Exploring Best Practices: The Use of Eye Movement Desensitization and Reprocessing in the Treatment of Trauma Presented by: Jennifer Barr, LCSW Apalachee Center, Inc. FACT Team Leader Tallahassee, Florida This presentation was adapted from the original presentation “EMDR: Eye Movement Desensitization and Reprocessing” co-created by Jennifer Barr, LCSW & Eman Moustafa, LMFT. Disclaimer: THIS MATERIAL IS BEING PRESENTED FOR EDUCATIONAL PURPOSES ONLY. PLEASE BE ADVISED THAT ATTENDEES WILL NOT BE QUALIFIED TO PRACTICE EMDR AFTER THIS TRAINING. What is EMDR? “Eye Movement Desensitization and Reprocessing (EMDR) is an integrative psychotherapy approach that has been extensively researched and proven effective for the treatment of trauma. EMDR is a set of standardized protocols that incorporates elements from many different treatment approaches. To date, EMDR therapy has helped millions of people of all ages relieve many types of psychological stress.” (emdria.org/) ◦ Video: EMDR in Practice: http://www.youtube.com/watch?v=zBtqWrs2-K0 What are your reactions to the video? History & Overview of EMDR Francine Shapiro, PhD, founder 20 years of developing EMDR Adaptive information processing theory Psychotherapeutic approach vs. technique Requires therapist basic clinical skills Basic EMDR protocol Advanced protocols developed (adapted for specific types of trauma: recent events, eating disorder, pain issue, working with children, traumatic grief, chronic childhood trauma/attachment issues, etc.) Understanding Trauma and the Brain Dan Siegel’s brain model (the fist) Brain activation in trauma (think of an “almost car accident”) Memory storage fragmented and state-dependent The terror generalizes to environmental elements (even benign ones) Triggers then initiate similar trauma reactions PTSD: persistent re-experiencing, arousal, and avoidance Normal brain processing is not completed, reprocessing is needed In comes EMDR (the desensitization to combat the avoidance so that reprocessing can occur) It is not in the past, and you can’t just get over it!!! EMDR as a Trauma Treatment Uses the natural processing of the brain (arm injury analogy) Minimizes re-traumatization of the traumatized person Avoidance versus processing (BLS) Traumatic memory fragmentation Actually treats trauma at a biological brain level Memory storage: “hot memory” vs. “bad memory” Processing occurs at a heightened speed, not all elements are discussed as in talk therapy Board analogy – targeting sequence plan Three-pronged approach: Addresses the past memory, current trauma reminders, and future anticipation of trauma reminders Target Populations Empirically researched and validated treatment for trauma ◦ Evidenced-based treatment approach for Post Traumatic Stress Disorder (PTSD) ◦ Recommended by the VA for trauma survivors (“all trauma populations”) Anecdotal evidence for the treatment of phobia(s) and panic disorder(s) ◦ Limited research exists regarding efficacy Is EMDR Effective? Research & Evidence Base EMDR is widely recognized as an acceptable and appropriate treatment methodology for trauma A wide research base exists The research is composed of meta-analyses, random clinical trials, non-randomized studies and other supporting studies A comprehensive list of clinical trials can be found at: EMDR Institute: The Efficacy of EMDR EMDR Endorsements American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines: --EMDR is recommended as an effective treatment for trauma. According to a taskforce of the Clinical Division of the American Psychological Association, the only methods empirically supported (“probably efficacious”) for the treatment of any post -traumatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy. Note that this evaluation does not cover the last decade of research. Department of Veterans Affairs & Department of Defense (2010).VA/DoD Clinical Practice Guideline for the Management of Post –Traumatic Stress. Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense. ----EMDR was placed in the Category of the most effective PTSD psychotherapies. This “A” category is described as “A strong recommendation that clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.” California Evidence. Based Clearinghouse for Child Welfare (2010). Trauma Treatment for Children. http://www.cebc4cw.org. ----EMDR and Trauma -focused CBT are considered “Well-Supported by Research Evidence.” The Research Shows… Jarero, I., Artigas, L., & Luber, M. (2011). The EMDR protocol for recent critical incidents: Application in a disaster mental health continuum of care context. Journal of EMDR Practice and Research, 5,8294.Participants were treated two weeks following a 7.2 earthquake in Mexico.