Expert Answers on E.M.D.R. Updated

THE NEW YORK TIMES

July 30 | Updated Dr. Shapiro responds to additional reader questions about E.M.D.R. and fibromyalgia, memories of child abuse, the costs and length of treatment, controversies surrounding the treatment, whether its effective for sexual perpetrators, and more. See her responses below.

May 10 | Updated Dr. Shapiro responds to additional reader questions about E.M.D.R. and personal relationships, treating clients with autism, sports performance and job interviews, and whether E.M.D.R. can be done in groups. See her responses below.

Apr. 10 | Updated See Dr. Shapiro’s additional responses to questions about E.M.D.R. and war trauma, broken relationships, The E.M.D.R. Humanitarian Assistance Programs and more, below.

Mar. 26 | Updated Dr. Shapiro responds to additional reader questions about E.M.D.R. and false memories, addictions, a cancer diagnosis, therapy in children and more.

Recently, readers of the Consults blog posed questions about eye movement desensitization and reprocessing, or E.M.D.R., a psychological therapy pioneered by Francine Shapiro that uses eye movements and other procedures to process traumatic memories. The therapy has been used increasingly to treat post-traumatic stress disorder and other traumas. You can learn more about what E.M.D.R. therapy is like here.

Below, Dr. Shapiro addresses reader questions about clinical applications of E.M.D.R., including how the therapy is done, what types of trauma it can treat, whether it helps anxiety or chronic pain, and more. Dr. Shapiro wrote about scientific studies on the therapy in an earlier post, “The Evidence on E.M.D.R.”

E.M.D.R. and Post-Traumatic Stress Disorder

Q. Please explain the mechanics of how P.T.S.D. occurs and why. Why is it some soldiers end up with P.T.S.D.? Why is it that not everyone raped gets P.T.S.D.?
NANA, Dania Beach, FL

A. Dr. Shapiro responds:
Post-traumatic stress disorder, or P.T.S.D., occurs when an experience is so disturbing that it disrupts the information processing system of the brain. This system has as one of its main functions the transformation of disturbing experiences into mental adaptation. That is, it takes a disturbing event and processes it in such a way that appropriate neural connections are made within the memory networks, which eliminate those aspects of the event (for example, negative thoughts, unpleasant emotions and physical sensations) that are no longer useful.

Sometimes, however, the event is so disturbing that the system is unable to perform these natural functions. The result is that the memory of the incident is stored along with the psychological and physical aspects of the event, including the negative beliefs that it engendered. Such an unprocessed traumatic memory may be stimulated by a current experience, and the encoded negative emotions, thoughts and sensations can emerge and color the perception of the present.

The reason that some people are affected more than others depends on genetics, the intensity of the experience, length of exposure and earlier life experiences. Some people have had positive experiences that contribute to greater resilience. Others have had negative experiences that can make them susceptible to later problems. For instance, an official diagnosis of P.T.S.D. requires that the individual experience a major trauma, like a rape, accident or battlefield experience. However, recent research indicates that in many cases, P.T.S.D. symptoms can occur as the result of less dramatic events. Some examples are hurtful childhood experiences with parents and peers, which can have a very negative effect on a person’s sense of self-worth. These events can set the groundwork for a wide range of symptoms, including a vulnerability to P.T.S.D.

E.M.D.R. and REM Sleep

Q. Please explain the process of R.E.M. and E.M.D.R.
NANA, Dania Beach, FL

A. Dr. Shapiro responds:
A Harvard researcher has suggested that the eye movements used in E.M.D.R. seem to stimulate the same processes that exist in rapid eye movement, or R.E.M., sleep. R.E.M. occurs in the same stage of sleep as dreaming, and during this time, scientists believe, the brain processes survival information. The implication is that, like R.E.M. sleep, the eye movements of E.M.D.R. facilitate the transfer of episodic memory, which includes emotions, physical sensations and beliefs associated with the original event, into semantic memory networks, in which the meaning of the event has been extracted and negative associations are no longer present.

The proposed link between E.M.D.R. eye movements and R.E.M. sleep has now been the subject of about a dozen randomized studies. Supporting the hypothesis were findings that E.M.D.R. eye movements decrease physiological arousal, increase episodic associations and increase the recognition of true information. Despite these results, many questions remain about the underlying mechanism for the effects of E.M.D.R. This is not a unique situation, however, since the neurobiological explanation for any form of therapy, and even many pharmaceuticals, remains obscure.

In addition, see my earlier post, “The Evidence on E.M.D.R.,” for information about studies on E.M.D.R. and R.E.M.

How E.M.D.R. Is Done

Q. Will you articulate to me and to the people here how you describe the E.M.D.R. process and protocol?
NANA, Dania Beach, FL

A. Dr. Shapiro responds:
The eight phases of E.M.D.R. therapy begin with history taking, in which the presenting problems and early clinically significant life events are identified, and goals for the client’s fulfilling future set. The next phase involves preparing the client for memory processing. During processing, the client is directed to attend briefly to certain aspects of the memory while the information processing system is simultaneously stimulated. During this phase, the client engages in periodic sets of eye movements (sometimes taps or tones) for approximately 30 seconds each. It is during this time that the process of transforming the “stuck memory” into a learning experience and an adaptive resolution is observed. New and useful emotions, thoughts and memories emerge, and old and counterproductive ones are resolved. For example, the feelings of shame and fear voiced by a rape victim at the beginning of an E.M.D.R. session may be replaced by the feeling that she is a strong and resilient woman. E.M.D.R. therapy specifically addresses issues involving the past, present and future.

You can learn more about the process of E.M.D.R. therapy here.

E.M.D.R. vs. Other Therapies for Trauma

Q. How is E.M.D.R. different from other kinds of therapies for trauma victims?
BizB, Rockville, MD

A. Dr. Shapiro responds:
Besides E.M.D.R. therapy, very few trauma treatments have a strong empirical basis. Two others that are well known are prolonged exposure therapy and cognitive processing therapy. Both are forms of trauma-focused cognitive behavior therapy, which require clients to describe in great detail their traumatic memory.

In prolonged exposure therapy, clients must describe the memory as if it were happening to them in the present. They repeat this two to three times during the session while an audio recording is made. The rationale for this form of treatment is that the reason clients’ problems persist is that they are avoiding reminders of the instigating events. Therefore, it is considered important for them to learn firsthand that they can experience the distress without being overwhelmed. Likewise, they are required to do daily homework between sessions that consists of listening to the recordings of their description of the event and visiting locations associated with it, to cause the disturbance to dissipate.

In cognitive processing therapy, clients are asked to provide details about the traumatic event so that their negative beliefs can be identified and then challenged and changed. This occurs during sessions and by doing daily homework assignments.

In contrast to the preceding treatments, the emphasis in E.M.D.R. is to help the information processing system make the automatic connections required to resolve the disturbance. Specific procedures are used to help clients maintain a sense of control during memory work as the therapist guides their focus of attention. They need only focus briefly on the disturbing memory during the processing while engaged in the bilateral stimulation (eye movements, taps or tones) as the internal associations are made. The client’s brain makes the needed links as new emotions, sensations, beliefs and memories emerge. All the work is done during the therapy sessions. It is not necessary for the client to describe the memory in detail, and no homework is used.

E.M.D.R. and Childhood Trauma

Q. I sought out an E.M.D.R. practitioner for the lifelong problems I’ve had from having rejecting, abusive parents. Do you agree that E.M.D.R. isn’t a good choice for someone like me? What do you suggest for someone with a difficult history like mine, who has been chronically anxious since very early childhood?
Shaun, Grand Rapids

Q. Why do some think E.M.D.R. isn’t helpful with childhood trauma? From what my therapist told me, it sounds like it is often used with individuals with issues stemming from childhood. Isn’t that the point? But in the past I’ve heard that it may not be indicated for P.T.S.D. related to chronic trauma over a period of years, particularly when the trauma was sustained in childhood. Is that true? If so, why or why not?
Ernest K, Denver

Q. Have there been changes in your E.M.D.R. methods over the years to address some of the questions being raised in this forum — specifically for treatment of people with complex trauma (multiple traumas) and childhood traumas like sexual abuse or neglect?
benslow, USA

A. Dr. Shapiro responds:
E.M.D.R. therapy is widely used to treat chronic childhood trauma survivors. However, with this presenting problem, it often takes longer than with adult trauma victims for the client to feel secure and safe enough to do memory processing. Further, because of the larger number of events and earlier onset for childhood trauma victims, the processing work itself generally takes longer.

As I noted above, E.M.D.R. therapy is an eight-phase approach. The first two of these phases — history-taking and preparation — need to be more extensive with multiply traumatized survivors of childhood abuse than with adult trauma survivors. Stabilization and the development of skills and self-capacities, like the ability to self-soothe and tolerate emotions, are the primary focus in the preparation phase of E.M.D.R. treatment. There are often fears related to emotion and connections with others that must be addressed during the early phase of treatment before a survivor is able to move into work that focuses on the past.

E.M.D.R. therapy targets the way in which memories are stored in the brain. These include “takeaway” messages, like “I’m not good enough,” “It’s not O.K. to ask for what I want” and “I’m powerless to protect myself.” These feelings and beliefs are based on the child’s perceptions at the time of the experiences, whether they involved a major traumatic event like the loss of a parent to death or divorce, or something less dramatic but more insidious, like a daily diet of criticism or fear that something bad is going to happen.

The amount of exposure to bad experiences affects the development of symptoms. In general, the more severe and longer the exposure and the younger the age at exposure, the greater the impact will be in the form of pervasive and debilitating symptoms. Not always, but often, the amount of time needed for therapy also depends on whether the person has had any positive role models and significant figures who were supportive and nurturing. When these have been lacking, more time will generally be needed for preparation and comprehensive treatment. For some clients, this process will take longer because they have more negative experiences to process. For others, more stand-alone experiences occurred that changed the course of their lives. And, of course, there’s everyone in between.

These childhood traumatic memories and the pain and symptoms associated with them can be systematically reprocessed over time with E.M.D.R. The bottom line is that given an opportunity, the information processing system of the brain will move toward health.

