Frontiers in the Treatment of Trauma

Transcription

1 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 1 Frontiers in the Treatment of Trauma The Power of EMDR to Treat Trauma: Identifying, Reprocessing, and Integrating Traumatic Memories the Main Session with Francine Shapiro, PhD and Ruth Buczynski, PhD National Institute for the Clinical Application of Behavioral Medicine

2 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 2 Frontiers in the Treatment of Trauma: Francine Shapiro, PhD The Power of EMDR to Treat Trauma: Identifying, Reprocessing, and Integrating Traumatic Memories Table of Contents (click to go to a page) EMDR: Its Origin and Use... 3 Defining EMDR as a Psychotherapy Approach... 5 Using EMDR with a Patient... 7 Early Reactions to EMDR as an Approach... 9 EMDR and the Controlled Trials... 9 How Eye Movement Causes an Effect Reconsolidation: From Original Memory to Shifted Memory EMDR and Issues of Shame How EMDR Defines Trauma The Eight Phases of EDMR The Safe Place Technique EMDR and Humiliation How EMDR works with Anxiety and Fear EMDR, PTSD, and REM Sleep About the Speakers... 26

3 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 3 Frontiers in the Treatment of Trauma: Francine Shapiro, PhD The Power of EMDR to Treat Trauma: Identifying, Reprocessing, and Integrating Traumatic Memories Dr. Buczynski: Hello everyone and welcome. I am Dr. Ruth Buczynski, a licensed psychologist in the State of Connecticut and the President of the National Institute for the Clinical Application of Behavioral Medicine and I m so glad that you re here and part of our program on the treatment of trauma. We re especially looking forward to our webinar tonight; we have Dr. Francine Shapiro. She is the originator of a technique called EMDR eye-movement desensitization reprocessing. I m going to say that she discovered this and is the inventor of it she ll clarify how she likes to think of herself. It has been a while she came to our conference many years ago, so I want to say to you, Francine, welcome back. It s great to have you here. You have a lot of important information to share and I m so glad to be able to provide this to all the thousands of practitioners who are watching from all over the world. EMDR: Its Origin and Use Dr. Buczynski: You discovered or invented EMDR many years ago. Can you give us a little background? How did that happen? Dr. Shapiro: It actually started two years before I discovered it. I had cancer and that changed my attention from being an English literature professor to mind-body issues. Certainly, the whole field of psychoneural immunology was coming up at the time, but not very much was known in terms of what to do. I was using my own mind and body as a laboratory. I set out to find what we could do and offer it to the general public which meant that for the next eight years or so I was using my own mind and body as a laboratory.

4 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 4 One day when I was walking along, I noticed that some disturbing thoughts were disappearing, and when I brought them back they didn t have the same charge. But I hadn t done anything deliberate, so I was wondering what had happened usually you would have to do something to get them to shift. I paid very close attention and noticed that when that kind of thought came up, my eyes started moving very rapidly in a certain way and the thought I noticed that when thought came up, my eyes started moving very rapidly and the thought shifted. shifted, and when I brought it back again it didn t have the same charge. I experimented to see if I could do it deliberately brought up something that bothered me and did the eye movements and I saw the same effect. Then, I wanted to see if it would work with anyone else. After gathering every warm body I could find and saying, Do you have something that bothers you? and amazingly, everyone had something! Dr. Buczynski: What did they say? Dr. Shapiro: When we started, I had them do the eye movement and they would find that the disturbance would begin to go away and then would stop. I developed procedures, and after working with about eighty people, I came to the point of developing what at that time was EMD, and this seemed to work very well. At that point, I was also in a psychology program looking to do a dissertation and decided to test it, but I had I discovered that with the use of these procedures, problems that people had been having for the last twenty years disappeared. just worked with the worried well. I needed to see if the procedure would work with a clinical diagnosis. Old memories were the easiest to work with that put me right in the middle of posttraumatic stress disorder. I went to a veterans outreach center and asked if someone would work with me there. I discovered that with the use of these procedures, problems that people had been having for the last twenty years disappeared. For instance, the first person I worked with had been haunted by something he had heard while he was unloading dead bodies from a helicopter.

