolution of the target.
Examples of sessions and a three-session transcript of a complete treatment can be found in F. Shapiro & M.S. Forrest (2004) EMDR. New York: BasicBooks. http://www.perseusbooksgroup.com/perseus-cgi-bin/display/0-465-04301-1
Phase 5: Installation
The goal is to concentrate on and increase the strength of the positive belief that the client has identified to replace his or her original negative belief. For example, the client might begin with a mental image of being beaten up by his or her father and a negative belief of "I am powerless." During the Desensitization Phase that client will have reprocessed the terror of that childhood event and fully realized that as an adult he or she now has strength and choices that were not there when he or she was young.
During this fifth phase of treatment, that person's positive cognition, "I am now in control," will be strengthened and installed. How deeply the person believes that positive cognition is then measured using the Validity of Cognition (VOC) scale. The goal is for the person to accept the full truth of his or her positive self-statement at a level of 7 (completely true).
Fortunately, just as EMDR cannot make anyone shed appropriate negative feelings, it cannot make the person believe anything positive that is not appropriate either. So if the person is aware that he or she actually needs to learn some new skill, such as self-defense training, in order to be truly in control of the situation, the validity of that positive belief will rise only to the corresponding level, such as a 5 or 6 on the VOC scale.
Phase 6: Body Scan
After the positive cognition has been strengthened and installed, the therapist will ask the person to bring the original target event to mind and see if any residual tension is noticed in the body. If so, these physical sensations are then targeted for reprocessing.
Evaluations of thousands of EMDR sessions indicate that there is a physical response to unresolved thoughts. This finding has been supported by independent studies of memory indicating that when a person is negatively affected by trauma, information about the traumatic event is stored in body memory (motoric memory), rather than narrative memory, and retains the negative emotions and physical sensations of the original event. When that information is processed, however, it can then move to narrative (or verbalizable) memory and the body sensations and negative feelings associated with it disappear.
Therefore, an EMDR session is not considered successful until the client can bring up the original target without feeling any body tension. Positive self-beliefs are important, but they have to be believed on more than just an intellectual level.
Phase 7: Closure
Ends every treatment session. Closure ensures that the person leaves at the end of each session feeling better than at the beginning.
If the processing of the traumatic target event is not complete in a single session, the therapist will assist the client in using a variety of self-calming techniques in order to regain a sense of equilibrium. Throughout the EMDR session, the client has been in control (for instance, the client is instructed that it is okay to raise a hand in the "stop" gesture at anytime) and it is important that the client continue to feel in control outside the therapist's office.
He or she is also briefed on what to expect between sessions (some processing may continue, some new material may arise), how to use a journal to record these experiences, and what calming techniques could be used to self-soothe in the client's life outside of the therapy session.
Phase 8: Reevaluation
Opens every new session. The Reevaluation Phase guides the therapist through the treatment plans that are needed in order to deal with the client's problems. As with any form of good therapy, the Reevaluation Phase is vital in order to determine the success of the treatment over time. Although clients may feel relief almost immediately with EMDR, it is as important to complete the eight phases of treatment, as it is to complete an entire course of treatment with antibiotics.
The Role of Past, Present, and Future Templates
EMDR therapy is not complete until attention has been brought to the past memories that are contributing to the problem, the present situations that are disturbing, and what skills the client may need for the future.
Excerpts above from: F. Shapiro & M.S. Forrest (2004) EMDR: The Breakthrough Therapy for Anxiety, Stress and Trauma. New York: BasicBooks. http://www.perseusbooksgroup.com/perseus-cgi-bin/display/0-465-04301-1