E.M.D.R. therapy is used extensively in the treatment of chronic victimization and childhood traumatization. In fact, a study conducted by a large H.M.O. reported that within 12 sessions, 77 percent of multiple trauma victims treated with E.M.D.R. lost the diagnosis of post-traumatic stress disorder (Marcus et al., 1997, 2004). Another study with adult survivors of childhood sexual abuse also found it to be effective (Edmond et al., 1999, 2004). Both adult and childhood abuse survivors are represented in most studies that involve participants with mixed forms of trauma, and 20 randomized studies have found E.M.D.R. therapy to be effective in the treatment of P.T.S.D.

However, as mentioned above, the amount of treatment needed will vary depending on the type of trauma and how pervasive it was during childhood. For instance, one study compared eight sessions of E.M.D.R. therapy with eight weeks of Prozac with multiply traumatized adults. It reported that after treatment, 100 percent of adult-onset participants treated with E.M.D.R. no longer received a P.T.S.D. diagnosis, and 75 percent of the childhood-onset E.M.D.R. participants no longer had that diagnosis. But losing a P.T.S.D. diagnosis is only part of the story; at the six-month follow-up, the E.M.D.R. group continued to improve, while the Prozac group became more symptomatic. At that point, 75 percent of the participants treated with E.M.D.R. who were traumatized as adults were symptom-free, compared with 33.3 percent of the E.M.D.R.-treated group traumatized in childhood; everyone in the Prozac group continued to be symptomatic.

In clinical practice it is to be expected that more than eight sessions will be needed for successful treatment of childhood abuse, as comprehensive E.M.D.R. therapy addresses the entire clinical picture. The goal is not only to remove symptoms, but also to bring clients to full emotional health and fulfillment, both individually and in their personal relationships. Initial results from research under way reveal positive effects after approximately 24 sessions for those suffering from severe childhood abuse. These results support clinical observations that although many victims of childhood trauma will need comprehensive E.M.D.R. therapy, significant benefit can be observed within a few months after starting memory processing. It’s also worth noting that once processing begins, it is unnecessary to address each and every memory; treatment effects will generalize from a given memory to other similar events.

In all cases, a three-pronged approach should be used that addresses earlier experiences of abuse, current situations that trigger disturbance, and the skills and education necessary to ensure that the person is not only symptom-free, but able to flourish and thrive in the world. When someone has had an extremely difficult childhood that includes neglect or abuse, it is important to interview prospective clinicians to find someone who is experienced and well trained in phase-oriented trauma treatment for chronic childhood abuse and the use of E.M.D.R. therapy. Ideally, the clinician chosen will also be someone who stays informed with regard to the newest developments in treatment.

Who Does E.M.D.R.?

Q. Is it possible to do E.M.D.R. treatment to friends or relatives if one identifies that the person needs E.M.D.R. treatment?
Mekdes, Ethiopia

Q. Even though I am a certified hypnotherapist and possess a master’s in health administration, I am not allowed to become an E.M.D.R. practitioner myself. Why not?
Julietta, NY

A. Dr. Shapiro responds:
E.M.D.R. therapy is taught only to people who are licensed to provide mental health services in their state. There are a wide variety of techniques from E.M.D.R. therapy that I have included in my new self-help book, “Getting Past Your Past” (Rodale, 2012). However, in this country, major memory processing with E.M.D.R. therapy should be conducted only by a licensed therapist who has had training approved by the E.M.D.R. International Association (www.emdria.org), an independent professional association that sets the standards for all E.M.D.R. therapy training conducted in the United States.

Comparable organizations exist in most countries worldwide, as well as regional organizations like E.M.D.R. Europe (www.emdr-europe.org), E.M.D.R. Asia (www.emdr-asia.org) and E.M.D.R. Iberoamerica (emdriberoamerica.org).

It is widely accepted in the field of psychology that training in any therapy being performed is ethically mandatory. However, clinicians may have been misled in their choices. Unfortunately, there are a number of substandard trainings being conducted in the United States that don’t meet the international associations’ criteria. Therefore, potential clients should interview clinicians to ensure they received the correct training and have experience with their problem, and inquire about their success rate.

E.M.D.R. and Epilepsy

Q. Can E.M.D.R. be safely used in patients with well-controlled epilepsy, and can it be successful in increasing seizure thresholds and/or eliminating the cause of the seizures (assuming no cerebral lesions cause the seizures)?
KFJ, NYC

A. Dr. Shapiro responds:
To my knowledge, there have been no negative reports using E.M.D.R. therapy with epilepsy patients. However, I suggest that the person work with an experienced clinician who can be sensitive to any potential negative reactions. The therapist should also carefully review with the client the cautions described in my text, “Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures,” so the person can make an informed choice.Two articles have been published that have reported successful results in the E.M.D.R. treatment of psychogenic seizures.

E.M.D.R. and Anxiety

Q. My teenage son has had E.M.D.R. therapy for anxiety attacks that were very limiting in his ability to progress (go for job interviews, attend college classes that were intimidating to him). After a period of time here he seemed to improve, he stopped going to therapy and said he felt only life experiences would help him overcome some of his anxieties. After not seeing a therapist for a year, he told me today that he thought he needed to return. Is this a common result? Are patients ever “cured” through E.M.D.R. therapy, or will some patients need recurrent therapy throughout their lives?
monkeyboy, Kansas

A. Dr. Shapiro responds:
I believe the problem here is that your son terminated therapy prematurely. Some clients stop because they feel better and then want to do the rest on their own. However, the full protocol for E.M.D.R. treatment involves (1) processing the memories that set the foundation for the problem, (2) processing the current situations that trigger disturbance and (3) incorporating the experiences into the memory networks that are necessary to overcome skill or developmental deficits.

With longstanding anxieties, this would involve venturing out and noticing any new anxieties that arise. These would be addressed with further processing, since some anxiety responses are not revealed within the confines of the therapy session alone. For stable treatment effects, your son should address his various anxiety issues using this full application of E.M.D.R. therapy.

E.M.D.R. and Pain

Q. I am a physical therapist specializing in the treatment of complex and chronic pain. Modern pain science views pain as an output of the brain, and there are novel therapies developed within my field to retrain the brain. Many (though certainly not all) of my patients also have a history of trauma. Is there any research (including functional M.R.I.) showing the effects of E.M.D.R. on chronic pain or on centers in the brain particularly associated with pain processing?
Helen Gattling-Austin, Charlottesville, VA

Q. I’ve read about and experienced the resolution of some traumas using E.M.D.R., but can E.M.D.R. resolve chronic pain that resulted from a physical injury?
Sally Stone, Northbrook, IL

A. Dr. Shapiro responds:
In the book “Practical Pain Management” (2001), A. L. Ray and A. Zbik have a chapter that describes their use of E.M.D.R. therapy for chronic pain. The authors note that the application of E.M.D.R. that is guided by a theoretical formulation known as the adaptive information processing model appears to provide benefits to chronic pain patients not found with other treatments. Specifically, rather than merely managing pain, the treatment often substantially reduces or eliminates it. This occurs because applications of E.M.D.R. therapy have revealed that the pain is frequently caused by the memory of the experience during which the injury took place.

E.M.D.R. therapy cannot remove pain caused by nerve damage. However, many types of pain that seem to have an organic cause are actually the result of “pain memory.” For instance, four researchers have independently published articles detailing the successful treatment of “phantom limb” pain. The aggregate of these, as well as anecdotal reports, indicates an 80 percent success rate involving the substantial reduction or elimination of the phantom pain once the trauma memory has been processed. Follow-up assessments reported as long as two years later have revealed stable results. Unfortunately, no brain scans were performed, and no randomized trials have yet been conducted on this topic.

Long-Ago Trauma?

Q. Is E.M.D.R. effective even if the event took place 15 years ago?
Kelly, Atlanta

A. Dr. Shapiro responds:
Yes, E.M.D.R. is effective regardless of the time since the event. The unprocessed memory remains stored in the brain. However, it can be accessed and successfully processed.

A year ago, an 80-year-old survivor of World War II asked her clinician to contact me. She had lived through numerous traumas during the war in Japan (bombing, rape, losing her mother and father) and had lived a life of “quiet desperation.” However, recently she had become severely dysfunctional because her husband had developed a hearing problem, and his shouting and playing the TV at a loud volume were bringing back reactions that emerged out of the chaos of the war years. This inability to cope any longer is often what brings people into therapy. After the traumas were processed, she told her clinician, “I feel free for the first time in my life.” Even at 80, her brain was able to “digest” and store appropriately the unprocessed information that had been embedded for the past seven decades. It’s never too late.

Mar. 26 | Updated: Dr. Shapiro responds to additional reader questions about E.M.D.R.

Stored Memories and E.M.D.R.

Q. You write: “Many people feel that something is holding them back in life, causing them to think, feel and behave in ways that don’t serve them. E.M.D.R. therapy is used to identify and process the encoded memories of life experiences that underlie people’s clinical complaints.” ?In my experience this feeling of being held back is common to people in general, not just those who have experienced a traumatic event.

Can E.M.D.R. be helpful even if people don’t remember specifically the traumatic event (example: abuse as an infant)? Or helpful to people who have had a traumatic event and remember it but do not necessarily associate it as being traumatic?
c.r., Brooklyn

A. Dr. Shapiro responds:
Recent research indicates that general life experiences can actually cause even more post-traumatic stress disorder symptoms than major trauma. In fact, our memory networks are the foundation of most clinical complaints.

While genetic defects or organic insults, like those caused by injuries or toxins, can certainly contribute to dysfunction, research indicates that life experiences are also generally involved. Childhood humiliations, rejections, disappointment, bullying by peers, insensitive actions by authority figures and parental fights can be so disturbing that they disrupt the brain’s information processing system. The experiences then become stored as unprocessed memories and set the groundwork for later dysfunction. These stored memories include the emotions, physical sensations and beliefs that were experienced at the time of the original event. When something happens in the present, it can trigger this memory and shape our current perceptions and actions.

In E.M.D.R. therapy, we use specific techniques to help identify the memories that underlie the problems so they can be processed. At other times, by focusing on the present disturbance during processing, the earlier event will automatically emerge because of the associations in the memory networks. If the event took place too early in life for it to be encoded with a visual image, implicit memory processing still occurs, as evidenced by the elimination of the symptoms. So, regardless of the events in the person’s history or how he or she currently views them, E.M.D.R. therapy can be useful as the appropriate connections are made during the information processing sessions.

False Memories and E.M.D.R.