5 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 5 When we started to use the procedure, he said that the person s mouth was moving, but the sound disappeared. He continued and said that it began to look like a pain-ship underwater and he was flooded with the feeling that he verbalized as, I can finally say the war is over and I can tell everyone to go home. EMDR is an eightphase treatment. Because these effects were happening in a single session, they allowed me to continue working with the veterans from Vietnam, and we found that these problems were going away and they were going away very rapidly. So that really began the journey to what is now EMDR. Dr. Buczynski: Was it diagonal eye movement? Dr. Shapiro: It was diagonal for me. What we ve discovered since then is to use bilateral stimulation. It can be diagonal or it can be from side to side. But at this point, through the development of this procedure, it s really a psychotherapy approach. It s on par with psychodynamic and cognitive behavior therapy. There s a different paradigm in terms of how we view pathology. The principles that guide psychotherapy are different and of course the procedures are different. At this point, EMDR is an eight-phase treatment. Defining EMDR as a Psychotherapy Approach Dr. Buczynski: We ll get to the eight phases, but let s first pick up on something you just said: it is a psychotherapy approach different from others. How would you contrast it to a psychodynamic approach or a cognitive behavioral approach? Dr. Shapiro: EMDR at this point is one of only two forms of psychotherapy that is approved for the treatment of trauma and is viewed as research-based and effective. If we look at what the differences are, using that approach, you re identifying... Dr. Buczynski: Who has approved this? Dr. Shapiro: EMDR is approved by the Department of Defense and the Department of Veterans Affairs, the American Psychiatric Association, and the International Society of Posttraumatic Stress Studies.

6 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 6 Internationally, there are multiple agencies that have designated it as an effective approach most recently the World Health Organization. EMDR has, at this point, twenty randomized controlled trials showing its effect with trauma and showing that it s not only effective but also quite rapid. EMDR has twenty randomized controlled trials showing its effect with trauma and that it s not only effective but also quite rapid. To contrast it with psychodynamic therapy if someone is coming from that orientation: they are identifying the conflicts that the person might have, and then they would be interpreting and they would be working through, via the relationship, and moving towards resolution in that way. If someone is using a cognitive behavior therapy approach for instance, one of the primary forms of therapy used by therapists in prolonged-exposure therapy the paradigm is that the person has the disturbance because of avoidance. In order to prevent avoidance, the person is asked to describe the memory in detail and not allow their mind to go any place else or to stop. As they repeat this in detail as if they were living it in the moment as if they were reliving it a feeling of a rape victim, I feel his hands on me, I smell his breath the individual would do that for two or three times during the session while it was being audiotaped. Then they would be asked to listen to the audio tape for homework every night and would also do homework such as going to areas where they were disturbed. If they were raped in a dark alley, they would be asked to go to a similar environment and to stay there until If someone is using a cognitive behavior therapy approach the paradigm is that the person has the disturbance because of avoidance. the anxiety remitted. Again, all this is with a paradigm of CBT, in which the person believes if they re made to stay with their anxiety, they will go crazy. So they re given behavioral experiments the in vivo exposure and this prolonged imagined exposure repeating it over and over again, in order to change the belief to let them know that they are not going to go crazy and to change their behaviors. That is the paradigm that s used. With EMDR, what we re basically stating is that pathology, whether it s posttraumatic stress disorder or

7 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 7 across the board, is caused by unprocessed memories of an experience. We have an experience, and because it s too disturbing, it is being held in the brain in the form it was originally input. It holds the emotions, the physical sensations, the beliefs that were there at the time. If an individual comes in for therapy, we use different techniques in order to identify the current disturbances and the earlier memories that are the foundations of the problem. Then we would be preparing them in a certain way and asking them With EMDR we re stating that pathology, whether it s posttraumatic stress disorder or across the board, is caused by unprocessed memories of an experience. to hold these disturbances and earlier memories in mind while we do various procedures, including the eye movement and allowing the information-processing system of the brain to take over so the appropriate connections are made. In using EMDR, we access these memories, stimulate the information-processing system, and you get changes in images, thoughts, sounds, emotions, physical sensations, and beliefs. The person doesn t have to talk about it in detail; they don t have to do homework of any kind. EMDR is simply allowing the brain to pick up from where it got stuck. Because it was too disturbing, the information was not processed and it is held in a certain form of memory. In using EMDR, we access these memories, stimulate the information-processing system, and what you get are changes in images, thoughts, sounds, emotions, physical sensations, and beliefs. All of these will shift simultaneously as the processing occurs. Using EMDR with a Patient Dr. Buczynski: Let s talk through a patient. If you could pick someone, anyone from your experience, could you walk us through a case? Dr. Shapiro: Yes. Someone came in and said that he felt that he was in a dead-end job and really wanted to find a better job but couldn t bring himself to quit or take action.

