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The Carlat Psychiatry Podcast
EMDR in Practice: A Clinician's Guide to Trauma Reprocessing with Roger Solomon, PhD
00:30:33
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- [00:01]
A
Hi, everyone. Welcome back to the Carlat Psychotherapy podcast where we review different types of psychotherapeutic approaches for you in an attempt to better expose you to the wide range of modalities available. This is your host, Abigail Rossell, and today I'm joined by Dr. Roger Solomon to discuss eye movement desensitization and reprocessing, more commonly known as emdr. I'm very excited for this conversation. I think EMDR is an approach that has been really rapidly rising in popularity over the last few years and for good reason. It's been proven to be really successful for PTSD in particular, but also for a number of other psychiatric conditions that we will delve into. Dr. Solomon is a clinical psychologist and psychotherapist who specializes in trauma and grief. He is a senior faculty member of the EMDR Institute where he's been teaching since 1993 after being selected and trained by Francine Shapiro, the original developer of EMDR herself. And since then he's provided basic and advanced EMDR trainings internationally for decades and has really become a leading voice in the application of EMDR for a wide range of psychiatric conditions. He's also authored more than 50 articles, book chapters and books about EMDR, as well as trauma, grief and association. So needless to say, we are very lucky to have Dr. Salomon with us here today to kick off this conversation and I'd like to just jump right into it. So, Dr. Solomon, if you could give us really a brief overview, say to some, somebody who knows absolutely nothing about emdr. What is it? How does it work? Who do you use it for? And then we'll just go from there.
- [01:43]
B
EMDR is an evidence based psychotherapeutic approach that is applicable to a wide variety of diagnoses. EMDR is guided by a theory, the Adaptive Information Processing Model, which states that present problems are the result of past memories that have been inadequately processed. When there is some kind of an event that is too much, that memory can get stuck in the brain, unable to process. There's an assumption here that the brain, like the body, has a tendency to heal. When we get cut, the body heals. When we go through a distressing event. We think about it, talk about it, mull it over, sleep on it, read about it, and it becomes integrated. That is, we discard what's not useful. We retain the information that is useful for survival with appropriate emotion, and this guides our present and future behavior. When something happens that's too much, it interferes with the brain's processing and that Memory gets stuck, frozen in the brain. The images, thoughts, emotions, sensations that were there at the time get stuck in state specific form, inadequately processed. And then when there's some kind of a reminder, the perception that we had at the time comes forward. In other words, the past becomes present. And this is what underlies present problems. So what EMDR does is that we want to access the memory as it's currently stored, bring up that image, the negative belief, I'm not safe, I'm going to die, the emotions, sensations, and then we do dual attention, bilateral stimulation. And by dual attention, what I mean is we hold the memory in mind while we apply the eye movement, tapping, auditory stimulation. So it starts an association process. And what happens is that adaptive information that we have stored in our brain starts to link in to that memory network, holding that maladaptively stored information, allowing that memory with the trauma to integrate into that wider memory network. And with integration, we retain what's useful with appropriate emotion, discard what's not useful, and it becomes a past event.
- [04:26]
A
I'm curious to better understand what exactly does rapid eye movement or tapping, whatever the bilateral stimulation is, have to do with memory consolidation? How do those go together?
- [04:38]
B
So there is research that the bilateral stimulation interferes with the working memory that we have. So when a person is bringing up the problem with a problematic memory and say, the eye movement, it will interfere with working memory. And research shows that the negative images fade and the emotionality reduces. In other words, the memory can be stored in a new way. And that's what we're doing with emdr. We're changing the way that the memory is stored in the brain. And we define trauma very broadly as any distressing event that is still impacting the person in the present. And that could be abuse, but also what didn't happen, neglect, also shame, humiliation, not belonging.
- [05:31]
A
And how do you target those less concrete traumatic memories, ones that aren't just a specific frozen moment in time of a traumatic event or occurrence, but rather these more subjective internal experiences or feelings really of shame, humiliation, for example.