Q. As a therapist, I work with a number of patients who were abused as children. As such they may have also created false memories in this process. How useful would E.M.D.R. be as treatment for them?
Ibialik1b, laguna hills, ca

Q. Can E.M.D.R. prompt memories of past trauma to emerge? Can E.M.D.R. cause the creation of false memories?
KJ, Seattle

A. Dr. Shapiro responds:
All memory is fallible. During E.M.D.R. memory processing, associated memories may arise, but as with any form of therapy, there is no assumption without corroboration that they are true.

For instance, one of my clients came to me claiming that she had been raped by the devil when she was a child. During processing, she recognized that it was someone in a Halloween costume. However, if the memory had emerged on its own during processing, there would have been no assumption that it had actually been the devil.

Likewise, another client entered therapy concerned that perhaps her father had molested her, because she felt herself being held down and saw his face. During memory processing she remembered being attacked in a barn by some adolescents, and her father had come in to rescue her. She realized that this was the image of her father that she had been remembering. She was able to corroborate that this event had actually happened by asking her mother about it.

Many “false memories” can be created throughout childhood by a variety of causes. In addition to abuse, children may hear a story or see something on TV and come to believe it happened to them. These vicarious experiences may then be stored accordingly.

Processing during E.M.D.R. therapy can allow these images to dissolve as the brain makes the appropriate connections. In talk therapy, false memories can sometimes be created through the inadvertent suggestions of the therapist, but this is unlikely in E.M.D.R. therapy because the clinical input is minimal while the client’s brain makes the appropriate internal connections.

Some of the randomized controlled research conducted on the eye movement component of E.M.D.R. has also indicated that it causes an increased recognition of positive information, and an increased accurate assessment of false information. Further research will determine to what degree these findings also enter into the memory processing outcomes.

Addictions and E.M.D.R.

Q. You mentioned that this can help people who “behave in ways that don’t serve them.” Could this help someone who is trying to quit drinking, or with other types of addictions?
Mamie Hetherington, Ontario

A. Dr. Shapiro responds:
It is now widely recognized that there is a relationship between addictions and trauma. There is also recent research indicating that general life events can cause even more P.T.S.D. symptoms than major trauma. So whenever we observe addiction in a client, the next step is to determine the earlier life experiences that might be causing the person to “self-medicate.”

There can be a wide range of such experiences, from a very disturbing one-time event during adulthood or childhood to pervasive abuse or neglect, especially from an addicted parent who raised the child and modeled that behavior. Life can also be problematic for those whose parents modeled the substance-abuse behavior and simultaneously failed to teach them how to deal with their own negative emotions. E.M.D.R. therapy processes the past experiences that are causing the emotional pain and the current situations that trigger the desire to use, while incorporating what is needed by the client to make healthier choices in the future.

The Thurston County Drug Court Program in Washington State initiated a randomized study to evaluate a combination of Seeking Safety, a “present-focused” cognitive behavior therapy treatment designed to help people struggling with both P.T.S.D. and substance abuse, and E.M.D.R. therapy. In this particular program design, Seeking Safety was used to establish safety and stabilization before moving on to individual trauma treatment with E.M.D.R. The combination of Seeking Safety and E.M.D.R. was intended to be compared against Seeking Safety without E.M.D.R. plus the drug court “program as usual” treatment services, which consisted of other types of weekly cognitive behavior therapy groups, individual counseling and substance abuse education.

The study was originally designed to randomly place participants reporting a trauma history into groups that provided Seeking Safety with either E.M.D.R. or the “program as usual.” However, after two months, the drug court administrator and the researchers decided to end the randomization part of the study because of ethical concerns. The participants who received E.M.D.R. spoke so highly of it and reported feeling so much better that those in the standard care group were upset that they weren’t going to have a chance to receive E.M.D.R. Since no other specific trauma treatment was being offered in the “program as usual,” this posed an ethical concern for the drug court program administrator and investigators.

As a result, the study was converted into an open pilot program in which all those who had experienced a major trauma would be offered E.M.D.R. on a voluntary basis. An evaluation of the program revealed that 91 percent of those who ultimately received E.M.D.R. therapy graduated from the program, compared with only 62 percent who did not receive it.

Graduation from such a program is considered to be the best predictor of whether people will relapse into criminal behavior. E.M.D.R. therapy is now strongly recommended for anyone in this Washington State drug court program who has a history of trauma.

A Cancer Diagnosis and E.M.D.R.

Q. I am 50 years old and was diagnosed with an aggressive form of breast cancer five years ago. My doctor has given me a clean bill of health, but I can’t shake my fear that it will return. I thought that with time I’d feel better, but I don’t. Everyone tells me it is important to “be positive.” Could E.M.D.R. help me to get on with my life?
ML Williams, North Dakota

A. Dr. Shapiro responds:
You are not alone in experiencing fear. In a study of 244 breast cancer survivors five to nine years post-diagnosis, published in the journal Oncology Nursing Forum, researchers found that fears of recurrence were frequent. The most commonly reported experiences that triggered fear included yearly follow-up appointments, doctors’ appointments, hearing of another’s cancer, physical symptoms or pain, news reports about breast cancer, and the anniversary of the diagnosis. The time that had elapsed since diagnosis was unrelated to the frequency of such triggers. Sadly, some people mistakenly believe that this overwhelming fear is the inevitable and “natural” outcome of cancer.

Receiving a life-threatening diagnosis can be classified as a trauma. Many people with a cancer diagnosis have entered E.M.D.R. therapy because of anxiety and fear that persists even after the medical treatment has been successfully completed. These long-lasting negative reactions can often be tracked back to the moment of diagnosis or something that happened during treatment that was particularly distressing.

The information processing system of the brain has stored the experience — with the emotions, physical sensations and beliefs that occurred at the time of the event. So, even though medical tests may now show no sign of the disease, the fear and anxiety encoded in that unprocessed memory remains. These feelings can increase dramatically around the time of yearly testing or by any event that reminds the person of the cancer experience. E.M.D.R. therapy is successfully used to process and alleviate these disturbing responses. The therapy allows people to get on with their lives without being haunted by fear.

Also relevant to many breast cancer survivors are unpleasant or painful physical sensations at the site of the surgery. Many times, these sensations can be caused by unprocessed memories. As I noted previously in “E.M.D.R. and Pain,” above, research has been published on the successful E.M.D.R. treatment of phantom limb pain, and the principles guiding the therapy applications are the same in the cases of “phantom breast sensations” which persist after a mastectomy in up to 55 percent of cases (Dworkin, 2006). Although E.M.D.R. therapy cannot eliminate pain caused by actual nerve damage, it is successful in treating the uncomfortable sensations and chronic pain caused by stored unprocessed memories.

The important thing to remember is that no matter how long it has been since diagnosis and treatment, fears of recurrence need not be a permanent psychological scar of breast cancer.

E.M.D.R. in Children

Q. What kind of results have been found using E.M.D.R. in children? Is it as effective/can it be tolerated?
Emily, CT

A. Dr. Shapiro responds:
E.M.D.R. therapy is widely used with children. It is designated as an effective treatment for trauma and considered “Well-Supported by Research Evidence” by the California Evidence-Based Clearinghouse for Child Welfare. Numerous studies with children have demonstrated that E.M.D.R. therapy is effective in reducing P.T.S.D. symptoms, as well as behavioral and self-esteem problems.

E.M.D.R. therapy is tolerated well by children, and positive results are often more quickly obtained than with adults because there are fewer memories to deal with. Although E.M.D.R. therapy entails specific, well-delineated procedures and steps, they are tailored to the needs of each individual. Therefore, playful and child-friendly strategies are used to make E.M.D.R. therapy developmentally appropriate and appealing for children.

Each child in E.M.D.R. therapy is seen as an individual with distinctive needs and assets. Each will need different levels of preparation before the traumatic memories that lie at the core of their suffering can be processed. The amount of time needed will vary depending on the level of traumatization, internal resources and external support available. The well-trained E.M.D.R. clinician will be able to assess how extensive the preparation should be for each child. As a result, when E.M.D.R. therapy is done appropriately, children will arrive at the moment of accessing and processing trauma memories with the proper psychological resources and abilities.

When possible, it is best to process disturbing experiences in childhood to prevent years of unnecessary suffering. These early traumatic and adverse experiences can have a profound and toxic affect on the child’s learning capacity, self-esteem and ability to form healthy and fulfilling relationships in the future. Aggressiveness, oppositional behaviors, school failure, anger outbursts, social isolation and the like may be some of the manifestations of past experiences that remain unprocessed in the child’s brain and continue to be activated by daily life triggers.

The ultimate goal of E.M.D.R. therapy is to tap into the child’s own information processing system so these memories of trauma and adversity can be processed and integrated. As a result, children can be free to respond to life’s demands with a healthy and age-appropriate sense of self, power and responsibility so they can follow a path to successful and rewarding lives.

E.M.D.R. and Failure to Thrive

Q. Is there any evidence that E.M.D.R. is successful with adopted children who, when adopted, were diagnosed with failure to thrive?
Martha Stern, San Marino, CA

A. Dr. Shapiro responds:
There are multiple possible medical causes for failure to thrive, but high on the list is likely to be parental rejection or withdrawal. One can only assume that the loss of the parent can also be an early trigger for the problem. When the child’s needs are not met, multiple systems shut down and the child becomes unresponsive.

Among the population of neglected or abused adopted children treated through The Attachment and Trauma Center of Nebraska, for example, it is not uncommon to find a failure to thrive diagnosis early in life that is related to pre-adoption conditions. A majority of the adopted children presenting for treatment also have some type of food-related problem, like poor appetite, hoarding or gorging, in addition to other behavioral issues. Research in which E.M.D.R. and family therapy are being used to treat these issues is under way, and the preliminary findings suggest that the food issues improve along with the other behavioral issues as the children begin to trust their adoptive parents to care for them.

Children learn to more closely attend to their emotions and the body’s signals for hunger, satiation, sleep and elimination when they have a secure attachment with a parent who is sensitive and responsive to their needs. Attuned parents help their children develop regular eating, elimination and sleep habits. Their children learn to trust adults to care for them and to seek comfort from them when they are stressed.

When children experience traumatic loss, neglect or abuse prior to adoption, they learn that they cannot trust or rely on their caregivers. Their inability to trust may leave them unable to seek or accept comfort or even simple nourishment from their caregivers. As they get older, they may sneak food, hide food or gorge on food as a survival mechanism. They may exhibit very challenging behaviors related to extreme underlying anxiety.