8 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 8 He always had the feeling and he described it as, I can t go after and get what I want. He had no idea where it came from but he felt that that had been running his whole life, and of course, it was preventing him from taking action now. He always had the feeling and he described it as, I can t go after and get what I want. In using one of the techniques that we have to identify what the earlier memory was, it turned out that it went back to something that happened when he was a child. He was about six years old and he was playing with a ball at the top of the stairs and his mom said, Don't go down the stairs. But the ball falls, so he started running after the ball. His mom had come and grabbed it and started spanking him for going after the ball. What got locked in his brain was that feeling, I can t go after and get what I want. That ran him for the following thirty years. Now, of course, his mom wasn t trying to be abusive; she was afraid he was going to be hurt. But those types of experiences, when they re so disturbing to a child, get locked into the brain and they, again, hold the emotions, the physical sensations, and the beliefs. They run the person s life until they get processed. Dr. Buczynski: So, Francine, what happens if you have a patient and you re trying to help them discover some kind of association or past experience and nothing comes to mind for them? Dr. Shapiro: We have a three-pronged approach; we would be targeting and processing the earlier memories that set the groundwork for the problem. Those types of experiences, when they re so disturbing to a child, get locked into the brain and run the person s life until they get processed. We target and then process the kind of situations that are disturbing. Then we do the same for a future template what they ll need for enhanced behavior in the future. If the technique does not work to identify the earlier memory, we start targeting the current situations that are disturbing. Most often we find that these start going automatically into an association which takes them into the past experience. In those instances, where it hasn t been fully stored with an image, it still shifts and you can see it by the

9 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 9 associations that then emerge the connections that emerge and ultimately the disturbance is no longer there. Early Reactions to EMDR as an Approach Dr. Buczynski: When you created this many, many years ago, what kind of reactions did you get? Dr. Shapiro: There was a lot of skepticism because the dissertation that I eventually did with rape victims was published in the Journal of Traumatic Stress and it was one of the first articles, one of the first research studies, that was done at the time. PTSD was viewed as pretty intractable back then yet here I was reporting treatment effects that were being achieved in a single session, so the skepticism was quite high. Of course, because the eye movements were very different, the question was: Why would they have any effects at all? How could anything be that rapid and how could eye movements have any effect? The controversy that occurred at the time had to do with: How could anything be that rapid and how could eye movements have any effect? Those questions have launched a lot of research over. EMDR and the Controlled Trials Dr. Buczynski: I d like to get into some of the controlled trials. You said there were twenty I d like to get into that a little bit. Can you tell us about a few of the ones that you thought were more interesting? Dr. Shapiro: Yes. There was one trial done very early on with rape victims and it was conducted by a very experienced cognitive behavior researcher therefore, it was quite credible. Ninety percent of the rape victims no longer had PTSD after three treatment sessions. She reported that ninety percent of the rape victims no longer had PTSD after three treatment sessions. That corresponded to another study that had been done and

10 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 10 was published in the Journal of Clinical Psychology that was showing the same thing with a mixed trauma group that after three sessions, eighty-four percent no longer had PTSD. We have continued to see that ongoing a rule of thumb is that a single trauma can be processed within the equivalent of three ninety-minute sessions. A study conducted by Kaiser Permanente that used fifty-minute sessions basically found the same thing: on average, with six sessions, one hundred percent of single-trauma victims no longer had PTSD and seventyseven percent of multiple-trauma victims no longer had PTSD. The substantiation is quite clear that we can get those rapid treatment effects. Dr. Buczynski: In reviewing the research, were they randomized and controlled trials? How many, approximately, subjects were in each study? Dr. Shapiro: Yes, all of these twenty trials are randomized controlled trials. Those three certainly were, yes. And let s see. There were eighty-four subjects in one that was in JCCP Journal of Clinical Psychology. There were about a hundred in the Kaiser study, and I don't recall how many in the rape study. Dr. Buczynski: Thanks for clarifying the Journal. We have so many On average, with six sessions, one hundred percent of single-trauma victims no longer had PTSD and seventy-seven percent of multiple-trauma victims no longer had PTSD. practitioners watching in a wide range of specialties, so I want to make sure that the nurses and physicians who might not know that Journal, get this information. Not all techniques are researched as much as EMDR has been. Why do you think that happens? To me, EMDR seems to be researched maybe more frequently than many other techniques. Dr. Shapiro: Again, just to be correct, it is a form of psychotherapy it s not a simple technique. Because it s an eight-phase treatment approach and it s also applicable to a wide range of populations, I simply encouraged research from the very beginning. The skepticism raised quite a few questions as to why and how it could be effective that quickly. There were questions about the eye movement as well that really brought a lot of researchers to the fore. There are twenty randomized clinical trials on clinical outcomes and another twenty randomized trials on the eye movements themselves showing that when you inaugurate the eye movement, you get an immediate