- [05:50]
B
There are big T traumas. For example, in war, there's that moment of terror, I'm going to die, or an auto accident, the car's coming at me, I'm powerless. But there's also what is termed small T trauma, these seemingly small, quite impactful moments of neglect, shaming, rejection. For a small child, this can lead to that belief I'm invisible, I'm not good enough, there's something wrong with me. And for a small child, being alone or not Seeing no comfort is survival fear. So this also is quite impactful. And EMDR therapy can be utilized to treat any distressing memory, from the big P trauma to the seemingly small but very impactful moments that underlie those negative beliefs we may have about ourselves. So that negative belief, I'm not good enough. That's not the cause of a person's problem. It's the symptom. It's the result of previous memories and experiences that get maladaptively stored and get triggered.
- [07:13]
A
I would love if you could take us into the EMDR treatment and walk us through what that looks like in the room for the clinician, for the patient, and also what the EMDR treatment program looks like more broadly. I understand there are different phases to the treatment. Perhaps if you could give us a sense of what each of those are and the role that they play in the treatment and how they all go together.
- [07:35]
B
So EMDR therapy is eight phases which I will describe, and also three pronged. And by that I mean we want to process past memories that have been maladaptively stored that underline the current problem. And then we also will process the more present triggers, the more recent events that trigger the problem. And then we want to provide a future template for adaptive behavior. For example, a person maybe gets nervous at a meeting because I'm not good enough. Where's that coming from? Well, maybe there's a childhood full of shame or rejection, humiliation, giving the person a sense of failure. There's something wrong with me. So these are memories we would want to process, or we use the term to reprocess. Then there's press and triggers. Maybe there was a meeting a month ago that was very stressful. We want to target that. And as a result of processing the past memories, there's a lot of healing. But there still may be, due to second order conditioning, some charge to attending a meeting. So we process more recent memories, those present triggers, and then lay down a positive future template. So now imagine being at a meeting and being able to behave, react, and handle the meaning in an adaptive way. So past, present, future.
- [09:13]
A
So those are the three prongs.
- [09:15]
B
Those are the three prongs. And then it's eight phases. And the first phase is history taking and treatment planning. So a person comes in, I have this problem, I'm socially anxious, or I'm depressed, nervous at a meeting. Okay, what are some recent examples? What are the present triggers? Of course we're going to explore that. And then we also want to take a history. What are the memories? The past Experiences that have been maladaptively stored that underlie the present problem. So we gather information on the negative memories, but we also of course want to gather information positive memories. We're doing assessment not just of what's negative, but also positive resources. We want to look at the whole person and based on the information we collect, we form a hypothesis. And all right, the problems are the result of these memories underlying the problem. The second phase is stabilization and preparation. We want to prepare our client for emdr. So clients come in with very horrific memories. It may be very difficult to start to remember the memories. It can be too much. So part of phase two, preparation and stabilization is teaching the clients self soothing strategies like a safe, calm emotional state. We do resourcing, we can have the client think of a situation or place where they feel safe and calm, or moments they felt confident, competent, good about themselves. And we can enhance these positive feelings, these resources also with bilateral stimulation. And we will also teach whatever coping skills the client may need. You know, clients come in with deficits. For example, I never learned how to express anger. And so EMDR therapy being therapies, of course we want to fill in developmental deficits as well. So certainly let's talk about how to express emotion. So again, we want to order or we want to provide coping skills, stabilization skills, self soothing skills according to the needs of the clients. Some clients are ready fairly quickly. Other clients where there's been a lot of severe childhood trauma, abuse or neglect, may need longer periods of stabilization.
- [11:43]
A
And how do you determine when a patient has stabilized sufficiently so that the EMDR treatment would not be more harmful than helpful?
- [11:52]
B
The basic criteria is the client is able to stay present with the emotions that may come up. An important part of integration is a person has to experience now what was too much then. But of course there's the therapist, there is the preparation, teaching of coping skills, self soothing strategies as well. The basic criteria is being able to stay present and even tolerate some intense emotions. And of course the therapeutic relationship is something that's important. And for many people that can happen very quickly. For other people, maybe where there's a history of never being able to trust anybody or a trauma. So it's difficult to think about what's going on inside. And it may take longer to develop the trust and affect tolerance to be able to go inside and access the memory. These are some of the basic readiness criteria.
