Psychotherapy and Neuroscience

EMDR

Eye Movement and Desensitization and Reprocessing (EMDR) (Shapiro, 1995, 2001) is a method that was developed by Francine Shapiro in the early 1990?s. EMDR is a short term psychodynamic psychotherapy method that focuses on helping the patient/client to access and process previously forgotten painful traumatic memory. Amnesia for an event or relationship need not only be traumatic in nature; memory relating to painful experiences of self in interaction within families is also very commonly forgotten from mid-adolescence onward. In fact unresolved thoughts of self in interaction and feelings with regards to a troubling parent-child relationship often underlies one’s later (Bremner et al., 1993) responses to a traumatic event(s), i.e. earlier stress and trauma set the stage for the later expression of PTSD symptoms. When painful memory is forgotten, it becomes trapped in the brain and central nervous system (CNS) (van der Kolk, 1996b), is presented in later neurobiological alterations of neural circuitry (van der Kolk, 1996b) and is inadvertently internalized and reenacted in later adult scripts (Goulding & Goulding, 1975; van der Kolk, 1996a).¬† Later¬† stressors and aging allow the expression of symptoms of chronic psychiatric, affective, or physical illness (van der Kolk, 1996a) that likely will someday require psychopharmacological intervention according to today’s standard.

The EMDR therapy session helps the patient to recall and process different aspects of a troubling or painful memory relating to a traumatic event or emotional loss. What was experienced as painful with recall at the start of therapy, after therapy, is no longer painful. In addition, the general arousal state of the patient and experience of uncomfortable symptoms decrease in response to progress in therapy. Successful processing of each painful memory removes a layer of stress that had been previously expressed in neurobiological terms and through symptoms prior to the completion of the EMDR processing. The decreases in arousal and physiological measures that come with complete processing of painful or traumatic memory simulates one?s sense of well being, similar to that experienced in response to successfully remitted psychopharmacological therapy. As will be demonstrated in a future section of this web site, the stress response tends to reduce the functional integrity of certain corticolimbic regions, e.g. pACC and the hippocampal formation, and this produces alterations in neural circuitry, in their metabolism as well as in the synthesis, release and secretion of certain stress neurohormones and neuroimmune markers. Successful therapies work to improve the function of these areas to promote the modulation of the stress response.

During the EMDR assessment (Shapiro, 1995, 2001) the therapist completes a thorough assessment and history with the patient, helps the patient to create and establish a safe place, and looks to identify the ‘negative cognition’ that has been associated with a negative event(s) or relationship(s) that impacts on the patient’s current sense of self. The therapist then inquires into the most disturbing sensory aspect to the traumatic event or relationship (feeling sore with having been beaten or hearing anger in an aggressor’s voice), visceral body messages (sinking feeling in the pit of one’s stomach or heart pounding), negative emotion (sadness) which accompanies the negative cognition (I am not good enough or I am unlovable). The EMDR therapist monitors the patient’s sense of disturbance and preferred thought of self with Subjective Units of Disturbance (SUDS) and Validity of Cognition (VOC) respectively. The patient is encouraged to reflect on all four areas of experience while visually guided, bilateral auditory, or somatotopic tapping induced eye movements are tracked by the EMDR therapist. Holding these different aspects of experience in mind along with tracked eye movements allows these experiences to fuse into one memory. This precipitates emotional learning that allows for future spontaneous memory retrieval without the experience of acute or chronic arousal. With increasing processing and decreasing discomfort, the patient experiences a positive cognition (I am good enough).

Many studies have monitored the efficacy of EMDR therapy by providing follow-up interviews. Reductions in SUDS ratings, basal heart rate, skin temperature, systolic blood pressure and galvanic skin response to previous traumatic eliciting imagery were reported (Montgomery & Ayllon, 1994; Wilson et al., 1996) immediately after the course and completion of EMDR therapy. After three and then fifteen-month follow-up meetings on three prior EMDR therapy sessions, 66 individuals, 32 of whom had been diagnosed with PTSD symptoms, experienced an 84% reduction in assessed PTSD diagnosis and 68% reduction in PTSD symptoms (Wilson et al., 1995, 1997). Two months after three 90-minute EMDR therapy sessions individuals who had previously experienced a civilian traumatic event no longer reported PTSD symptoms at the conclusion of therapy (Lazrove et al., 1998). EMDR therapy has also been reported to be effective at three-month follow-up at alleviating PTSD and depressive symptoms with 21 rape victims over a course of three 90 minute therapy sessions (Rothbaum, 1997). After three months of EMDR therapy and a three month follow-up, combat veterans with post-traumatic stress disorder reported reductions in symptoms of memory intrusion, avoidance, and arousal, and reported overall improvements when compared with veterans receiving routine care (Carlson et al., 1998).