11 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 11 de-arousal effect. This also has a very pronounced effect in imagery vividness and on emotional reactivity, so the disturbance level goes down immediately. Besides those trials, they ve also done ones investigating the cognitive effects. What they find is that When you inaugurate the eye movement, you get an immediate de-arousal effect. compared to exposure alone, the eye movement increases recognition of true information and also increases recognition that information is false. There are quite a number of cognitive and emotional changes that have been verified by these other randomized control trials. A recent metaanalysis has indicated that it s significant for laboratory trials and for clinical trials. The skepticism about the eye movement is really old information through people who haven't kept up with the literature. How Eye Movement Causes an Effect Dr. Buczynski: What do we know about what is causing the effect? What is it about the eye movement? Dr. Shapiro: There are basically two different theories and both have clinical/research support. There is one theory that says that the eye movement is disrupting working memory. If we bring something to mind a trauma or other event to mind we only have a limited capacity in working memory to hold it. Then, if we have a dual attention we ask the person to hold it in mind and then to follow our fingers, for instance we re over-taxing working memory, which is disrupting it and therefore disrupting its vividness. This causes the arousal to decrease. There are about twelve studies that have investigated that hypothesis and support it. One theory says that the eye movement is disrupting working memory. There are another ten studies that work with the theory having to do with the orienting response and REM rapid eye movement sleep. Those are more or less connected. If an animal in the wild is feeding or grazing and hears something, they will stop and check for danger. There

12 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 12 is a freeze response there. When they discover that there s no danger, there s an automatic relaxation response. That orienting response that parasympathetic response is one that many researchers believe occurs with the eye The processing done with the EMDR procedures shifts it from episodic memory into semantic memory. movement going back and forth. Robert Stickgold, who is a Harvard researcher and written a number of papers, believes this response links into the same processes that occur during REM sleep. With EMDR procedures, as a whole, in accessing a memory that is disturbing, the belief is that it s being held in episodic memory and has the emotions, the physical sensations, and the beliefs that were there at the time. The processing done with the EMDR procedures shifts it from episodic memory into semantic memory so that the appropriate meaning now has been extracted and that old the way it was held initially no longer exists. Dr. Buczynski: Just for the people watching, who aren t familiar with some of these terms, let s just define episodic memory and semantic memory. Dr. Shapiro: Episodic memory would be a memory that is held. Let s say there is danger, it is being held with emotion, physical sensation, and belief Semantic memory is one in which the meaning has been integrated into the larger memory networks the meaning is understood, so the way it was previously held is no longer needed. These are the hypotheses about what is underlying the treatment. But of course there is not enough known about any form of treatment to know exactly what the mechanisms are. But these are the best hypotheses and, again, there are about twelve research studies supporting working memory and another ten studies supporting the orienting response in REM hypotheses. Dr. Buczynski: Do you have any sense which hypothesis is the one? Or do you think there is a third one that hasn t been discovered yet, or...? There are about twelve research studies supporting working memory and another ten studies supporting the orienting response in REM hypotheses.

13 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 13 Dr. Shapiro: I think it s both! We re quite complex. In starting the procedures, we are disrupting working memory, and then with extended eye movement, it moves into the orienting response. Reconsolidation: From Original Memory to Shifted Memory Dr. Shapiro: If you observe an EMDR session, you can see a shift in this memory in form and content. For example, a person may start out that they were raped at night and the room can get flooded with light. It If you observe an EMDR session, you can see a shift in this memory in form and content. corresponds to a different emotion it corresponds to a different belief. That actually works into other mechanisms that people talk about. For instance, the prolonged-exposure therapy I spoke to you about is primarily believed to be based on extinction that in repeating it over and over again and staying with it, you re desensitizing through extinction processes. With that, the original memory doesn t change it creates a new memory. The person who starts out with prolonged exposure believes that they re going to go crazy if they concentrate on a disturbance, but then, through the relationship through the procedures learns that that is not so. That process creates a different memory, but the original memory is intact, and that may be responsible for relapse because the original memory is still there. With EMDR, because you see these changes with each set you basically say, What are you getting now? The person gives you whatever comes to mind it can be a new memory, it can be a different belief, it could be a different emotion or a different physical sensation. You see it shift with each set of eye movements until it arrives at an adaptive resolution. The belief that started out, I m a terrible person moves to, I m fine. The rape victim believing, I m shameful comes to, I m a strong, resilient woman. You see it shift with each set of eye movements until it arrives at an adaptive resolution. All of these shift and we believe what is occurring is based on reconsolidation that is, you access the original memory. It becomes labile and changeable. The processing begins, the internal connections are made, and that changes the original memory, which then

