EMDR--How it may work. And how to make it work better.
The research is very clear, over 88 studies of it since the late 80's, that EMDR is highly effective in treating all sorts of mental complaints, from depression to anxiety to PTSD, and even marriage stress. While no one knows precisely how EMDR works on a brain-science level, there are some theories that have also been explored, and somewhat substantiated. I will not be quoting the research, but I can give relevant, published articles for anyone interested.
Also, you can read up on what EMDR actually looks like in other EMDR blog posts (search by topic with the buttons).
Research has established what EMDR is NOT, namely, that EMDR is definitely not hypnosis or suggestion. I have written a post on this on this blog. EMDR is also definitely NOT talk therapy, which many of my clients have years of unsuccessful experience with. I am not knocking other therapies--as I will show, EMDR often incorporates other therapies for maximum effectiveness. Many therapists learn EMDR at a basic level to "supercharge" therapies they are already using. That's how I started out.
Theories of how EMDR works:
1. Working memory taxation: This very well-validated theory suggests that when working memory is overloaded at the same time that the client's mind is attempting to confront a traumatic memory, the memory begins to "crack and fade," allowing for a natural resolution of self-belief about the incident ("I'm safe now," "It wasn't my fault," I'm good enough as I am," etc.
2. Lessening the arousal response: Some research shows that the "bilateral stimulation" of traditional EMDR (the eyes moving back and forth quickly) lowers the tendency to be disturbed by a particular memory, including those that are not "traumatic," but simply depressing or anxiety-inducing. This allows for the mind to naturally resolve traumatic, negative, or confusing memories, in the way that would naturally happen if they weren't "stuck."
3. Bilateral brain stimulation/REM activation (this is a longer one, so it's several paragraphs here): The initial theory of how EMDR works was that fast, back-and-forth eye movements activate a memory processing function most common in sleep. This is not far-fetched, but it's difficult to research as it gets into speaking about deeper issues of life meaning.
There are four rotating phases of sleep, and during the rapid eye movement phase (REM sleep), we dream. This occurs every night, whether we remember dreams or not, and brain scans prove that. When people aren't allowed to sleep for extended periods, they get something like PTSD, so it seems that dreams are a very high-level manner of taking daily chaos and writing it into a meaningful narrative.
Jungian psychoanalysts use this as a cure when they allow clients to simply speak freely about their problems in the context of also looking at their dreams. EMDR may work the same way, but in a more efficient and unconscious manner, when the chaotic event is brought up very specific to the chaotic element, and then the REM process is directly and intentionally activated with eye movements. So in EMDR, the narrative may not make conscious sense until it results for the client in realizing that what happened simply feels like something that happened, and fits into a narrative of life--good, bad, ugly--without being disturbingly chaotic and therefore threatening to meaning. That last part is a whole blog entry in itself.
EMDR has nothing to do with making people sleepy, if you follow this theory, but rather turning on a brain function where it is needed. We go into deep REM processes every few hours during the day, and disrupting these moments with excessive business causes a sense of chaos much larger than what has happened--sound familiar? In fact, Alexander Luria, the father of neuroscience, discovered that the hemispheres of the brain are specialized, one for dealing with order, and the other for dealing with chaos. It may be that REM sleep and eye movements reflect the brain balancing itself from left to right, and that EMDR facilitates that specific to the memory being treated.
However, some believe that this theory has been discredited, although there is some research supporting it, by studies that show that bilateral eye movements are not necessary for EMDR--for instance, when needed, I use vertical eye movements, tapping, speech, and other things. The research is clear that horizontal eye movements work best for EMDR, but are not absolutely necessary. The "working memory people" (see 1. above) claim that since humans are hunter-gatherers, the brain's order-making abilities are best activated by quick, visual scanning of the landscape, as this is how food and lions would be identified in a chaotic situation. Francine Shapiro discovered EMDR while taking a walk in NY's Central Park! Regardless,
4. All of the above: This is what I feel is likely the case, if you study how other therapy methods work. Change that occurs in EMDR is the same change that would occur in any effective therapy, just more efficient and less likely to get stuck. Any therapy is essentially about resolving phobias. Anxiety is a phobia of something that might happen in the future. Depression is a phobia of of a loss of meaning. PTSD is a phobia of a traumatic memory, reflected in the terrible cost of feeling that it is still happening on some level. Proper therapy involves resolving the chaos by having the client face it and bring order to it in a useful way, as facilitated by a therapist. The indicator of the brain bringing order to chaos is the "orienting reflex," so in other words, bringing up that reflex specific to a client's complaint is the purpose of therapy.