“One session of EMDR-PRECI produced significant improvement on symptoms of posttraumatic stress for both the immediate treatment and waitlist/delayed treatment groups, with results maintained at 12-week follow-up, even though frightening aftershocks continued to occur frequently. Marcus, S., Marquis, P. & Sakai, C. (1997). Controlled study of treatment of PTSD using EMDR in an HMO setting.Psychotherapy, 34, 307-315. Funded by Kaiser Permanente. Results show that 100% of single-trauma and 77% of multiple-trauma survivors were no longer diagnosed with post-traumatic stress disorder after six 50-minute sessions. Rothbaum, B. O. (1997). A controlled study of eye movement desensitization and reprocessing in the treatment of post-traumatic stress disordered sexual assault victims. Bulletin of the Menninger Clinic, 61, 317-334. Three 90-minute sessions of EMDR eliminated post-traumatic stress disorder in 90% of rape victims. Nijdam, M.J. Gersons, B.P.R, Reitsma, J.B., de Jongh, A. & Olff, M. (2012). Brief eclectic psychotherapy v. eye movement desensitisation and reprocessing therapy in the treatment of post traumatic stress disorder: Randomised controlled trial. British Journal of Psychiatry, 200,224-231. A comparison of “the efficacy and response pattern of a trauma-focused CBT modality, brief eclectic psychotherapy for PTSD, with EMDR . . . Although both treatments are effective, EMDR results in a faster recovery compared with the more gradual improvement with brief eclectic psychotherapy. Hogberg, G. et al., (2007). On treatment with eye movement desensitization and reprocessing of chronic post -traumatic stress disorder in public transportation workers: A randomized controlled study. Nordic Journal of Psychiatry, 61,54-61. Employees who had experienced “person-under-train accident or had been assaulted at work were recruited.” Six sessions of EMDR resulted in remission of PTSD in 67% compared to 11% in the wait list control. Significant effects were documented in Global Assessment of Function (GAF) and Hamilton Depression (HAM-D) score. Follow-up: Högberg, G. et al. (2008). Treatment of post-traumatic stress disorder with eye movement desensitization and reprocessing: Outcome is stable in 35-month follow -up. Psychiatry Research. 159, 101-108. For more studies go to: ◦ http://www.emdria.org/associations/12049/files/EMDR%20Research%202013.pdf Components of the Model Phase 1: History taking & Client selection Phase 2: Preparation Checklist Phase 3: Assessment Phases 4-7 (Reprocessing Procedures): Desensitization; Installation; Body Scan; Closure Phase 8: Reevaluation Phase 1: History taking & Client selection The goal(s) of Phase 1 is to collect routine background information about the client ◦ Clinicians use their typical history or intake forms (i.e. Psychosocial Assessment); ◦ Informed consent is obtained; ◦ EMDR is explained and incorporated into the client’s treatment plan The clinician must determine the client’s ability to engage in the EMDR process, as well as the client’s ability to cope with stressful situations Oftentimes, before the EMDR process is started, the client and clinician spend time developing resources and coping skills Phase 1: History taking & Client selection Adaptive Information Processing (AIP) Case Conceptualization The clinician assesses if current symptoms are caused by earlier, unresolved traumatic experiences Single incident/single issue or symptom Multiple issues/symptoms Strengths and deficits are assessed “Target memories” are explored Coping skill building Phase 1: History taking & Client selection Three-Pronged Protocol ◦ Past What incidents are contributing to current problems? What skills are needed? ◦ Present What distressing symptom(s) is the client experiencing now? ◦ Future What does the client want to happen? Phase 1: History taking & Client selection Clinical concerns ◦ Client stability Rule out Dissociative Identify Disorder ◦ Acute presentations substance abuse; suicide; self injury ◦ Stabilization/appropriate coping skills ◦ Medical considerations Medications; eye pain ◦ Time considerations Is the client and therapist available for needed sessions? Phase 1: History taking & Client selection Targeting Sequence Plan ◦ The clinician begins exploring dominant irrational beliefs and developing positive beliefs that will be installed during future sessions Dominant irrational beliefs about the self translate in to negative cognitions (NC) I am a bad person I cannot trust anyone I am weak I deserve to die What the person prefers to believe about the self translates in to the positive cognition (PC) I am fine as I am I did the best I could I am adequate Phase 2: Preparation Phase This phase takes one to four sessions for most clients (for others with traumatized background or other diagnoses, it can take longer) The therapist will be working on three main areas ◦ Establishing a therapeutic relationship of trust between the client and the therapist ◦ Psycho-education: Explain the theory of EMDR, how it is done, and what the person can expect during and after treatment ◦ Teach the client a variety of relaxation techniques for self soothing in the face of any emotional disturbance that may arise during or after a session (Resource Development) When the client is ready, therapist works with client to identify the first target to be worked on (can be a current trigger or past memory) Phase 2: Preparation Phase Resource Development: What does the person need to be able to face the terrifying experience? ◦ ◦ ◦ ◦ ◦ Think of a beloved friend or family member A place of safety A comforting memory or experience A special object A quality of courage, strength, compassion, confidence, love, etc. Using bilateral stimulation (slow movements) to reinforce positive memory networks Relaxation exercises & Self-soothing techniques ◦ Exercise: Calm/Safe place Phase 3: Assessment Setting a