The E.M.D.R. therapy with these children focuses first on reinforcing positive experiences of closeness with their adoptive parents. It then targets and reprocesses past experiences in which the children learned not to trust. Current triggers to problematic behaviors are reprocessed, and finally, E.M.D.R. is used to develop future templates for positive behaviors.

Children who learn to turn to their adoptive parents for comfort and security can more readily allow them to help regulate their emotions, food, sleep cycles and behaviors. They are moved on to a positive course in life as the memory processing and new experiences allow them to develop a healthy attachment. This is the foundation for the development of a positive sense of self and safety in the world. It also sets the foundation for positive future relationships.

These are among the outcomes currently being documented with research in The Attachment and Trauma Center of Nebraska with severely disturbed children, many of whom previously experienced multiple failed adoption attempts.

Grief and E.M.D.R.

Q. Has E.M.D.R. been successful in treating P.T.S.D. or complicated grief from loss of a child from suicide?
Karen Schreiber, Palo Alto

A. Dr. Shapiro responds:
With the sudden loss of a child from any cause, a parent can be troubled by intrusive thoughts and images. Many times these include images of the deceased in pain, or the scene of death — real or imagined. The negative emotions can often involve feelings of sorrow about things the grieving person now wishes he or she could have done, or guilt about mistakes or things not done. These feelings can be overwhelming. In addition, people are often unable to remember the person at all without the intrusion of such thoughts and imagery.

E.M.D.R. therapy has been very successful in addressing these grief-related issues. In a multi-site study published in the journal Research on Social Work Practice, E.M.D.R. significantly reduced symptoms more often than cognitive behavior therapy on behavioral measures, and on four of five psychosocial measures. E.M.D.R. was more efficient, inducing change at an earlier stage and requiring fewer sessions. After treatment, those who had received E.M.D.R. could remember the deceased in a positive way, without the negative emotions. The heartfelt connection was still there, but without the pain.

Self-Help Using E.M.D.R.

Q. Is the self-help book effective with people who have already had extensive therapy that was found to be very effective but with time, the effects faded, i.e., the anxiety, negative self-talk and critical nature returned? I am very interested in finding methods, strategies, etc. for people who haven’t the means or wherewithal to get therapy.
LindaMC, Arlington, MA

Q. Dr. Shapiro, does any source for laypeople, including your upcoming book, provide effective instruction on self-administration of E.M.D.R.? Is there a way for a motivated, suffering person who either can’t afford– or otherwise won’t see– a therapist to help heal themselves? Thank you.
Shaun, Grand Rapids

A. Dr. Shapiro responds:
Yes, my self-help book “Getting Past Your Past” contains a wide range of techniques used in E.M.D.R. therapy that readers can employ to deal with disturbing emotions, physical sensations and beliefs. The reason for writing the book was to provide people with the ability to take both personal exploration and empowerment into their own hands. For that reason, I’ve also included chapters to explain how different problems develop, as well as clinical cases that will illustrate the interconnectedness of memory networks and our automatic responses. They can help readers to better understand themselves, family members and others in their lives.

In the book, I’ve included a wide range of self-help techniques that will allow people to (a) manage stress, (b) change their emotions, physical sensations and negative thoughts in the present, (c) help get rid of negative intrusive images, (d) identify situations that trigger negative reactions and help prepare for them in advance, and (e) identify the unprocessed memories that are causing the negative reactions. People will be able to understand the causes of problems, including areas where they feel stuck, or pushed into unhealthy behaviors.

Additional techniques include ones taught to Olympic athletes to achieve peak performance. These can also help people prepare for challenges like presentations, job interviews and social situations. These techniques can benefit any reader.

However, if they are not sufficient to resolve any particular problem, there are guidelines to help determine if more comprehensive memory processing would be beneficial, and suggestions about how to find a fully trained E.M.D.R. therapist who would be most suited to address the issue. In those cases, having completed the exercises suggested in the book, readers will already have finished most of the E.M.D.R. history-taking and preparation phases, which should accelerate the therapy process.

Apr. 10 | Updated: Dr. Shapiro responds to additional reader questions about E.M.D.R.

Overcoming the Trauma of Medical School

Q. I have a 60-year-old physician patient who has ongoing anxiety, now with associated depression of many years. Her anxiety began with the trauma of medical school, which she experienced much as a “hazing,” demeaning experience along with the usual stress of learning the expected amount of information in a limited amount of time. She experienced three years of almost debilitating anxiety, then became depressed.

Psychodynamic “talk therapy” and medication have helped some, but she has never been able to resolve the anxiety issues from this period. She feels she has never been able to return to her previously relaxed self. She is an excellent clinician, conscientious, happy and successful in her practice. Could she be a candidate for E.M.D.R. ?
William Goodin, M.D., Batesville, Ark.

A. Dr. Shapiro responds:
Your client would be an excellent candidate for E.M.D.R. therapy. The bottom line is that disturbing experiences like those you describe can overwhelm the information processing system and be stored in the brain with the emotions, physical sensations and beliefs that were experienced at the time of the event. The negative reactions continue to be triggered because the stored memories remain unchanged and are unable to link up with anything more adaptive. This means that regardless of the number of positive experiences your client may have had as a physician, the feelings of anxiety and insecurity that were encoded in medical school remain. Processing those earlier experiences can allow these negative feelings to dissipate.

Even though the experiences have been debilitating her for the past 30 to 40 years, they can be accessed and processed. For instance, a French-Egyptian woman in her 70s had experienced similar feelings stemming from a childhood experience in which she had felt demeaned by her mother. Her mother placed her brother in front of her and went behind him like a coach, urging him on by saying: “She’s a girl, go on, beat her.” As she described it, “When I heard that, my whole world tumbled down, the stars and moon fell down.” She realized during the E.M.D.R. memory reprocessing session that because of the event she had “always been subservient.” After processing her grief and anger, she declared: “I’ve never wanted to be a boy. I’m proud of being a woman.”

These encoded experiences, whether 1, 10 or 60 years ago, can continue to distort a person’s sense of self and place in the world. But they can be fully processed. As the woman described above put it: “When I started I was down on the ocean floor; now I’ve surfaced.”

Conversion Disorder and E.M.D.R.

Q. Are there studies that show the effectiveness of E.M.D.R. in treating conversion disorder? My understanding is that “conversion,” or the manifestation of physical symptoms that result from a psychological disturbance (as opposed to having a physiological cause), is closely related to — or a form of — P.T.S.D.?

Two years ago, I was diagnosed with conversion disorder that, at its worst, caused violent seizurelike symptoms and temporarily paralyzed me from the neck down. I have been doing E.M.D.R. on a regular basis with a licensed therapist trained in the method (in addition to traditional talk therapy), and the physical symptoms have steadily improved.

It’s been difficult finding info on E.M.D.R. as it relates to conversion disorder.
MB, Baldwin, N.Y.

A. Dr. Shapiro responds:
Conversion disorder is a subcategory of somatoform disorder and involves medically unexplained symptoms that give the appearance of being neurological in nature. These would include psychogenic nonepileptic seizures, myoclonic (jerking) movements and paralysis. Research has indicated that more than 50 percent of those with medically unexplained symptoms like these have P.T.S.D. However, other research has indicated that “adverse life experiences” that do not rise to the level of major trauma can also be associated with the condition.

As I’ve described previously, research has also indicated that a wide range of life experiences can cause more symptoms of P.T.S.D. than result from major trauma. In short, there is ample evidence that psychological factors are implicated, and from an E.M.D.R. therapy perspective, the primary contributors to these are unprocessed memories of the events that preceded the physical symptoms.

There are no randomized controlled studies of E.M.D.R. treatment with those suffering from conversion disorder, but clinicians and researchers have reported success with this population. For instance, in their article “Eye Movement Desensitization and Reprocessing in the Psychological Treatment of Trauma-Based Psychogenic Non-Epileptic Seizures” (2007), Susan Kelly and Selim Benbadis reported that “at the outset, it was predicted that PNES with a trauma base could be eliminated or substantially improved by treating the trauma with E.M.D.R. This proved to be true for two of three patients.” They conjectured that the third patient might have been hampered by fear of giving up disability payments.

Another case report, from The Journal of Clinical Psychology, describes the treatment of a combat veteran, “Bob,” who suffered from “frequent myoclonic movements that began in 1968.” The report continues:

He described an upper-body “shaking” occurring at least 20 times a day and “over 50–60 times a day” when in social situations. . . . Processing the first experience, being left alone and unarmed in the field at night, linked to several other experiences, including being asked to escort the remains of his younger cousin home after Bob’s return from Vietnam. He experienced an abreaction that faded with two sets of eye movements and, by the end of the first session, he reported “feeling joy at being alive.” Before the next session his daughter reported his jerking motions were down to no more than three a day.

After completing E.M.D.R. treatment, the report said, “at one-month and 6-month follow-ups Bob reported no incidents of shaking and all other symptoms were in remission.”

Approximately 20 published articles have reported success in treating a variety of somatic problems and somatoform disorders. Over all, these indicate that the processing of earlier memories related to the physical symptoms appears to alleviate many medically unexplained symptoms. These include the treatment of phantom limb pain that I’ve previously described.

Hyperactivity and E.M.D.R.

Q. What is the effectiveness of E.M.D.R. with hyperactive individuals, like those with diagnosed A.D.H.D.?
Shaleela L, Brooklyn

A. Dr. Shapiro responds:
E.M.D.R. therapy will not cure organically based A.D.H.D. However, sometimes people are misdiagnosed with A.D.H.D., but it turns out that the problem is really caused by unprocessed memories that produce symptoms that mimic those of A.D.H.D. For instance, inability to concentrate, anxiety, inattention, hyperarousal, jumpiness, impulsivity and acting out can also be symptoms of a traumatic event or other “adverse life experiences.” A well-trained clinician using E.M.D.R. therapy should be able to help determine if these kinds of unprocessed disturbing experiences are involved. They can be either causal or contributing factors.

In addition, those in whom A.D.H.D. has been accurately diagnosed are often exposed to a wide variety of experiences that can exacerbate the problem. These include failure experiences at school, rejections, humiliations and other kinds of interactions caused and/or contributed to by the inattentiveness, overactivity and impulse-control deficits that characterize this behavioral disorder. These unprocessed memory systems also become the foundation for how individuals with A.D.H.D. form and shape their sense of self.