- [12:52]
C
Are there particular clients or client presentations that you would say this is just not a candidate for emdr, whether because it would be more harmful than Helpful or because it wouldn't be effective for their particular set of difficulties.
- [13:08]
B
Well, let's broaden what EMDR is. There's different phases. So I talked about history taking, then I talked about preparation. Then there's also memory reprocessing phases. First of all, we're going to integrate whatever therapeutic frameworks and methods are going to help the client. The EMDR therapy is an integrative therapy. So for example, if I'm working with somebody where there are dissociative symptoms, there's certain interventions I'm going to utilize that inform what I'm doing with the client. Stabilization skills and self soothing skills and strategies to start understanding what's going on inside. When I'm working with a traumatic loss, I'm informed by frameworks for grief and mourning that will inform your treatment. So if somebody comes in, they're not ready for memory processing, we spend more time in phase two and we can bring in EMDR elements.
- [14:03]
C
So let's get back to those. I think we had phases three to seven or three to eight remaining, which you called the memory reprocessing phases. If you could take us through those
- [14:11]
B
a little bit, the memory reprocessing phases. Phase three we call the assessment phase. And what we're doing here is we're accessing the memory that we are going to target with EMDR therapy. This is access and target identification. That's the formal name. So we want to access that memory as it's stored in the brain. Remember that memory is maladaptively stored. And what we want to do is access it so we can start reprocessing. So how do we access it? We ask what image represents the worst part? Then we want to get that negative cognition, the negative irrational belief the person has about themselves. I'm not good enough. I'm not safe. I'm powerless. I don't belong. Then we identify a therapeutic goal, a positive cognition. So I'm not safe. I'm safe today if the negative cognition is I'm powerless. Positive cognition, I have choices. So this is a therapeutic dialogue to identify the negative irrational belief about the self. And then we identify that therapeutic goal. Because if we process the negative memory, there will be adaptive information and positive belief that will arise.
- [15:33]
C
So are you doing this separately for each memory that the person needs to work through?
- [15:38]
B
Yes, we are. We're starting with one memory at a time, and we're starting with that specific moment in time and accessing this one specific memory. It starts to get us into the whole memory network. So again, we Talked about the image, we talked about a negative cognition, positive cognition. And then we take a measurement. When you bring up the memory, how true do those positive words, I'm safe or I'm good enough feel? A one to seven scale. One false. Seven true. So in the beginning, that negative belief resonates more. So that positive cognition, I'm safe. Today I know in my head it's true, but in my gut, on a one to seven scale, it feels like a three. So that's a measurement. Of course, by the end of treatment, we want it to be seven. All right, so we have that image, negative, positive cognition, that scale. We call it validity of cognition. One to seven. One false, seven true. Now we're going to get the emotions and then we're going to take another measurement. Subjective units of disturbance. How disturbing is it? 0 to 10. 0 being calm. 10, the worst it could be. And then finally, where do you experience the distress in your body? So that's how we access the memory as it's stored in the brain. Then we're going to start doing the bilateral stimulation reprocessing. So we ask the client to bring up that image, that negative belief, notice the sensations, and then we start with sets of bilateral stimulation. The eye movement, according to research, is the most efficient for most, not everybody. Some people will respond better to the tapping or auditory. We start the eye movement and that may be anywhere from 20 to 30 seconds or a minute. And we fine tune it to the client. We'll do a set, okay, pause, take a breath. What do you notice? And then the client gives us feedback. And if things are moving, changing and shifting, we do another set. So what's happening, just briefly, is that as we start to stimulate the brain's information processing mechanisms through the bilateral stimulation, adaptive information starts to link in and so that distress level starts to go down. And so there we take a measurement. The goal is zero calm. Maybe it be that ecologically adaptive one. Like for example, with grief, a good person died, so it's a one, not a zero. Then we're ready for the next phase, phase five, the installation phase, where we bring up the memory and that positive belief, I'm safe today, hold them together and we continue the processing. We're focusing on the positive cognition, doing sets of bilateral stimulation, measuring the effect by that 1 to 7 scale. And, and the goal is that they can bring up the memory, that positive belief, I'm safe today, I'm good enough. And it feels true on one to seven scale, seven. So the negative distress is down. That positive Cognition feels true. And then we do a body scan. That's a final check to bring up the memory positive cognition and scan your body and let me know if there's any unusual sensation, if there's any disturbance, and if there is, we continue to