EMDR Therapy and Medical Trauma

Guest Blog Post by Dr. Livia Perez

Tell us a little bit about you, your experience becoming an EMDR therapist, and how you became interested in medical trauma and health psychology?

I initially graduated from law school. While working as an attorney, I had to take a workshop in psychology, and a shift occurred that led me to change my career. The connection I felt with psychology during that training was what I call “my real purpose.” I honored it and decided to follow my new professional path.

When I graduated with my master’s degree in psychology, I began to work with trauma, specifically with sexually abused children and adolescents. In addition to the sexual abuse trauma, some of my patients had also experienced physical abuse and neglect, and others presented with physiological challenges, including tuberculosis and catatonia, among others.

I always had the impression that we were missing “something” in the trauma work we were doing without having any idea at that time of how “the body keeps the score.” I questioned if the body could hold traumatic material that talk therapy would not be able to assess. On one occasion, I had a patient who required involuntary hospitalization after being in therapy for sexual trauma. At the hospital, she reported another sexual abuse experience. When she was discharged from the hospital and returned to therapy, she verbalized that years ago, she had promised herself that she would not talk about the aforementioned sexual abuse incident because of the overwhelming shame. She then stated that a therapist at the hospital “made me follow his fingers with my eyes, and I could not hold this secret anymore.” She noted that she experienced an urge to disclose this incident as she moved her eyes back and forth. That is when I felt eager to attend my first EMDR training, which motivated me to open my private practice and continue expanding my EMDR skills and knowledge.

In time, I graduated from a doctoral program with a concentration in health psychology. During my doctoral program studies, I continued working in my private practice. I completed rotations in the medical field, including Jackson Memorial Hospital, University of Miami Hospital, and the Design Neuroscience Center. During my rotations, I completed biopsychosocial clinical intakes and individual psychotherapy for patients with spinal cord injury, cancer, multiple sclerosis, and other degenerative conditions. I conducted neuropsychological evaluations of geriatric populations and neuropsychological evaluations, as well as individual and group psychotherapy for patients with traumatic brain injury (TBI) and a variety of other neurological diseases. The aforementioned provided me with the opportunity to treat patients with medical trauma and to expand my specialty by integrating psychological trauma and physical illness.

How can EMDR therapy help with medical trauma? What successes have you experienced when using EMDR therapy with fears related to medical treatment or past medical trauma?

In her article “The Role of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in Medicine: Addressing the Psychological and Physical Symptoms Stemming from Adverse Life Experience,” Dr. Francine Shapiro explains the benefits of using EMDR with medical cases. EMDR therapy is not just beneficial in releasing the traumatic symptoms triggered by adverse medical events but in promoting a shift from total hopelessness to appreciation and meaning, including in those cases with a permanent medical condition, such as transplant and traumatic brain injury (TBI). With TBI cases, I have observed a rapid improvement in depressive symptoms, including a drastic decrease or elimination of daily suicidal ideas. Regarding the fears of experiencing a medical challenge again or complications of chronic conditions, I have observed my patients gaining peace and hope when integrating EMDR therapy with the faith/religion they practice and also an improvement in their relationship with their support system or caregiver.

Are there any cautionary measures you would like to mention regarding the use of EMDR therapy with medical trauma?

I do not use eye movement as bilateral stimulation in cases of traumatic brain injury (TBI); I use tappers. Some TBI patients present with an ocular dislocation when they have to look at one point that is not easily observable other than during a neurological examination. I am also careful with auditory bilateral stimulation, as some TBI patients develop Tinnitus.

In cases with physical permanent damage, such as paraplegia, we should be careful with accepting “I am permanently damaged” as a negative cognition as it is a fact that the patient has permanent damage. In this case, we should seek a negative cognition that is more objective to eliminate.

An important warning is when a patient’s cardiovascular condition is unknown, and the patient is presenting with TBI, high blood pressure, high cholesterol, and other comorbidities, such as panic attacks, which may mimic hypoglycemia, coronary heart disease, cardiac arrhythmia, or pericarditis. Before engaging the patient in processing traumatic memories, a referral to rule out a cardiovascular condition is necessary. These are some of the examples of precautions we should take. However, there are others to consider with spinal cord injury patients, TBI, geriatric population, and cognitive decline due to degenerative disease and/or neuromuscular condition.

Are there any myths you’d like to break about using EMDR therapy with this population?

Myth: With medical cases—the ones with permanent physical challenges—it is not possible to reduce the Subjective Unit of Disturbance (SUD) to zero. Contrary to this myth, I have had patients who, in these circumstances, have been able to report a zero.

What multicultural considerations might EMDR therapists need to keep in mind regarding using EMDR therapy and clients coping with medical trauma?

We all are characterized by unique belief systems, perceptions, and attitudes, most unseen to the naked eye. Diversity is not measurable; it is unique and only captured when we can be present with the patient. My original idea about diversity was based on an individual’s color, sexual orientation, culture, and religion. During my practicums in the medical field, I learned that having a disability was also a significant aspect of diversity. To help our patients adjust and adapt, we should recognize the multicultural framework implicit within our field. EMDR standard protocol may have to be adapted to some patients with disabilities, such as a low IQ score and limited speech. Cards or other tools may need to be integrated with the protocol to facilitate processing.

What would you like people outside the EMDR community to know about EMDR therapy and medical trauma?