14 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 14 The processing begins, the internal connections are made, and that changes the original memory. gets stored in an altered form. That old memory, the way it originally started, is not there anymore and those physical sensations and reactions are not there anymore. The types of clinical responses we re seeing to substantiate that include, for instance, discovering that when someone has been traumatized let s say in different war experiences with wounded and amputated limbs where a significant portion have phantom limb pain we ve discovered that with EMDR processing of these trauma memories, not only do the trauma symptoms remit, but the pain does also. There are about five different articles that have been published, and the aggregate appears to be about an eighty percent success rate in either full elimination or substantial reduction of the pain through the processing alone. With EMDR processing of these trauma memories, not only do the trauma symptoms remit, but the pain does also. We believe although it hasn t been reported but we believe that with CBT therapies and the like, the original memory is still there and it s holding the pain sensation. If the memory is changed, it is not. We have discovered that if we process the memory of their own early molestation they re now able to take responsibility for what they have done. We re finding the same thing with the treatment of child molesters. With a subset of child molesters, we have discovered they were themselves molested as children. We have discovered that if we process the memory of their own early molestation, not only does the denial get broken through and a sense of empathy and being able to put responsibility where it belongs on the person who molested them, but they re now able to take responsibility for what they have done. Ultimately, in the processing, when they have checked the penile plethysmograph, which is a device that can be wrapped around the penis in order to see the amount of deviant arousal, they have discovered that the deviant arousal is all gone. When they ve done a one-year follow-up, that result has been maintained. Again, that s because of the underlying basis of reconsolidation the memory itself has changed and those physical sensations that were part of these original memories are no longer there. They re no longer getting triggered in the present.

15 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 15 Now, when former child molesters look at a child, they don't get sexually aroused; they see the person as a person and not as a sexual object. EMDR and Issues of Shame Dr. Buczynski: Hearing your story about the treatment with child molesters makes me want to raise the issue of shame. Does EMDR work with shame issues? I would think that as they get more empathic toward children and others they re going to feel an awful lot of shame for what they have done. As they take more responsibility, they re also going to feel more shame. How does EMDR see shame? Does it work with it? Has there been any study on that? Dr. Shapiro: Yes. Whether it is fear or anxiety, shame or guilt, there is no difference in terms of the processing. The appropriate connections are made and that allows the The person now recognizes that what they did as a perpetrator is not appropriate, but they also recognize why it happened. person to understand what happens. The person now recognizes that what they did as a perpetrator is not appropriate, but they also recognize why it happened. They become in touch with the fear that they have been molested, which is something they have been blocked off from. Very often molesters who have themselves been molested minimize it they don't remember what they actually felt like. Within the EMDR processing, they connect to what they actually felt at the time they really didn t want to be molested but they understand. The movement goes through denial responsibility, shame, understanding, acceptance and determination. The movement goes through denial and certainly through responsibility, shame, understanding, acceptance and most often, which I think is beautiful a determination to help others so that it doesn t happen to them as well. We have seen that so often with those who have been victimized the rape victim, the molestation victim they move towards that sense of wanting to make it fruitful, wanting to

16 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 16 make it useful, wanting to help others. Seeing this happen with those who have been perpetrators is just a wonderful statement to what healing actually is. How EMDR Defines Trauma Dr. Buczynski: We ve been talking a lot about a range of clinical issues, and just now the treatment of people who had experiences of early-childhood molestation. What, from the EMDR point of view, is the definition of trauma? How would you look at or define trauma? Dr. Shapiro: With PTSD you have criterion A there are certain standards that rape or molestation or a severe accident would meet. But what we ve found over the past twenty-five years is that standard is basically too limiting, and what we view as a trauma is really anything that has a lasting negative effect upon self or psyche. This has been substantiated with research. In 2005, they did a survey and discovered that general life events can cause even more PTSD symptoms than a major trauma. Trauma is anything that has a lasting negative effect upon self or psyche. When an individual is in a situation as a child and their parent leaves home this would not be considered a major trauma or be defined as PTSD. But it s clear that it has a major impact and can set the foundation for a lot of problems later on. So, you can call it big T trauma and small t trauma. We know that early humiliations and a variety of different types of mental assault that can occur during childhood have a negative effect. As a matter of fact, recent studies have even shown that bullying has set off psychotic symptoms in children. Recent studies have shown that bullying has set off psychotic symptoms in children. Now, we ve all been raised with Sticks and stones will break my bones but words will never harm me. But that is completely wrong. These negative experiences that children have all through childhood can set the foundation for a wide range of problems.