The studies noted above documente EMDRs efficacy at reducing symptoms and physiological measures in response to the processing of a single traumatic event, but another noted after two sessions of EMDR, that more sessions were needed to resolve a trauma (Scheck et al., 1998). The population of 21 individuals in this study presented many dysfunctional behaviors, such as substance abuse, incarceration, friendships with individuals who had engaged in prostitution, and relationships with partners who were in current incarceration with histories of substance abuse. In clinical practice such patient populations tend to present chronic stress histories of multiple traumas (physical and/or sexual abuses) and emotional losses throughout their lives. Another study did a five-year follow-up of previous EMDR therapy and found that therapeutic benefits experienced immediately after EMDR therapy were lost at follow-up (Macklin et al., 2000). This study like the one noted above used a sample population of veterans who were described as ‘entrenched and chronically ill’. The fact that both sample populations were noted to be severely dysfunctional and chronically ill suggest that they presented histories of multiple traumas in their lifetime and/or unresolved feelings with regards to emotional losses. The individuals cumulative stress responses to these other traumas were not accounted for in the processing of one single traumatic event. This dynamic would make the method appear ineffectual, because several sessions were actually needed to process numerous traumas to produce long-term effective results.

After successful EMDR threrapy posttreatment salivary cortisol levels were significantly reduced in response to dexamethasone challenge and were also associated with reductions in perceived sensitivity to the impact of prior aversive life events and in anxiety symptoms (Heber et al., 2002). In a SPECT neuroimaging study post-treatment activations of the perigenual anterior cingulate were strongly correlated with post-treatment decreases in sensitivity to reliving trauma and rated distress values as well as reductions of anxiety symptoms that met previously assigned PTSD diagnosis (Levin et al., 1999).

In summary, EMDR, a short term psychodynamic therapy method has been tested by many researchers for its short-term and long term effectiveness. With individuals with limited traumas in their histories the EMDR therapy method has been found to be short, direct, and proven to be quite effective. However, with individuals with multiple traumas and many emotional losses in their histories, the processing of a single traumatic event is not sufficient by itself to offset the neurobiological cascade precipitated by a lifetime of chronic, cumulative responses to stressful interactions with the environment. A plan needs to be developed with these individuals to address and target each trauma with each succeeding EMDR session.

References

Bremner JD, Southwick SM, Johnson DR, Yehuda R, Charney DS (1993): Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. Am J Psychiatry, 150(2): 235-9.

Carlson JG, Chemtob CM, Rusnak K, Hedlund NL, Muraoka MY (1998): Eye movement desensitization and reprocessing (EMDR) treatment for combat-related posttraumatic stress disorder. J Trauma Stress, 11(1): 3-24.

Goulding M & Goulding RL (1979): Changing Lives Through Redecision Therapy. Grove Press, New York.

Lazrove S, Triffleman E, Kite L, McGlashan T, Rounsaville B (1998): An open trial of EMDR as treatment for chronic PTSD. Am J Orthopsychiatry, 68(4): 601-8.

Macklin ML, Metzger LJ, Lasko NB, Berry NJ, Orr SP, Pitman (2000): Five-year follow-up study of eye movement desensitization and reprocessing therapy for combat-related posttraumatic stress disorder. Compr Psychiatry, 41(1): 24-7.

Montgomery RW & Ayllon T (1994): Eye movement desensitization across subjects: subjective and physiological measures of treatment efficacy. J Behav Ther Exp Psychiatry, 25(3): 217-30.

Rothbaum BO (1997): A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims. Bull Menninger Clin, 61(3): 317-34.

Shapiro F (1995): Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. The Guilford Press, New York.

Shapiro F (2001): Level I Training Manual: Part One of a Two Part Training. Pacific Grove, California.

Scheck MM, Schaeffer JA, Gillette C (1998): Brief psychological intervention with traumatized young women: the efficacy of eye movement desensitization and reprocessing. J Trauma Stress, 11(1): 25-44.

Van der Kolk B (1996a): The complexity of adaptation to trauma: self-regulation, stimulus discrimination, and characterological development. From: Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. Eds: B van der Kolk, AC McFarlane, L Weisaeth, pp. 182-213, Guilford Press, New York.

Van der Kolk B (1996b): The body keeps the score: approaches to the psychobiology of posttraumatic stress disorder. From: Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. Eds: B van der Kolk, AC McFarlane, L Weisaeth, pp. 214-41, Guilford Press, New York.

Wilson SA, Becker LA, Tinker RH (1995): Eye movement desensitization and reprocessing (EMDR) treatment for psychologically traumatized individuals. J Consul Clin Psychol, 63(6): 928-37.

Wilson DL, Silver SM, Covi WG, Foster S (1996): Eye movement desensitization and reprocessing: effectiveness and autonomic correlates. J Behav Ther Exp Psychiatry, 27(3): 219-29.

Wilson SA, Becker LA, Tinker RH (1997): Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment for posttraumatic stress disorder and psychological trauma. J Consul Clin Psychol, 65(6): 1047-56.