They may perceive themselves as not being good enough — or competent enough or adequate enough — and experience accompanying feelings of shame, anxiety or depression. The memory networks that contain such information become the basis for how they perceive and respond to present experiences and challenges. As they continue to be debilitated by the negative feelings, new failure experiences pile up and continue to make matters worse. E.M.D.R. therapy can be used to process the memories of the negative experiences, which can help reduce the symptoms being caused by anxiety and promote the development of a healthier sense of self and competence.

In sum, E.M.D.R. therapy can assist individuals with misdiagnosed A.D.H.D. by directly addressing causal factors, and processing the memories of trauma and adversity that are at the core of the A.D.H.D.-like symptoms. Further, in the case of organically based A.D.H.D., E.M.D.R. therapy can be used in conjunction with well-accepted A.D.H.D. treatments to address contributing psychological factors that exacerbate present symptoms.

Primal Therapy and E.M.D.R.

Q. How can E.M.D.R. heal trauma without requiring a person to relive and integrate it, as in primal therapy? Where do all those powerful feelings go?
brucethewriter, Ste-Adèle, Quebec

A. Dr. Shapiro responds:
There are many different forms of therapy, and each is guided by a different underlying theory. Primal therapy involves the belief that a “forceful upheaval” is necessary to eliminate neurosis. However, the theoretical stance that it is necessary to relive your past is not supported by research. There are now more than 20 randomized studies documenting the positive effects of E.M.D.R. therapy with trauma victims, with follow-up evaluations as long as three years out. The elimination of post-traumatic stress symptoms with E.M.D.R. is achieved without reliving the trauma because a different understanding of how the brain works and the mechanisms of healing guide this form of therapy.

Clinical experience and research over the past 25 years indicate that the intense feelings that disrupt the lives of trauma victims exist because of the way the memory of the trauma was stored. The event was so disturbing that it disrupted the information processing system of the brain, and the memory therefore became encoded with the emotions, physical sensations and beliefs experienced at that time.

However, in E.M.D.R. therapy, the client is prepared in a certain way, and once the memory is accessed, the information processing system of the brain is stimulated and the appropriate connections are made. During that time, the experience of processing is unique to the individual client as the brain digests the information.

Some can feel disturbance as a shadow of the original experience. Others can feel a momentarily high arousal. And still others can feel any gradation in between.

We prepare E.M.D.R. clients with self-control techniques so they feel free to “let whatever happens, happen” without forcing the experience into any particular mold – like an emotional upheaval. When the information is allowed to process spontaneously, the negative emotions are replaced with more positive ones as the memory takes its proper place in the past. These psychological events mirror the experience of uninterrupted information processing that occurs in everyday life. The shifts in powerful feelings occur automatically, just as any disturbance you might have in the present is naturally replaced by different emotions once you have come to terms with it.

In E.M.D.R. therapy, it is unnecessary for the client to relive the disturbing event for his or her reactions to change. In fact, numerous studies of the eye movement component of E.M.D.R. have shown that it causes an immediate decrease in negative emotion and imagery vividness. Once it is processed, the memory is transformed into a learning experience that is appropriately stored in the brain.

According to the Harvard researcher Robert Stickgold, the memory is transferred from episodic to semantic memory, where the meaning of the event is extracted and no longer contains the emotions associated with it at the time of the event. In short, it is not necessary to relive the trauma for the memory to become integrated within the semantic memory network.

E.M.D.R. and a Broken Friendship

Q. Is E.M.D.R. effective on past trauma that was created by the individual? For example, if an individual sabotaged a relationship by saying mean and hurtful things and as a result relives the events and what she said on a daily basis, would E.M.D.R. help her move on from this past mistake? (The friend hasn’t talked to her since and the relationship cannot be repaired.)
O Sullivan, Wilmington, Del.

A. Dr. Shapiro responds:
The research now indicates that many kinds of life experiences can cause more post-traumatic stress disorder symptoms than major trauma does. Having intrusive thoughts of an event are one of the symptoms of P.T.S.D. Regardless of the cause of the disturbing experience, E.M.D.R. therapy can help process the memory of the event so that the person is able to learn from it and get on with life.

The protocols used in E.M.D.R. involve processing the past events that set the groundwork for the disturbance, processing the current situations that trigger distress, and processing what is needed for the future. This three-pronged approach can help to expand the person’s awareness and incorporate the skills necessary to guide him or her to more life-enhancing responses in the future. For instance, there may have been a variety of unprocessed memories that pushed the person into behaviors that sabotaged the relationship, and in comprehensive E.M.D.R. therapy this issue would be addressed as well.

Treating War Trauma With E.M.D.R

Q. When I was an internist at the most highly academically affiliated Veterans Affairs hospital in the country, I asked a clinical psychologist with whom I worked whether E.M.D.R. would be applicable to some of my patients, and I was told that there was reluctance to use it because it had been tried in some Vietnam veterans and had elicited emotions that neither the patient or the therapist could control without untoward outcomes. What are your ways of getting around this experience, and why does it happen?
cbchill, Chapel Hill

Q. Could you talk about E.M.D.R. as a way to treat combat and war trauma?
Elaine, Minneapolis

A. Dr. Shapiro responds:
E.M.D.R. is an eight-phase therapy approach. The second phase is preparation, which includes teaching clients a range of emotional state change techniques so that when memory processing begins they can control the feelings that may emerge during sessions, and allow them to return to “neutral” if they desire. The preparation is also important so that the techniques can be used to deal with any negative emotional responses that arise between sessions. For a detailed description see my recently published book “Getting Past Your Past.”  The self-control techniques provide clients with a sense of self-mastery. Without the ability to feel and be in control of the therapy process, “untoward outcomes” can occur with any form of trauma treatment.

When E.M.D.R. therapy is performed appropriately, it is well tolerated by combat veterans. For instance, a randomized study of Vietnam veterans conducted at a V.A. medical center reported that after 12 sessions, 77 percent of them no longer had post-traumatic stress disorder. Importantly, none of the veterans dropped out of the study, which means that the therapy was well tolerated by all those who participated.

As mentioned in my post “The Evidence on E.M.D.R.,” other research with combat veterans has been faulted for insufficient treatment doses and/or faulty application. For instance, in some research, only one memory was treated with the multiply traumatized combat veterans and/or only two sessions were administered. Clearly, this is an insufficient time for both preparation and adequate processing for this population.

The most recent recommendation for the E.M.D.R. treatment of combat veterans is to use approximately 12 sessions, including at least one session of preparation. When the veteran has mastered the self-control techniques, it is appropriate to proceed with processing.

E.M.D.R. therapy has been used extensively with combat veterans and, as described in an article by the Department of Veterans Affairs and Department of Defense clinicians in The Journal of Clinical Psychology, it has a variety of advantages for veterans. While other forms of trauma treatments need detailed descriptions of the event by the client, this is unnecessary in E.M.D.R. Therefore, the veteran can be effectively treated even if he or she chooses not to discuss the event for any reason, including that it is classified information.

Not needing to speak in detail has also been reported to make the therapy easier for those with traumatic brain injury. In addition, unlike other trauma treatments, there is no homework, which is why it is being employed in combat situations. Further, physical symptoms such as pain and unexplained medical symptoms remit along with the trauma symptoms and emotions that are often most troubling to veterans.

As reported in the article:

Combat veterans with P.T.S.D. may report large amounts of survivor guilt, perpetrator guilt, grief and anger. [E.M.D.R.] generally has no more difficulty with these emotions than any other emotion, or cognitions, or physical sensations. Indeed, E.M.D.R. has been found to reduce symptoms of mourning on behavioral and psychosocial measures in a multisite study…. For veterans, this translates into the ability to access positive memories of the dead where once they may have feared that reduction of their grief might equate to a loss of the memories of the dead….

E.M.D.R. provides rapid encouragement to remain in treatment by often providing symptom relief in the first or second session of desensitization. The client-centered nature of E.M.D.R. is empowering while not requiring details of the event, sustained disturbance or focus on the event, homework, or other tasks. This is particularly salient, as veterans in crisis may not be able to complete in vivo exposure or homework. Finally, E.M.D.R. encourages the resolution of disturbances manifested physically, emotionally, and cognitively, and does so even when the disturbance is generated from several different experiences. For war veterans whose traumatic events are usually multiple, this is an effective tool.

Since E.M.D.R. therapy is not available in all V.A. facilities, the E.M.D.R. Humanitarian Assistance Programs, our nonprofit group, has made arrangements for free treatment for combat veterans in certain locations. Because E.M.D.R. therapy does not require homework to be effective, it can be provided on consecutive days. In fact, some programs now provide morning and afternoon sessions, which can allow treatment to be completed within a week.

You can find locations for free treatment at the EMDR Humanitarian Assistance Programs Web site.

The E.M.D.R. Humanitarian Assistance Programs

Q. Dr. Shapiro, How can I, can we, begin to form an outreach somehow to support those who need us the most — P.T.S.D., trauma, emotional people with such painful memories, those on the brink of suicide — with empathy and compassion? Give me options to consider. Thank you.
NANA, Dania Beach, Fla.

A. Dr. Shapiro responds:
Thank you for your interest. Our nonprofit organization, the E.M.D.R. Humanitarian Assistance Programs (HAP), provides support for underserved populations throughout the United States and worldwide. It began when an F.B.I. agent called and requested help after the Oklahoma City bombing in 1995, because the local clinicians were traumatized. We sent volunteers to help conduct treatment and provided pro bono clinical trainings. Since then, we have provided similar services after every natural and manmade disaster, including the 9/11 attacks, Hurricane Katrina and the Columbine shootings. The organization has also arranged to provide free E.M.D.R. therapy for combat veterans at various locations.

HAP also provides free training for underserved populations worldwide. These include working with local clinicians after the earthquake in Haiti and other natural disasters throughout Latin America and in the aftermath of the tsunamis in Asia. We also work with clinicians to provide trauma treatment in areas of ethnopolitical and religious violence. It is clear that ongoing unhealed trauma begets more violence.

The aftereffects of trauma can be transmitted across generations, resulting in ongoing cycles of violence and pain that affect individuals, families and societies. For those people and organizations working in countries in need of significant conflict prevention, mediation, reconstruction and reconciliation, these unhealed memories can present a grave challenge.