17 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 17 Negative experiences that children have all through childhood can set the foundation for a wide range of problems. It has been found that forty percent of those with panic disorder occurred because there was a separation from a parent in childhood. You wouldn t call that a major trauma according to PTSD criteria but, again, we see this negative, lasting effect. In EMDR therapy, we simply view it as an unprocessed memory that holds emotion, physical sensations, belief and can come out in a variety of different ways that form different diagnostic classes. The Eight Phases of EDMR Dr. Buczynski: Let s get a little bit into your eight phases. Dr. Shapiro: We start off with a history-taking phase, and during that time, we re identifying: What are the earlier memories that set the foundation for the problem? What are the current situations that trigger disturbance? What is needed for a healthy, active future? For instance, if someone was molested multiple times during childhood, that anxiety would certainly have potentially caused an isolation and separation so that they didn t learn the appropriate social skills. Without those social skills, they wouldn t be able to establish good relationships or learn how to show appropriate behaviors: how to stand up for yourself rather than being aggressive. That is overall what we identify during the history-taking phase. During the preparation phase, we teach a number of self-control techniques that allow the person to access the positive memory networks and identify whether these positive memory networks exist. If someone hasn t had a good relationship in their life they haven t had good parental guidance or they haven t had a good significant other During the preparation phase, we teach selfcontrol techniques that allow the person to access the positive memory networks. then we would be looking at what s necessary to inaugurate within the therapeutic relationship these positive memory networks. We need to have enough stabilization to allow the processing to occur. We need the person to feel in control

18 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 18 We need to have enough stabilization to allow the processing to occur. and we need the person to feel stable during processing. We do the appropriate education during preparation. Then, we move into what we call the assessment phase where we re bringing up a past memory that needs to be processed. We have the person hold it in mind, identify the image the negative belief that they have, what they would prefer to think instead, what emotion they re feeling, where they re feeling it in their body and the level of disturbance, and how true that positive belief feels. During the assessment phase, we re getting information about the characteristics of the memory and measures that we ll be using. We move into the assessment phase where we re bringing up a past memory that needs to be processed. EMDR is a very accountable therapy. It lets the clinician know from one moment to the next, not only by what the person is saying, but with the measurements, how the progression has gone. Then, we move into processing phases where insights come up, emotions change, physical sensations change. We re guiding that by measuring from zero to ten: zero is neutral and ten is the worst feeling they can think of. If they start off at an eight level, we ll be processing and moving to that zero distress level. We look at that positive cognition and how strong that is the positive belief. For example, the rape victim might be saying, I m a good person and not, I m a shameful person. We re testing how strong that is and we re moving to a seven level; from one completely false to seven completely true, we want a firm foundation that they truly do believe the positive about themselves. What we re seeing in the processing is really a transformation of the event. It is not that it disappears it doesn t go away, but rather these early experiences become a source for resilience; they become, through What we re seeing in the processing is really a transformation of the event. self-understanding, a better understanding of their strengths and who they are now in relation to that event. We have another phase where we look at physical response. For instance, the rape victim, unhealed, may be in bed with a very loving partner, but he touches her in a certain way and there s an automatic negative response that gets triggered.

19 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 19 By the end of EMDR processing, that no longer occurs because those physical sensations that would come up at the touch no longer exist in the memory network. We move to a closure phase in order to make sure the person has complete equilibrium. Then the eighth phase is reevaluation in order to check the earlier experience that was processed to see what else may need to be addressed. It is structured therapy, but it s also creative. The person who starts with a psychodynamic background, let s say, has certain training to be able to understand defenses and that is not lost in EMDR. Folks from the Menninger Clinic said that they learned EMDR and found that it helped them use what they knew that defense in EMDR terms would be caused by an earlier unprocessed memory of interactions that We move to a closure phase in order to make sure the person has complete equilibrium. occurred in childhood. The EMDR treatment would be to access these earlier memories and process them. You would get that shift and a defensive reaction would no longer emerge. For those who were cognitively oriented, they can very easily recognize beliefs. From an EMDR vantage point, the belief is not the cause of the pathology; it is the symptom. The cause is the unprocessed memory that holds that belief. If they recognize that an individual has a negative belief, the EMDR procedures allow them to identify where the earlier memory is that set that in motion and then to process it. Someone who is somatically oriented could recognize different postural changes and the techniques in EMDR the procedures would allow them to identify the memories in which that got launched. For instance, if an adolescent is walking around hunched over all the time what are the earlier memories that set that in motion? In this one example, she was a very weak child when she was born; she From an EMDR vantage point, the belief is not the cause of the pathology; it is the symptom. was in the hospital for many months and her parents were very, very worried. Although she grew out of that, they were constantly worried for her if she ran, they would stop her so that she wouldn t overtax herself. This constant over-attention, which came purely out of love, gave her the feeling of being a burden, not good