process that. So clear body scan. So sub zero voc seven body scans clear. And then we want to do a closure. We won't always complete the processing in one session, so we want to be sure the client is grounded. So we will do methods to ground the client that were taught in the second phase of EMDR therapy, preparation and stabilization. So we'll do breathing exercises, we'll bring in the resources that ground the client according to what's needed. And then we also prepare the client for what may happen during the week. Because we scraped out the beaver dam, other memories may come up and client can use their other coping methods that we've talked about. And we encourage clients also to keep a log of what comes up. Where do they get triggered during the week? When are their memories may come on up, what dreams do they have? And then at the next session we talk about it. And that's phase eight, re evaluation. We ask what happened during the week, and we also evaluate if the treatment effects from the last session had maintained and what else has come on up. Okay, what else has happened or come on up. And that's how we determine what we will do for this next session. Okay, so that's just a nutshell of the eight phases of EMDR therapy.
- [20:18]
A
And how would you go about selecting which memory to work with or which memory to start with for a patient who may have a really prolonged trauma history or multiple traumatic memories?
- [20:29]
B
So again, this is the history taking. We identify the problems that a person has, what's happening, what are the present triggers, and then we identify the memories that underlie the present problem. And that's how we select which memories. Start with if it's a problem having to do with self esteem, for example, we want to start with these earlier memories that gave rise to that negative belief, I'm not good enough, there's something wrong with me. If it's a traumatic event, then of course we can go in and process the robberies, the tornadoes, war experiences.
- [21:09]
C
Probably a lot of the clients that you work with are not necessarily clients that have been through one capital T trauma, but rather ones that have more prolonged traumatic experiences, whether it be childhood abuse or neglect, but really people who have been through years and years of trauma and have an abundance of traumatic memories stored up. And so in Situations like that is the idea that you need to systematically work through every single traumatic memory that there is. Or once you work through whatever set amount or certain amount, those being resolved sort of symbolically resolves the others as well, if that makes sense.
- [21:49]
B
There is a generalization effect. Memories of my parent not picking me up from school, or these are memories of finding my parent passed out. And we can group these and cluster them and target a representative memory or that worst memory. And what we find is that there'll be some generalization through that cluster. Of course we want to check to be sure, but we do get a generalization effect so we don't have to target each and every negative memory a person has. Each time that we're able to successfully process a memory, there's a generalization effect, but there's also a rise in integrative capacity as well along the healing journey.
- [22:28]
A
One of the things that we know about trauma is that a common traumatic response is to block out a lot of the distressing memories. And at the same time, EMDR relies on really being able to consciously bring up those traumatic memories. So I'm curious if there's any way to make EMDR work for individuals who have blocked trauma out.
- [22:48]
B
Yes, there is. So first of all, let's understand that now we're talking about complex trauma. So somebody coming in says I don't have memories, then I know there's a complex process going on. There may be detachment, avoidance, suppressing affect, because that was the best survival strategy in childhood. And so a person starts to come on in and they may say, I don't have memories, but they are coming in with problems. Problems in relationships, problems in regulating affect, problems in everyday living, problems in self esteem. So we will start where the client's at. And again, if there aren't memories, that's all right. We start dealing with whatever problems in life are there, teaching coping skills. And we can also use EMDR therapy enough the client meets the readiness criteria on the more recent problems we can do again, resourcing, safe state exercise, ways to calm. We can teach skills, we can teach home solving to deal with problems in living. And we can also use EMDR therapy in very gentle, in very focused ways on present triggers. Also what we would be doing with these clients is building the integrative capacity by building up not just external resources and coping, but also internal resources. So think of a moment you felt confident, competent, good about yourself, a moment of success, something like that. And then we have specialized methods to add the bilateral stimulation to enhance that positive Affect. So these are things that we would be doing in the preparation and stabilization phase. Raise integrative capacity and resource, the client, teach coping skills. And as healing starts to occur, then we start to get to the underlying memories. And of course we're going to go at the pace of the client. We're not there to go and rush it. And also, of course, the therapeutic relationship is important in creating safety so the client feels safe to explore what's going on inside.