baseline before reprocessing Activate memory with image Identify negative cognition or belief Create positive belief (gives hope) The emotions, the body, and SUDS Phase 3: Assessment Select a target memory ◦ “I almost drowned in a pool when I was 14 years old. Image ◦ “The bottom of the swimming pool.” Negative Cognition (NC) ◦ “I am not in control.” Positive Cognition (PC) ◦ “I am now in control.” Validity of PC ◦ Clinician utilizes 1-7 scale Emotions ◦ Terror, out of control, “I am dying” Physical sensation ◦ Tightness in chest, can’t breathe, stomachache Subjective Units of Disturbance Scale (SUDS) ◦ Clinician utilizes 0-10 Phases 4-7 (Reprocessing Procedures): Desensitization; Installation; Body Scan; Closure Phase 4: Desensitization ◦ BLS is used to process the image, using the NC and SUDS ◦ This part can take most of the session or multiple sessions Phase 5: Installation ◦ BLS is used to install the PC; the goal is to have a VOC of 7 Phase 6: Body Scan ◦ BLS is used to process any physical sensations left in the body Phase 7: Closure ◦ It is important to debrief the client and advise that reprocessing may continue after the session ◦ Determine if containment or relaxation exercise is needed by client to tie up loose ends Phase 8: Reevaluation Once reprocessing of the original memory target is complete and client returns in the next session, disturbance related to the re-processed memory is once again assessed Why? Sometimes target was not completed or other material was triggered between sessions ◦ Therapist assesses current level of disturbance ◦ If client remains at a SUDS=0, resourcing or new target may be tackled ◦ If client shows some level of disturbance when the original target is brought up, reprocessing continues with current upsetting image and baseline (NC/PC do not need to be elicited again) Reevaluation occurs throughout course of therapy Light bars are often used to simulate the BLS (visual) BLS can also be simulated while holding pulsating devices (tactile) Finger puppets are often used for BLS with children The client can also listen to music alternating from ear to ear (auditory) How to become a Certified EMDR Therapist From EMDRIA Certification Criteria: 1) EMDRIA Approved Training 2) License/Certification: Show evidence of a license/certification/registration as a mental health professional. 3) Do you have at least two years experience in your field of license/ certification/ registration? 4) Have you conducted at least 50 EMDR sessions with at least 25 clients? 5) Have you received 20 hours of consultation by an Approved Consultant in EMDR? 6) Attach letter or letter(s) of recommendation from one or more Approved Consultant(s) in EMDR, regarding your utilization of EMDR while in the consulting relationship 7) Attach two letters of recommendation regarding your professional utilization of EMDR in practice, ethics in practice, and professional character. 8) Attach certificates of completion of 12 hours of EMDRIA Credits (continuing education in EMDR). 9) EMDRIA's Professional Code of Conduct. Applicants must read and verify on the application form that they agree to adhere to EMDRIA's Professional Code of Conduct. EMDR Resources EMDRIA.org (EMDR International Association for training, membership, research, find a therapist link and therapist support) Emdrhap.org (EMDR Humanitarian Assistance Program: for training, materials, and service work) Emdr.com (EMDR additional training, information and resources) Eye Movement Desensitization and Reprocessing Basic Principles Protocols and Procedures (Book by Francine Shapiro; technical resource for therapists) Getting Past Your Past (Book by Francine Shapiro; offers practical procedures that demystify the human condition and empower readers looking to achieve real change) Other types of Trauma Treatment Prolonged Exposure (PE) Cognitive Processing Therapy (CPT) Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) Art therapy Hypnotherapy Structured Play Therapy Trauma release exercises (TRE) Specialized Massage therapy Other Trauma Training Links EMDR International Association www.emdria.org (training and certification link) National Institute for Trauma and Loss in Children - www.starrtraining.org/about-tlc Cognitive Processing Therapy through the Medical University of South Carolina - cpt.musc.edu/index (free) National Child Traumatic Stress Network www.nctsn.org/resources/training-and-education Trauma-Focused Cognitive Behavioral Therapy through the Medical University of South Carolina - tfcbt.musc.edu (free) Additional Trauma Resources EMDR International Association (emdria.org) Clinician’s Trauma Update (www.ptsd.va.gov/professional/newsletters/ctu-online) The International Society for Traumatic Stress Studies (istss.org) National Center for Posttraumatic Stress Disorder (www.ptsd.va.gov) National Institute of Mental Health (nimh.nih.gov) The PTSD Alliance (ptsdalliance.org) Traumatic Stress Education and Advocacy (www.sidran.org) National Child Traumatic Stress Network (nctsnet.org/resources/topics/treatments-thatwork/promising-practices) Any questions? What will you take away from this presentation? Did you learn anything you can use in your own work? Do you know how to find a certified EMDR therapist for client referrals? Who wants to learn EMDR? Thank you!