20 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 20 By accessing and processing these earlier memories the whole body changed and the hunching over was no longer there. enough, and insecure. So, that posture followed suit. By accessing and processing these earlier memories the whole body changed and the hunching over was no longer there. For those who have a relational orientation, EMDR is very often used in family therapies when you re trying to teach and educate how to respond to each other, but you have earlier memories that are causing negative reactivity or causing anger or causing people to be pushed away. By identifying that within a relational context, once again you use EMDR procedures to identify the earlier memories that are causing clinging behavior, reactive behavior, anger and allow that to be processed. What s important is the processing of those earlier memories that set the foundation. Because EMDR is an integrative therapy and complements different and other orientations, people are able to use their own strengths and be creative in terms of its use. What s important is the processing of those earlier memories that set the foundation. The Safe Place Technique Dr. Buczynski: You have a safe place technique. Would that be useful perhaps to share with people? Dr. Shapiro: Yes. There are a variety of self-control techniques that we use, and one is the safe place or a calm place because many clients are not able to achieve a sense of safety. With this technique, you identify an emotion that they would need in order to feel in control of the situation to let go of anxiety or pain. It s simply asking them, for instance, for a sense/place of safety or empowerment: where do they feel safe? It might be on a beach or it might be on a mountaintop, or it might be in a different location. You ask them to bring that up and hold it in mind. You can use guided imagery for them to identify and connect with what they re seeing, what they re feeling, and what they re hearing. You want to allow those emotions to come into them so that they are able to feel them. You then use key

21 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 21 words to allow them to bring those emotions back when they need them. That is just one of a number of different techniques that an individual can use. In order to get rid of the negative image that a person might continue to have they are upset about something coming up over and over again they can use a paint-can technique. We re allowing a person to make life more manageable until the full processing takes place. Here they are imagining this image on top of the can of paint and just stirring it up. This disrupts working memory and allows it to dissipate; it becomes more handable. What we re looking at in EMDR are these different self-control techniques. Everyone can use these at different times, but we re looking at them as a bridge we re allowing a person to make life more manageable until the full processing takes place. Eventually, a person won t need these very often because what was getting triggered negative emotions, negative beliefs, negative feelings from an unprocessed memory, are no longer there. EMDR and Humiliation Dr. Buczynski: You also have a technique that is useful with humiliation and I bring that up because in trauma, so often but not always, there is an element of humiliation that goes with it. Could you talk to us about that technique? Dr. Shapiro: The technique that we use very often, in order to allow people to see how they may be affected by their unprocessed memory, is to simply remember. Let s put it like this every time that I do a conference presentation, I ask people in the audience how many remember being humiliated sometime in grade school. They are invited to then go back and remember that experience, noticing what happens in their body and noticing the thoughts that emerge. If you bring up this old memory of humiliation and you feel If you bring up this old memory of humiliation and you feel your body shift, tighten, change, this is an indication that the memory has not been processed.

22 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 22 your body shift, tighten, change, or you get the thoughts/emotions that you were feeling at the time, this is an indication that the memory has not been processed. At that point, take a look at the different areas of your life in the present that you might have difficulty with: Many of these earlier humiliation experiences are really the evolutionary equivalent of being cut out of the herd. speaking to authority, being in groups, asserting yourself and notice if tentacles from that experience are wrapping themselves around your present. Many of these earlier humiliation experiences are really the evolutionary equivalent of being cut out of the herd. Being humiliated in grade school is like being cut out of the herd. That fear can simply be holding this memory in place, unprocessed. Anything that happens in the present has to link up with your memory networks in order to make sense of it. If you walk into a room with a large group of people and you have an earlier childhood unprocessed memory of humiliation in that group, those feelings can come up right there. We re invited to take a look at how often we re being pushed and prodded by these earlier experiences. Now, some people may go back to that early childhood experience and they don't feel anything negative; the thing that comes up for them is, Boy, that teacher shouldn t have been teaching, or, Boy, I was really something. We would say that memory is processed because what you have is the integrated adult response to it. We re invited to take a look at how often we re being pushed and prodded by these earlier experiences. Why does that happen for one and not for another? It may simply have been that after the humiliation, a good friend came over and put an arm around you and said, It s going to be fine, and that was enough to allow it to integrate. Another individual might have been awakened the night before by a car backfiring and was particularly tired so it would have a negative effect. Here s the bottom line it s basically the luck of the draw: we didn t ask for these experiences, but they re ubiquitous throughout childhood.