The evidence is clear that even with the best of intentions, those attempting to reach across the table are hampered by the negative reactions that automatically arise because of earlier experiences of violence, pain and humiliation. The very sight of those on the other side of the divide and/or the mere mention of the conflict by those attempting to mediate disputes can trigger these unhealed memories that are stored in the brain and contain the negative emotions, thoughts and physical sensations encoded at the time of the event. These involuntary reactions hamper the ability to be rational, pragmatic and open to new ways of thinking.

Because the “past is present,” these unprocessed memories of traumas have resulted in generations of ongoing hostility. The stories of violence, oppression and human rights abuses told to children often result in vicarious traumatization, in which children feel as though the experience is happening to them. Those who have been traumatized carry internal wounds that can result in flashes of anger and pain that can prevent reconciliation and cause a variety of other societal problems, like addictions and domestic violence. These effects are also seen in victims of natural disasters and domestic abuse. All of these disturbing events can affect productivity and the ability to learn and participate in reconstruction programs and development opportunities.

Two important goals for HAP are to educate the public about the effects of trauma and help those in need of treatment. All of the clinicians and educators participating in HAP projects volunteer their time. You can help support the humanitarian efforts for these global efforts through donations and outreach assistance.

May 10 5:30 p.m. | Updated

Relationships and E.M.D.R.

Q. Can E.M.D.R. help with relationship problems or other interpersonal issues?
Liz, Boston

A. Dr. Shapiro responds:
E.M.D.R. therapy is widely used to address relationship problems. Interpersonal issues generally stem from childhood experiences that forged the person’s self-perception and view of the world. These include a sense of how relationships should be and what to expect from others.

In many instances, people duplicate problems they have witnessed in their families of origin. Parental discord, for example, can set the groundwork for future relationship problems. In addition, there is a large body of literature that demonstrates how relationship problems between parents and children can create insecure attachment styles that are duplicated in adult relationships. A child who has not been listened to or who is dismissed or not shown love, for instance, will come to expect these responses as an adult. In extreme cases, this can result in someone remaining in an abusive relationship. When children have not been taught appropriate ways to communicate their needs, their adult relationships are likely to suffer.

Relationship issues are dealt with in E.M.D.R. therapy by using a multipronged approach. The first step is to process the earlier memories that have set the groundwork for the interpersonal difficulties. Then the current situations that trigger the negative responses are processed, and finally the appropriate communication skills are taught.

Many family therapists incorporate E.M.D.R. therapy into their clinical practices in order to overcome “therapeutic impasses.” These occur when, despite instruction on “how” to act with partners or children, the old, dysfunctional patterns of behavior continue to emerge. From an E.M.D.R. perspective, this is because the unprocessed memories are being triggered, causing the negative emotions and perspectives to arise and inappropriately shape the client’s reactions in the present.

Processing the persons’ earlier memories can liberate them to make the adaptive responses needed for healthy interpersonal relationships. Examples of how E.M.D.R. therapy is used for these purposes are described in the Handbook of E.M.D.R. and Family Therapy Processes.

Autism and E.M.D.R.

Q. Can E.M.D.R. work for someone with Asperger’s?
Lawrence W. James, Colorado

Q. Can E.M.D.R. help treat people who are intellectually disabled?
Mamie Hetherington

A. Dr. Shapiro responds:
E.M.D.R. therapy has been shown to be highly successful with those suffering from autism spectrum disorder as well as intellectual disabilities, as reported in both published articles and conference presentations. Since E.M.D.R. therapy does not require that the client provide coherent descriptions of the traumatic event, it is highly amenable for those with Asperger’s syndrome and other forms of autism spectrum disorder, as well as those with intellectual disabilities.

In people with intellectual disabilities only, E.M.D.R. therapy doesn’t differ significantly from the way it is generally applied with children. The procedure has to be adapted to the client’s developmental level of functioning. However, intellectual disabilities often accompany other disorders, including autism spectrum disorder, and additional adjustments would need to be made.

Since the autism spectrum disorder population is acutely sensitive to environmental disruption, many everyday experiences can cause emotional disturbance, including trauma symptoms. For instance, one child displayed a high level of post-traumatic stress symptoms after going through a car wash. While recent research has shown that general life experiences can cause even more symptoms of post-traumatic stress disorder than major trauma in the general population, the susceptibility is even more problematic for those with autism.

Reports of positive treatment effects with autism spectrum disorder include a loss of trauma symptoms, increased stability of mood, greater communication and an increase in socialization. For instance, a boy with autism spectrum disorder was found to have developed P.T.S.D. symptoms after watching the movie “E.T.,” with symptoms that persisted for several years. As part of his treatment, he was asked to draw the most disturbing picture that came to mind when he thought of the movie. This image was targeted and processed in one E.M.D.R. session. It soon became clear that the fear caused by the movie had blocked his personal growth. After processing, major changes took place. He no longer clung to his parents, took up a variety of activities and was very proud of his new-found strength. It turned out that a large part of his over-dependency on his parents had been due to his P.T.S.D.

Another boy with autism spectrum disorder was beaten up by children while playing outside. According to his mother, most non-autistic children would have been able to handle what happened. However, her son stayed inside the house for about a year and a half. He only went out to go to school by bus, and he became very aggressive toward his brother. After one E.M.D.R. session his pattern of fear was eliminated, and within two sessions the disturbing memory was completely processed. Subsequently, his behavior returned to what it had been before the event.

On the other hand, two other autism spectrum disorder clients had experienced various events that the clinician assumed would be traumatic (that is, a mother’s serious illness, and forced separation from a parent for several years), but produced no disturbance at all. Nevertheless, both suffered from their own outbursts of anger, which was posited to be because they knew that their behavior was “breaking the rules.” As the clinician verbalized it, ”Working with people with autism spectrum disorder often is like solving a puzzle.”

For clients with autism spectrum disorder, the way E.M.D.R. treatment proceeds can vary greatly depending on the person. Some clients are totally nonverbal, some are over-precise with regard to linguistic usage, some show little emotion, some overreact and show fierce abreactions, sometimes the process goes incredibly fast, while in other cases it takes a lot of time.

Potential problems the clinician has to be able to deal with include social and communicative deficits, lack of imaginative power, difficulty with change, limited interest, lack of initiative, and sensory under- and over-sensitivity. Consequently, it is critical that any E.M.D.R. therapist selected be familiar with the population being treated.

Peak Performance and E.M.D.R.

Q. Dr. Shapiro, you wrote that your book “Getting Past Your Past” includes techniques “taught to Olympic athletes to achieve peak performance. These can also help people prepare for challenges like presentations, job interviews and social situations.” What’s the relationship between sports performance and job interviews or social situations, and what does it have to do with E.M.D.R. therapy?
Ernest K, Denver

A. Dr. Shapiro responds:
People seek therapy for a variety of reasons, but in general the reasons can be summarized as being “stuck” and prevented from acting in ways that are healthy and adaptive. E.M.D.R. therapy is used to process the memories of experiences that set the foundation for the problems, process the current situations that cause disturbance and trigger negative behaviors, and incorporate the skills needed to achieve positive outcomes in the future.

For those interested in achieving “peak performance” in sports, the person’s history is examined to identify what memories may be blocking them from achieving their goals. Often this turns out to be previous failures, injuries and negative comments by coaches or peers. These memories remained stored in the brain with the negative emotions, beliefs and body reactions that occurred at the time of the event. For instance, as I describe in “Getting Past Your Past”:

Kyle was a top state-ranked high school athlete who came to therapy to work on his lack of confidence and motivation. He processed memories of injuries and distractions such as imposing opponents, parental comments and disappointing looks on his coach’s face. A number of techniques [in the book] were used to help him stay focused on the game. Upon graduation, Kyle received a scholarship to attend a prominent university as part of their NCAA Division I highly ranked team. As he said, “This doesn’t just help with my sport, does it? I’m getting straight A ’s for the first time!” He’d attended an academically challenging parochial school and had been struggling with learning disabilities.

Some of the techniques taught in the book involve ways to achieve a state of calm and confidence. Many people mistakenly believe that it is important to feel anxious in order to perform well. However, performance research demonstrates that while “arousal” is involved, the way we deal with the arousal makes the difference between success and failure. Therefore, performers, executives and athletes are taught ways to achieve optimal emotional and physical states. In addition, E.M.D.R. therapy incorporates “positive memory templates” that set the stage for positive performance in the future. A survey of Olympic athletes and coaches reported that 90 percent of the athletes and 94 percent of the coaches incorporated these kinds of imagery techniques into their training programs.

So whether your desired “peak performance” involves athletics, executive functioning, social interactions or optimizing a job interview and social interactions, you can utilize these techniques to prepare yourself to do your best.

E.M.D.R. and the Harried Mother

Q. I recently went to six E.M.D.R. sessions to treat chronic anxiety and have experienced about 60 percent relief. I realize that I should now try to stop the anxiety from building up again, but the reality is I’m a working mom of a toddler, so I generally come last, meaning I can’t just devote myself to this work fully. Have you seen E.M.D.R. help people going forward even if they don’t have the time to always focus on relaxation techniques? Also — thank you — it really helped!
Kim Z., Pa.

A. Dr. Shapiro responds:
I can sympathize with the time constraints you have. However, there are two good analogies from other fields that might help put things into perspective: (1) finish the bottle of antibiotics, and (2) put on your own oxygen mask first.

There is a three-pronged approach to E.M.D.R. therapy: Processing the past experiences that set the groundwork for the problem, processing the current situations that trigger the disturbance, and addressing needs for the future. The last of these also includes putting yourself on the priority list.

Once the processing is complete, there will be a better foundation for emotional stability, which means less susceptibility to stress and anxiety. The self-help techniques you learn in E.M.D.R. therapy are there to help you to quickly shift from anxiety to calm when needed. They are procedures that everyone can benefit from. Once you learn the techniques, they take only a moment to employ. And, if you complete the therapy there will be much less need for them.

So, if you achieved 60 percent relief in six sessions, can you permit yourself six more to process the memories that are pushing the remaining anxiety?

Can E.M.D.R. Be Done in Groups?

Q. Does E.M.D.R. have to be done one-on-one? Or is it possible to do in groups?
Brave Heart, Chicago

A. Dr. Shapiro responds:
E.M.D.R. is generally used one-on-one for comprehensive therapy. However, a group protocol has also been developed and has been used extensively in the aftermath of natural and man-made disasters.

