Across Australia there is a growing interest in the consequences of trauma in children and adults. In December 2017 the Royal Commission presented a final report after a five-year inquiry into institutional responses to child sexual abuse and related matters. The organised nature and extent of this abuse shocked Australia and the world. We see veterans and first responders struggling for years with posttraumatic stress symptoms. Many of them are heavily medicated, addicted, and unable to work and maintain relationships. When they have seen a psychologist or counsellor, they tend to focus on symptom management but they may not be addressing the underlying trauma – the root of the problem.
Eye movement desensitisation and reprocessing therapy (EMDR) is a key intervention in treating trauma but many psychologists do not have a good understanding of EMDR therapy and this article aims to demystify it. Even though the World Health Organization (WHO, 2013) and the International Society for Traumatic Stress Studies (ITSS, 2019) both recommend EMDR therapy as one of the treatments for adults and children with posttraumatic stress disorder, only recently has EMDR therapy become more recognised in Australia.
Widespread myths around EMDR therapy lacking evidence or being a form of hypnosis have prevented clients access to this effective treatment. Even now, some Australian organisations discourage or forbid the use of EMDR therapy. It was only in 2018 that the APS included EMDR therapy as a Level I evidence-based psychological intervention for posttraumatic stress disorder in adults and Level II for children (APS, 2018).
The use of EMDR with children has been demonstrated to be effective in more than 70 child studies (Barron, 2018; Beer, 2018). A number of randomised controlled trials demonstrated that EMDR therapy matched trauma-focused cognitive behaviour therapy variants in effectiveness and acceptability while outperforming in efficiency (de Roos et al., 2011; de Roos et al., 2017; Diehle, Opmeer, Boer, Mannarino & Lindauer, 2015; Jaberghaderi, Greenwald, Rubin, Zand & Dolatabadi, 2004).
What is EMDR therapy?
EMDR therapy follows standardised procedures. Treatments begin with psychoeducation and mapping out the client’s symptoms, support systems, resources and self-regulation skills. After making an overview of the client’s traumatic memories, for example on a timeline, one of the networks of memories is selected.
Mary, a 23-year-old woman, presents for treatment describing a difficult, traumatic history.
Mary: “domestic violence between mum and dad when I was three to seventeen, sexual abuse by my uncle at the age of 11, sexual abuse by my grandfather from the age of six to nine, bullying in year nine, domestic violence with first partner and a car crash”.
The domestic violence is selected to process first. Mary is asked to provide a brief summary of what happened and then select what has become the worst image in her mind. The psychologist then asks what makes this memory still so disturbing. Clients may report feeling powerless, or they feel it was their fault or that they are worthless. The aim is to change these negative ideas and help the client to understand that it was not their fault, and that despite what happened to them, they are not worthless. Clients then rate how true this positive belief feels now on a 1–7 point scale, with 1 being completely false and 7 being completely true. They usually say it does not feel true at all.
Mary: “I am five and I see myself standing beside mum who is bleeding and I do nothing. Dad is drunk and is yelling and screaming. This was my fault because I should have helped mum and distracted dad. I know it was not my fault, but I still feel so guilty”.
The client is then asked which emotions they feel, to rate their distress on a scale of 0–10, and the location where they feel this distress in their body. The purpose of this whole process is to activate the memory, the associated images, thoughts, feelings and bodily sensations.
Mary: “I feel sad and scared, very scared, about a 9 or a 10 in my stomach”, and she starts to cry and shake.
The clinician then instructs the client to concentrate on the image, think about their negative belief and feel the distress in their body while simultaneously applying a form of bilateral stimulation, most commonly in the form of repeated eye movements. Clients are asked to follow the clinician’s fingers moving left to right in front of their eyes. Every 30–45 seconds the clinician asks the client to briefly describe what they notice and instructs them to continue tracking. Clients report all sorts of associations such as, it is like a movie playing in their head, they think about other memories, they feel afraid, angry, sick or pain in their body. Some report being distracted by the eye movements or they think about other things.
After the first set of eye movements, Mary notices the scared feeling in her stomach getting stronger and she is asked to concentrate on that. After the next set she feels like she wants to vomit and she is asked to concentrate on that. She then remembers the smell of alcohol on her dad’s breath.
Mary: “I see flashes of many other situations. That little girl was only five, she could not do anything”.
The client regularly rates the level of disturbance and the same process is continued until the memory is rated zero and the memory does not affect them anymore. Clients usually say the memory is vague and distant or they cannot really remember it clearly anymore. The client is then asked to rate the believability of the positive belief again. They concentrate on the memory and this belief, while focusing on the bilateral stimulation again. The process is repeated until clients rate the believability as a 6 or 7.
Mary: ”I know it happened and it was terrible growing up like that, but it really feels like it does not affect me anymore. I no longer feel afraid, but strong. My mum and dad’s fighting was not my fault, I know it and it feels very true.”
Generally it takes one or two sessions of 60 minutes to process one memory and the effect generalises to most or all other similar situations. Then the next category can be addressed.
Mary said all the other memories of domestic violence between her parents were also processed in this single session. In the next session she addressed the sexual abuse by her grandfather.
EMDR therapy may seem like an easy job, waving your finger and letting the client do all the work. Obviously it does not work like that. During the 30 to 45 seconds when the client is concentrating on the memory and bilateral stimulation, the EMDR clinician is tuned into the client, notices changes in the client’s body or expression and co-regulates. When clients become too overwhelmed, are not concentrating, get stuck in repetitive thoughts or feelings, the EMDR clinician intervenes to get the client back on track by for example asking brief questions such as “How old were you then?”, “Did you really die?”, “Who was responsible, you or him?” or changing the speed, intensity or length of the bilateral stimulation.
Empowering the client
EMDR therapy is a very empowering technique for clients as they take control to resolve their trauma. They themselves come to more positive conclusions, such as, “It’s not my fault”, “I am worthy”, “I am safe now”. Obviously EMDR clinicians guide the client and assist when the normal processing gets stuck, but from the client’s perspective the actual process goes on inside their own head and they have fixed themselves. The feelings of being able to make changes often generalise to other daily life problems.
How does it work?
Although it is clear that EMDR therapy works, it is still unclear how it works. One of the theories is that our working memory has a limited capacity. Simultaneously retrieving a traumatic memory and following eye movements requires more working memory capacity than is available. Consequently the traumatic memory is not completely retrieved. It is less vivid with fewer associated feelings of fear, anger or sadness. This memory is then stored in the long-term memory, and overwrites the old memory so it remains less distressing.
Who benefits from EMDR?
EMDR therapy is most commonly used to treat posttraumatic stress symptoms but since EMDR therapy changes the meaning and the emotional content of memories, EMDR therapy can be used for any symptom related to memories of experiences in the past. To treat anxiety and phobias the memories of situations where the client has learned to fear something are addressed, reducing anxiety. Depressed clients very often struggle with guilt and shame over adverse experiences where they have failed, felt powerless or insignificant. Processing these memories relieves their guilt and shame and changes their core beliefs.
Research is increasingly exploring the use of EMDR in other psychological presentations and with a range of populations. Australia has been catching up with the rest of the world and the EMDR community in Australia has grown significantly. We now have a strong EMDR Association of Australia, accredited training has become widely available, and one of the leading researchers on EMDR is Australian. Posttraumatic stress disorder does not have to be a chronic condition and clients can recover and heal from their trauma if we provide them with an evidence-based therapy to do so.
The author can be contacted at: [email protected]