23 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 23 The negative feelings we have about ourselves and about the world now can most often be traced back to these earlier unprocessed memories and happily they can be processed, which means liberation from this current suffering. How EMDR works with Anxiety and Fear Dr. Buczynski: We don't have a lot of time left but before we stop, I just want to touch briefly on anxiety and fear because that also comes up an awful lot in trauma. Could we talk a little bit about your approach to thinking about and working with anxiety and fear? The trauma basis for anxiety and fear is made up of the physical sensations and the emotions were stored at the time. Dr. Shapiro: The trauma basis for feeling anxiety and fear whether it s guilt, anxiety, or shame is made up of the physical sensations and the emotions that were stored at the time. The rape victim, going into a variety of different circumstances, will have these earlier memories triggered, and the anxiety and the fear that is experienced is part of that unprocessed memory. The identification of the earlier memories that are holding those emotions and the physical responses are dealt with in EMDR by preparing the client in a certain way, accessing the memory in a certain way, and stimulating the information-processing system to allow that movement to take place. It becomes a shift from anxiety and fear to a sense of safety, which is an external locus of control. Let s say, the rape victim recognizes that they re not in current danger. Continued processing takes it to an internal locus of control recognition of personal power and sense of worth. The movement of processing is from the anxiety and pain to positive self -regard, a positive sense of power. The movement of processing is from the anxiety and pain to positive self-regard, a positive sense of power. We see this consistency in the treatment going from, There s something wrong with me. I m defective in some way. I brought these feelings upon myself to feelings of safety and ultimately to power and control.

24 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 24 EMDR, PTSD, and REM Sleep Dr. Buczynski: There is one more thing before we stop: disruptive REM sleep is often a marker of PTSD. Why do you think that is and how can EMDR help? During REM state, the brain is attempting to process survival information into resolution. Dr. Shapiro: Yes, it is a perfect example, actually, of what s occurring. The earlier memory, the trauma, let s say, in the PTSD, is being held, unprocessed, with the emotions, physical sensation and belief. The brain is trying to process the trauma and that is what dreaming is about. REM researchers, dream researchers, say that during REM state, the brain is attempting to process survival information into resolution. That s why all of us have had the experience of feeling disturbed at something, going to sleep, and getting up the next morning and feeling better about it having a better understanding of what to do. The brain has done what it s supposed to do it has processed the information and guided us appropriately in the future. When a trauma has occurred, the processing is disrupted. When a trauma has occurred, the person continues to wake up in the middle of the dream nightmare because it s too disturbing. The brain is trying to process the trauma during a dream, but the person continues to wake up in the middle of the dream nightmare because it s too disturbing. With EMDR, we look at what the nightmare images are and what a person reports. For instance, if a person says that they continually wake up in the middle of a nightmare in which they re being chased by a monster through a cave, we target that dream image. The person is holding in mind being chased through a cave by the monster. We start the processing, and most often what happens is like a veil getting peeled back. The person sees what the actual experience is and reports, Oh, my god that s the person who molested me, chasing me through my childhood home. The processing moves the trauma to resolution and the person, again, no longer has that dream image.

25 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 25 Once fully processed, it s integrated with the larger memory networks and arrives at adaptive resolution. That nightmare-dream image does not come back again. We start the processing, and most often what happens is like a veil getting peeled back. Happily, that is one way that EMDR is able to function. You don't have to try to change the person s mind about it or talk about it; they don't have to describe it in detail at any time. It s simply identifying the image and their thoughts that go with it, and then processing it to complete resolution. Dr. Buczynski: Thank you so much. Thanks for the time you have given us tonight, and also thank you for all of the work you have done in the last thirty years. Once fully processed, it s integrated with the larger memory networks and arrives at adaptive resolution. This is just amazing. You have made such a huge contribution. Thank you for your encouragement for more research to be done on EMDR. Thank you for inviting people to look at this skeptically so that the research could be done and would be done. I think that is so important in the development of any approach, or technique, or method, or theory. So thank you. Dr. Shapiro: My pleasure, Ruth. It was lovely being here. Thank you.

26 The Power of EMDR to Treat Trauma Francine Shapiro, PhD - Main Session - pg. 26 About the speakers... Francine Shapiro, PhD is the originator and developer of EMDR, which has been so well researched that it is now recommended as an effective treatment for trauma in the Practice Guidelines of the American Psychiatric Association, and those of the Departments of Defense and Veterans Affairs. Dr. Shapiro is a Senior Research Fellow Emeritus at the Mental Research Institute in Palo Alto, California, Executive Director of the EMDR Institute in Watsonville, CA, and founder and President Emeritus of the EMDR Humanitarian Assistance Programs, a non-profit organization that coordinates disaster response and low fee trainings worldwide. Ruth Buczynski, PhD has been combining her commitment to mind/body medicine with a savvy business model since As the founder and president of the National Institute for the Clinical Application of Behavioral Medicine, she s been a leader in bringing innovative training and professional development programs to thousands of health and mental health care practitioners throughout the world. Ruth has successfully sponsored distance-learning programs, teleseminars, and annual conferences for over 20 years. Now she s expanded into the cloud, where she s developed intelligent and thoughtfully researched webinars that continue to grow exponentially.