A number of articles have been published reporting the positive effects with groups of children and adults. For instance, a group intervention with E.M.D.R. [Fernandez, I., Gallinari, E., & Lorenzetti, A. (2004). A school- based E.M.D.R. intervention for children who witnessed the Pirelli building airplane crash in Milan, Italy. Journal of Brief Therapy, 2, 129-136.] was provided to 236 schoolchildren exhibiting P.T.S.D. symptoms in Italy 30 days after they witnessed an airplane crash into a skyscraper adjacent to the school. In addition to the usual symptoms of P.T.S.D., the children refused to play in the courtyard and would only eat lunch in the school corridors. The majority also declared they would never fly, and refused to go on travel planned by their parents. The children were treated in groups of 19 by two therapists who administered one 90-minute session. The entire school was treated in three days. At four-month follow up, teachers stated that after the one treatment session all but two children returned to normal functioning. The parents also reported that they were finally able to confirm vacation plans since their children were no longer afraid to fly.

The same group protocol has been used after natural disasters for both children and adults throughout Latin America [Jarero, I., Artigas, L., & Hartung, J. (2006). E.M.D.R. integrative group treatment protocol: A post-disaster trauma intervention for children and adults. Traumatology, 12, 121-129]. In these cases, one session has been sufficient to reduce trauma symptoms from the severe range to low (subclinical) levels of distress. In addition, the group E.M.D.R. therapy [Zaghrout-Hodali, M., Alissa, F. & Dodgson, P.W. (2008). Building resilience and dismantling fear: E.M.D.R. group protocol with children in an area of ongoing trauma. Journal of E.M.D.R. Practice and Research, 2, 106-113.] was provided to children experiencing trauma reactions due to violent conflict. Four sessions were sufficient to eliminate their symptoms and also provided “inoculation” against further traumatization:

A follow-up consultation (session 5) four to five months after closure confirmed that the children continued to live normal lives in spite of ongoing traumatic incidents. The children did not show symptoms of posttraumatic stress that they had prior to E.M.D.R., even though, for example, a new guard tower had been built, giving the military full control of the area with the ability to shoot directly into the residences of the refugee camp and the children’s home. . . . At follow-up, the therapists noted that none of the symptoms of posttraumatic stress had returned and none of the children had developed posttraumatic stress disorder.

Unlike other empirically supported forms of trauma treatment, E.M.D.R. therapy does not require homework to be successful. Therefore, the individual and group E.M.D.R. therapy protocols can be used on successive days. This makes it highly useful for field teams interested in treating those suffering from natural and manmade disasters worldwide. More information about the use of E.M.D.R. in these instances is available through the nonprofit E.M.D.R. Humanitarian Assistance Programs (www.emdrhap.org).

July 30 12:45 p.m. | Updated

Memories of Childhood Abuse

Q. Is E.M.D.R. effective for repression of childhood abuse memories? I have no memories of abuse, but circumstantial evidence is strong expert answers
Aaron Euler, Missoula, Montana

A. Dr. Francine Shapiro responds:
We don’t use the word “repression” in E.M.D.R. therapy. That is a term generally used in psychodynamic therapy and involves a specific theory of causation.

With E.M.D.R. therapy, the premise is that an experience is incompletely processed and dysfunctionally stored in the brain. For instance, some experiences can be so disturbing that the memories are stored in isolation, or without a clear image. However, whether or not the event is remembered, there are ways to process and relieve the current disturbance.

Most people do not seek therapy to retrieve memories. Rather, most generally seek therapy because they feel stuck in some way, or have symptoms such as negative thoughts, emotions or behaviors. If you have symptoms often associated with childhood abuse, they are interfering with optimal functioning in the present. Since memories are stored in associative networks, with E.M.D.R. therapy it is possible to target a recent or particularly disturbing example of a time when you experienced these negative reactions.

During processing of that event with E.M.D.R., earlier memories may arise. However, it is important to keep in mind that all memory is fallible. Just because an image emerges does not make it true. For instance, children can be tricked or traumatized by a movie, TV program or story. Many children hear a story that feels so real they can later believe it happened to them.

Also, memory can come up in fragments and be misleading. For instance, one client believed that her father might have molested her because she felt herself being held down and saw her father’s face. During E.M.D.R. processing, she remembered being attacked by some boys and that her father had come to her rescue. She was later able to verify this fact. In other words, some corroboration is needed to make sure that any emerging imagery is actually true. This is the case with any form of therapy.

It’s important that you make sure to go to a well-trained clinician who does not pressure you in any way. In my book “Getting Past Your Past,” one of the first stories I relate is of a client who spent years going from one therapist to another. At one point, at her therapist’s suggestion, they spent two years trolling for memories of satanic abuse because she had abandonment issues, anxiety and an eating problem, as well as recurrent images of the color red and a candle.

Since she continued to suffer, she tried another therapist who told her about E.M.D.R. therapy. Using the E.M.D.R. procedures, they targeted the images, and processing brought up the memory of a car accident that appeared to be the actual cause of all her problems. But the only way she could be sure was by specifically asking her mother about it. The irony was that her mother had tried to protect her when she was a child by not talking to her about the accident. This attempt to shield her had inadvertently resulted in years of suffering and confusion. Processing eliminated all of the symptoms.

The bottom line is that a true memory may emerge or it may not. But it is not necessary to regain an image for successful processing to take place. So, consider going for E.M.D.R. therapy to eliminate your symptoms, regardless of whether you retrieve an image.

Fibromyalgia and E.M.D.R.

Q. My daughter has been diagnosed with fibromyalgia. A typical 18 year old with life-after-school-related stress but with this added factor working against her health. She doesn’t sleep well or eat well and has anxiety, usually escalating at night and first thing in the a.m. . . . A friend psychologist suggested we look into E.M.D.R. I read your article yesterday and wondered what you might offer.
L. Narducci Ask, Brooklyn, N.Y.

A. Dr. Francine Shapiro responds:
At present, fibromyalgia falls into the category known as medically unexplained symptoms, or MUS. However, trauma has been identified as one of the possible causes or contributors. Although many people discount that possibility because they have not experienced a major upheaval such as rape or combat, psychological research has indicated that general life experiences can cause even more post-traumatic stress disorder symptoms than major trauma. Many different types of life experiences may be negatively affecting your daughter. In addition, the field of psychoneuroimmunology has clearly revealed the negative impact of stress on the immune system.

Positive results with E.M.D.R. therapy have been reported with medically unexplained symptoms and with a variety of pain conditions. Further, your daughter’s inability to sleep, in addition to the anxiety, indicates to me that E.M.D.R. therapy may be a useful addition to her treatment. An E.M.D.R. therapist can help identify and process the events that may be negatively impacting her. In addition to the 20 randomized trials supporting E.M.D.R. therapy in the treatment of trauma, one study specifically evaluated symptoms “such as sleep, depression, anxiety and poor quality of life” and found E.M.D.R. to be highly effective.

Please make sure to chose a clinician trained in a course that has been approved by the E.M.D.R. International Association (www.emdria.org), and who has had experience with your daughter’s symptoms.

Bipolar Disorder and E.M.D.R.

Q. I have bipolar I disorder. . . I had been having a mild depression with generalized anxiety. . . . Do you think E.M.D.R. helps with depression and generalized anxiety and will it stick? In other words will I have to do E.M.D.R. again?
Edith Willimas, Pottersville, N.J.

A. Dr. Francine Shapiro responds:
Many clinicians have reported positive results subsequent to E.M.D.R. therapy with those suffering from bipolar disorder. Research is currently under way in Spain, and preliminary reports indicate positive effects with this population. Preliminary research has also shown positive E.M.D.R. treatment outcomes with generalized anxiety disorder, with effects maintained at follow-up. Positive effects have also been reported in numerous E.M.D.R. studies for those suffering from depression related to trauma and other life experiences. In one of these studies, E.M.D.R. therapy outperformed Prozac.

It should be noted that psychological research has indicated that there is often a relationship between bipolar disorder and trauma. In that regard, more than 20 randomized controlled trials have indicated that comprehensive E.M.D.R. therapy results in the remediation of symptoms related to trauma and other disturbing life experiences. The effects are maintained at follow-up.

E.M.D.R. therapy can help address the disturbing life experiences that may be contributing to your symptoms. Please be sure to chose a clinician trained in a course approved by the E.M.D.R. International Association (www.emdria.org), and who has had experience with your symptoms.

The Cost of E.M.D.R.

Q. EMDR is. . . an eight-step process. How much would that cost?
Jeff Eastman, Saint Louis

A. Dr. Francine Shapiro responds:
E.M.D.R. therapy is an eight phase approach that includes: history taking, preparation, and the steps needed to complete processing targets that involve (a) the memories that set the groundwork for the problems, (b) the current situations that trigger disturbance, and (c) needed skills and education for the future.

The cost for any form of therapy varies from one region to another throughout the United States, as well as the degree/license of the clinician. The other factor is the length of time needed to complete the therapy.

If a person is suffering from a single trauma, research indicates that E.M.D.R. therapy can be completed in as little as three sessions. If there are more issues involved, the length of treatment, and cost, increases.

The E.M.D.R. Humanitarian Assistance Programs has conducted low-cost trainings for many non-profit organizations throughout the United States. These organizations offer a sliding scale and, at times, free treatment for underserved populations and for combat veterans. You can access a list of those organizations on the HAP Web site or by e-mail at: treatment@emdrhap.org

How Long do People Need E.M.D.R.?

Q. I received E.M.D.R. for longstanding issues from childhood after so many other types of therapies had been unsuccessful. While previous (non-E.M.D.R.) counselors taught me how to counteract negative thoughts and gave me tools to use when things upset me, following E.M.D.R. therapy I simply don’t slide into those negative thoughts and feelings in the first place. I find it easy now to care for myself in more healthy ways, and I don’t get blown out of the water by daily challenges as I used to.? The results of E.M.D.R. have been really dramatic; and did not require the amount of time that other types of therapy were requiring. I guess I just wonder if my experience was typical. Is there actually any research on how long people need E.M.D.R. therapy compared to other types of therapy? ??
Ernest K, Denver

A. Dr. Francine Shapiro responds:
There is research supporting your experience that E.M.D.R. therapy can be completed rapidly. There are two randomized studies reporting 84 percent to 100 percent of single-trauma victims no longer had P.T.S.D. after three 90-minute treatment sessions. In addition, a study funded by Kaiser Permanente indicated that within an average of six 50-minute sessions, 100 percent of the single-trauma victims and 77 percent of the multiple-trauma victims no longer had P.T.S.D.