- [24:55]
C
And so the idea is that as you continue working in this second phase of really building stabilization and the sense of safety and resilience, that once the client feels safe and strong enough, those memories would naturally come out at the right time.
- [25:10]
B
That is the idea. And of course, there's a number of different frameworks that can integrate with EMDR therapy or inform EMDR therapy that will help us work with the complex situations too. There is the complex trauma. There can be a division in the personality. There's going to be one side of the person that engages in everyday life, but there could be another side of the client that that's holding the memory, reliving, experiencing it. And there's such avoidance and maybe not able to remember it. So we know we can work with the different sides of the person without opening everything up or stabilization and also creating the atmosphere where the memories can start to come on up and the person is within that window of hollow.
- [25:55]
C
In terms of zooming out and what the complete EMDR treatment protocol looks like, is there any sort of timeline that we're looking at in terms of number of sessions for successful treatment? Is it really individual to the person and the amount of trauma and their access to memories, what does that look like?
- [26:15]
B
So it depends on the person. Now, if a person's coming in with an acute trauma, an auto accident, a robbery, an assault, and then assuming that there's not a history of trauma, the research shows that with these clients that with three to six sessions, six 90 minute sessions, person no longer will meet criteria for PTSD. They still may need other sessions to deal with other problems. For example, I worked with a man who worked in a mine and there was a cave in and he was injured. So I worked with him and in two sessions he no longer was having the nightmares and the flashbacks. However, more sessions were needed because he felt guilty for the burden he put on his family. Because he was injured. He also had anger about the accident. So what I'm saying is those three to six sessions we can treat, that memory will no longer meet criteria for ptsd. But of course it's going to be integrated within an overall therapeutic framework. So I'm certainly not going to say recessions. You're done. It could be, but there may be other issues to address. Now, on the other end, when somebody's coming in with a history of abuse and a history of neglect, haven't trusted, never trusted anybody before. That's going to be, of course, a longer process. So that's why, again, we're going to adapt EMDR therapy according to the needs of the client. We will go at the pace of the client. But I can say this, that EMDR therapy is effective and efficient in reprocessing these negative memories. And it goes deeper than words. EMDR therapy goes to places words don't go. Trauma gets stored in the brain, places words don't go. And EMDR will get to that level of affect to be able to reprocess that memory. So it does become integrated in ways that are more efficient than talking therapy alone.
- [28:14]
C
Absolutely. As I was reading about it, that's also one of the things that struck me about EMDR is it almost feels more raw, in a sense, when you are in a more traditional therapy setting. There's almost a filter between what goes on internally in the memories and what you're working on, because that filter is how you're articulating or interpreting or sharing whatever it is you're dealing with. Whereas here you're really just getting into the most raw depths of that experience inside of you. And so, like what you were saying, it gets somewhere that we, with words are not able to. And I think that's one of the things that makes it rather unique. We don't really have another modality that does something like that, at least not one that I'm familiar with. I'd like to close off with just a general question of any sort of guidance that you would be able to give a clinician that's listening to this episode and this is a treatment that they'd like to learn further about, perhaps add to their repertoire what's a good place for them to start.
- [29:13]
B
Therapy is an effective therapy. And because it's an effective therapy, it's very important that the clinician have effective training. So it's very important that they go to a training that has been certified by the EMDR International Association. Be sure that you're getting trained by a trainer who has been credentialed by EMDR International association or the EMDR Europe association or EMDR EMDR Australia, New Zealand, to. Because there are imposter trainings there is the EMDR International association that is kind of like the watchdog organization that sets standards for who can be trained. You have to be a licensed therapist, graduate student in a licensable track under supervision, and they also credential the person who does the training.
- [30:12]
A
Well, thank you so much, Dr. Salman, for joining us. And thank you to our listeners for following along. We'll see you back here soon.