EMDR offers a unique way to access subconscious material compared to other therapeutic interventions. In some cases, EMDR may facilitate the differentiation between what portion of the symptoms are physiological and psychological. For example, a patient with rheumatoid arthritis will typically report physical pain; however, what portion of the pain is physical vs. psychological? EMDR therapy will help decrease the pain by eliminating the somatic symptoms, thus decreasing the general pain.

Is there anything else you’d like to add?

Lastly, the patient’s medical history is paramount and should be taken and considered meticulously, as there are psychological presentations that mask medical conditions. I have had a significant number of patients with “unknown or unfound” medical conditions. Traumatic brain injury (TBI) had been one of the cases. MRIs do NOT always detect all types of brain injuries. Other cases I have had with misdiagnosed medical conditions have been tethered spinal cord syndrome and lupus, among others. We spend more time with the patient than medical doctors. The knowledge of health psychology can make a difference in our patient’s life and determine the course of medical and psychological treatment.

Dr. Perez is a psychologist; LMHC; and an EMDR Certified Therapist and Consultant. She specializes in health psychology and in EMDR to treat traumas. In 2013, inspired by one of her patients, she attended the EMDR training and opened her private practice in the same year.

Resources

Broad, R. D., & Wheeler, K. (2006). An adult with childhood medical trauma treated with psychoanalytic psychotherapy and EMDR: A case study. Perspectives in Psychiatric Care, 42(2), 95-105. https://doi.org/10.1111/j.1744-6163.2006.00058.x

Gattinara, P. C. (2009). Working with EMDR in chronic incapacitating diseases: The experience of a neuromuscular diseases center. Journal of EMDR Practice and Research, 3(3), 169-177, Open access: https://doi.org/10.1891/1933-3196.3.3.169

Gielkens, E. M., Sobczak, S., Rossi, G., & van Alphen, S. P. J. (2022). The feasibility of eye movement desensitization and reprocessing (EMDR) for older adults with posttraumatic stress disorder (PTSD) and comorbid psychiatric and somatic disorders. Psychological Trauma: Theory, Research, Practice, and Policy, online. https://psycnet.apa.org/doi/10.1037/tra0001402

Haerizadeh, M., Sumner, J. A., Birk, J. L., Gonzalez, C., Heyman-Kantor, R., Falzon, L., Gershengoren, L., Shapiro, P., & Kronish, I. M. (2020). Interventions for posttraumatic stress disorder symptoms induced by medical events: A systematic review. Journal of Psychosomatic Research, 129: 109908. https://doi.org/10.1016/j.jpsychores.2019.109908

Kearney, B. E., & Lanius, R. A. (2022). The brain-body disconnect: A somatic sensory basis for trauma-related disorders. Frontiers in Neuroscience, 16. Open access: https://doi.org/10.3389/fnins.2022.1015749

Luber, M. (2019). Treating Trauma in somatic and medical-related conditions: Eye movement desensitization and reprocessing EMDR therapy scripted protocols and summary sheets. New York, NY: Springer Publishing Company, LLC.

Luber, M., & Shapiro, F. (2009). Illness and somatic disorders protocol. In M. Luber (Ed.), Eye movement desensitization and reprocessing (EMDR) scripted protocols: Basics and special situations. (pp. 189-211) New York, NY: Springer Publishing Co.

Meentken, M. F., van Beynum, I. M., Aendekerk, E. W. C., Legerstee, J. S., El Marroun, H., van der Ende, J., Lindauer, R. J. L., Hillegers, M. H., Moll, H. A., Helbing, W. A., & Utens, E. M. W. J. (2018). Eye movement desensitization and reprocessing (EMDR) in children and adolescents with subthreshold PTSD after medically related trauma: design of a randomized controlled trial. European Journal of Psychotraumatology, 9, 1:536287. Open access: https://doi.org/10.1080/20008198.2018.1536287

Meentken, M. F., van der Mheen, M., van Beynum, I. M., Aendekerk, E. W. C., Legerstee, J. S., van der Ende, J., del Canho, R., Lindauer, R. J. L., Hillegers, M. H. J., Moll, H. A., Helbing, W. A., & Utens, E. M. W. J. (2020). EMDR for children with medically related subthreshold PTSD: Short-term effects on PTSD, blood-injection-injury phobia, depression and sleep. European Journal of Psychotraumatology, 11, 1705598. Open access: https://doi.org/10.1080/20008198.2019.1705598

Meentken, M. F., van der Mheen, M., van Beynum, I. M., Aendekerk, E. W. C., Legerstee, J. S., van der Ende, J., del Canho, R., Lindauer, R. J. L., Hillegers, M. H. J., Helbing, W. A., Moll, H. A., & Utens, E. M. W. J. (2021). Long-term effectiveness of eye movement desensitization and reprocessing in children and adolescents with medically related subthreshold post-traumatic stress disorder: A randomized controlled trial. European Journal of Cardiovascular Nursing, zvaa006. Open access: https://doi.org/10.1093/eurjcn/zvaa006

Morrison, J. (2015) When psychological problems mask medical disorders (2^nd ed). New York, NY: The Guilford Press.

Shapiro, F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical symptoms stemming from adverse life experiences. The Permanente Journal, 18(1), 71-77. Open access: https://doi.org/10.7812/TPP/13-098

Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols and procedures. New York, NY: Norton and Company, Inc.

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EMDR Therapy and Medical Trauma