Each form of therapy is guided by a different theory of practice and contains different procedures. E.M.D.R. therapy and two forms of trauma focused-cognitive behavioral therapy (C.B.T.) have the most research support and are considered “A” level treatments by organizations such as the Department of Defense. There are many differences between the treatments, including the procedures considered necessary to achieve positive effects. The C.B.T. treatments focus on challenging negative beliefs and behaviors, both during sessions and with daily homework. E.M.D.R. therapy, on the other hand, focuses on processing the memories so that associations spontaneously arise as learning takes place. No treatment homework is assigned.

There are now 10 randomized studies comparing C.B.T. and E.M.D.R. therapy. In seven of the 10 studies, E.M.D.R. therapy had superior outcomes on at least some measures and/or was more efficient, using fewer sessions in five of the seven studies (Arabia et al., 2011; de Roos et al., 2011; Ironson et al., 2002; Jaberghaderi et al., 2004; Lee et al., 2002; Nijdam et al., 2012; Power et al., 2002). The other three studies (and four of the ones just mentioned) all used daily homework in the C.B.T. condition compared to none in the E.M.D.R. condition (Rothbaum et al., 2005; Taylor et al., 2003; Vaughan et al., 1994). The Taylor study is the only one that found C.B.T. superior on some measures, and it used both imaginal and therapist-assisted in vivo exposure (where the client goes to a feared location) during half the sessions, plus an additional 50 hours of homework.

The bottom line is that E.M.D.R. therapy generally appears to be more rapid and does not use homework to achieve positive effects. As you discovered, the negative thoughts and feelings disappear once the memories are processed. In addition, your quality of life improves as you view yourself and life’s challenges in a different way.

E.M.D.R. and the Brain

Q. I have little knowledge of the controversies behind it; is it because it is still relatively new? What parts of the brain are highlighted during this therapy?

My observation is this: to lay people, connecting eye movement to trauma and treatment sounds wacky, almost a hoax. I suspect that this may be, in part, why E.M.D.R. is not better known — it sounds too unbelievable. Are there any plans for a public information campaign by credible sources so that more people can be helped? What are the roadblocks to this?
Joshua, San Francisco

A. Dr. Francine Shapiro responds:
The controversy regarding E.M.D.R. therapy stems from misinformation. When it was first introduced in 1989, the use of eye movements did seem strange to many people, and unfortunately the early research examining that component did not show positive effects. In 2000, a committee of the International Society for Traumatic Stress Studies (ISTSS) criticized all the previous research on the eye movement component as being poorly done. However, many people remain influenced by those discredited initial research reports.

Critics are also generally unaware that in the past 10 years more than 20 new randomized studies have demonstrated positive effects for the eye movement, including immediate declines in negative emotions.

At this point, most major organizations, such as the American Psychiatric Association, ISTSS and the DVA/DoD, recommend E.M.D.R. as a treatment for trauma. Consequently, few people argue that E.M.D.R. therapy is not effective, but others say it is controversial because “no one knows for sure why it works.” However, that is true of all forms of psychotherapy and most pharmaceuticals. Others claim E.M.D.R. therapy is no different than traditional C.B.T. However, as I described above, there are indeed major differences between the treatments, including the fact that E.M.D.R. therapy does not need the one to two hours of daily homework used in C.B.T. trauma treatments to achieve positive effects.

Unfortunately, articles on the Internet continue to fan controversy by circulating outdated criticism and other misinformation. Therefore, the best public information campaign is for those people who have had positive experiences, and know the actual facts, to let others know about it.

As for your question regarding the brain, there are about a dozen neuroimaging studies with a range of findings summarized in an article by Bergmann.

Pre/Post evaluations of E.M.D.R. therapy have reported left frontal lobe activation, decreased occipital activation and decreased temporal lobe activation. These findings are indicative of (a) emotional regulation due to increased activity of the prefrontal lobe, (b) inhibition of limbic over-stimulation by increased regulation of the association cortex, (c) reduction in the intrusion and over-consolidation of traumatic episodic memory due to the reduction of temporal lobe activity, (d) the reduction of occipitally mediated flashbacks, and (e) the induction of a functional balance between the limbic and prefrontal areas.

Recent modifications in neuroimaging paradigms have illustrated findings of bilateral dorsolateral prefrontal activation, as well as left orbitofrontal and right ventromedial prefrontal activation. The implications of these findings have yet to be fully understood, but suggest repair in memory function, working memory/concentration, and affect regulation, respectively. In addition, the finding of increased thalamic activation following successful E.M.D.R. treatment was noted for the first time. The consequence of such a change suggests the repair of failures in cognitive, memorial, affective, somatosensory, and interhemispheric integration, which are disrupted in P.T.S.D.

Similarly, consistencies have been seen in psychophysiological studies, manifested by findings of parasympathetic relaxation responses, increased heart rate variability parasympathetic tone, reduced electrodermal function, reduced EEG P3a function, and increased vagal parasympathetic function. These findings suggest that E.M.D.R. affects the affect regulatory systems, inducing an initial “compelling” parasympathetic state change that facilitates information processing and neural linkage repair and the eventual stable trait change that is seen as a result of successful E.M.D.R. treatment.

Breathing and E.M.D.R.

Q. I’m curious about the relationship of intentional, lateral eye movements and changes both in the psoas and diaphragm. Obviously both of these soft tissue structures are involved in traumatic responses. But why is it that, when I intentionally shift my eyes laterally, my breathing softens & deepens rather than being triggered into a panic response?
Lynn, Santa Fe

A. Dr. Francine Shapiro responds:
There are approximately 10 randomized studies that have investigated the hypothesis that the lateral eye movements cause relaxation because of a so-called orienting response, or O.R. All the studies have documented a decrease in negative emotion and arousal.

When an animal in the wild is startled because of sudden movement it reflexively shifts its eyes to investigate. When safety is noted, the animal relaxes. This compelled O.R. response is parasympathetic, habituating and geared toward information processing. The O.R. is differentiated from the startle response (S.R.) and defensive response (D.R.), both of which are sympathetic, sensitizing and geared toward action, rather than information processing.

Research has identified both the relaxation response and the retrieval of information during the sets of eye movements used in E.M.D.R. therapy. In clinical practice, clients report that new associations are made, indicating that learning is taking place.

Sexual Perpetrators and E.M.D.R.

Q. Has E.M.D.R. been successful with sexual perpetrators?
Liz, Boston

A. Dr. Francine Shapiro responds:
While research indicates that traditional programs for sex offenders are not successful, the reason may be that these programs have not changed much in the past 20 years. They primarily involve group therapy that focuses on clarifying motives, learning skills to help avoid situations where deviant feelings might be triggered, and ways to try to deal with the desires.

In comparison, a small study reporting the successful E.M.D.R. treatment of sexual perpetrators was published in the Journal of Forensic Psychiatry and Psychology. Ten perpetrators who had themselves been molested as children were evaluated after receiving E.M.D.R. treatment. An average of six sessions of E.M.D.R. therapy were added to a traditional cognitive-behavioral therapy (C.B.T.) program, and the results were compared to C.B.T. alone.

In addition to the Sexual Offender Treatment Rating Scale (SOTRS), the researchers used the penile plethysmograph to evaluate levels of deviant arousal pre/post and at a one-year follow-up. The results indicated that all but one of those receiving E.M.D.R. therapy experienced a decrease in deviant arousal that was also correlated with a “decrease in sexual thoughts, increased motivation for treatment, and increased victim empathy.” The effects were maintained at follow-up. This change was not demonstrated in the C.B.T.-only condition.

Transcripts of interviews with the molesters indicated that important alterations took place in both self-awareness and the way they viewed their victims after E.M.D.R. treatment. While molesters often exhibit profound denial that they had done anything wrong and a lack of empathy for their victims, after treatment these perpetrators took responsibility for their actions and no longer viewed children as sexual objects. The following is an excerpt from one of the transcripts published in “Getting Past Your Past,” in which the perpetrator explains what changed because of the E.M.D.R. processing of his own molestation:

I was still blaming myself for what happened, as well as putting blame on my victim like she was the one who caused this now. Up until this, thinking of what happened to me, I thought, “You’re not a victim, because you brought this on to yourself. You was asking for it.” But I didn’t do jack squat. I didn’t do nothing. I didn’t cause it. And it helped me to have insight into my own abuse and see that it wasn’t my fault. No more than it was my victim’s fault. It’s hard. It’s hard to look at. But, the more you do, the more clear you become on what you did, as well as reality. Once you do see it clear, you can go back and say, “Oh, why in the world did I do this?” Or “How in the world could they do this to me?” and “How could I do this to them?” And that hurts. It’s a big reality check. I had no understanding of feelings, of my own feelings. To be able to understand theirs, I had to really be able to understand mine. And once I could understand mine, I could understand theirs.

The processing of the perpetrators’ own memories of their abuse changed their views and physiological reactions. Given their new perspectives and sense of self, they no longer needed to fight deviant arousal. Reports of E.M.D.R. therapy with other sexual perpetrators (child molesters and rapists) continue to indicate positive effects, and additional research is underway.

Targeting memories of sexual abuse with E.M.D.R. therapy results in learning taking place. What is useful is incorporated and what is useless is discarded. That includes the transformation of negative emotions, thoughts and body reactions.

In the case of these sexual perpetrators who had themselves been molested as children, after E.M.D.R. treatment, the men placed responsibility for their own childhood experiences on their abusers, where it belonged. Simultaneously, they took on the appropriate level of responsibility for their own actions. The remorse they felt regarding their own deviant actions is consistent with a new sense of awareness and the long-lasting physiological changes in sexual response demonstrated by the penile plethysmograph. It indicates that, with the proper treatment, offenders can be reclaimed into society. It further indicates that generations of victimization can be halted if sufficient resources are directed towards perpetrator treatment.

We look forward to the outcomes of more extensive research in this area.

Francine Shapiro, Ph.D., is a senior research fellow at the Mental Research Institute in Palo Alto, Calif., director of the EMDR Institute, and founder of the nonprofit EMDR Humanitarian Assistance Programs, which provides pro bono training and treatment to underserved populations worldwide. Her latest book is “Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy” (Rodale, 2012).

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