When EMDR gets stuck:
All therapies involve real people and complexities that don't fit neatly in with theories of how the mind works. Some clients try EMDR (or any other therapy) unsuccessfully and say, "Well, it didn't work for me." In those cases, generally, the therapist had inadequate training to resolve the client's complex stuck-ness. EMDR as a process of stimulating the orienting reflex always works, as that's just a neurobiological process. However, if bringing up the orienting reflex with EMDR doesn't resolve a memory, as with any therapy, something is getting in the way, and needs to be addressed to get the process on track. The same thing is true of any therapy, and the solution in those cases would be similar--borrow ideas from other therapies. In more complex cases, other methods of therapy often need to be combined with EMDR, and from the first, many of these have been built into EMDR as a therapy, and even taught in the Basic Training for the method. Here are reasons for blocks to EMDR, and the common ways they are addressed (by me and many others):
1. More complex structural dissociation: Structural Dissociation is a theory specific to trauma disorders, and refers to how events in childhood create fractures in the developing mind, intense fears, which might be further complicated by adult trauma. Trauma is not just PTSD. Some common trauma disorders include attachment disorders, Borderline Personality Disorder, Complex PTSD, dissociative disorders, acute stress disorder, and many types of anxiety and depression. When dissociation is prominent, simple EMDR is going to get stuck, given that the part of the mind that needs treatment might be on the other side of one of these childhood mental fractures--on the other side of a canyon, essentially, rather than a ditch that can be easily bridged. To facilitate the EMDR process, the ditch must be closed up. One simple way to do this is to attend to the life chaos that surrounds the disorder with cognitive therapy, which builds up the "mental level" required to bridge the canyon. I had one client stop drinking energy drinks in the morning, and addressed issues of life motivation/meaning with cognitive therapy by drawing on family traditions. All of a sudden her trauma was easily treatable. In other cases, dealing with "parts" of the mind using Ego-State Therapy, which creates a "stage play" in the client's imagination, is useful for bridging a fearful gap that can't be bridged with language alone, but requires something like art. Exposure therapies are good too, as they address phobias that might be over-complicating the treatment issue. There are many other methods for obtaining the necessary mental level to carry out EMDR.
2. The "goldilocks" effect (too hot/too cold/just right): This is quite simply when a memory is so overwhelming that the client is either flooded with emotion (too hot), or entirely withdraws and is unable to bring up any emotion (too cold). Sometimes this is due to dissociation, as above, but not necessarily. We want things to be just right--realistically disturbing, such that the client can effectively confront the reality of what happened. Taking the temperature down generally involves teaching calming skills, to reduce the fight/flight problem. Getting the temperature up to a useable level can involve exposure therapies, or Ego-State Therapy to conceptualize fear as that of a scared child who needs help by a parent. This can resolve the freeze/submission problems. Some therapists wrongly believe that these issues are always due to trauma, and misuse the word "dissociation," when what is happening is a space-out or overload seen in many mental issues, like anxiety.
3. Inadequate internal resources: This is most clearly seen in people who have had a terrible childhood, such as foster-care teens. They have very little framework for making sense of terrible things, even if the orienting reflex makes it possible to release those terrible things for mental processing. In other words, mental processing requires that the memories that are released by EMDR have somewhere to go. Clients who were exposed to rich metaphors as a child, through a parent or teacher helping them learn to love reading, are rarely is severe trouble from even the worst trauma. This is also true of religious training, whether it is believed to be literally true, as religions often involve rich stories that address life meaning. When a client does not have these metaphors to incorporate resolved memories into, the resolved memories simply bounce back into trauma. I've seen it. Clients can, however, develop metaphors like this in therapy through Resource Development and Installation, a technique developed by EMDR therapist Andrew Leeds. This process draws on existing resources (a kind relative, a TV show character) to develop useful and more complex metaphors. Things get difficult when a foster kid, for instance, has very little ability to imagine anything that is not chaotic. That is serious damage, and explains why there is a foster-care-to-prison pipeline for young men. I have a blog on that. Such cases require that the therapist build a secure relationship with the child over a long period, so that the therapeutic relationship itself becomes a metaphor for secure attachment. But foster kids rarely have this long before they "disrupt" (lose) their placement due to bad behavior.
4. Inadequate mental energy: This means inadequate rest, food, water, exercise, and so on. Also drug use. All of these things artificially lower the mental level through exhaustion and distraction. I used to think that this was because the client has "bigger fish to fry," but that's not the case. For instance, I mentioned the client above who dealt with a dissociative disorder. That client's life didn't just remain complicated after we resolved the massive exhaustion from crashing after only having an energy drink for breakfast--it got even more stressful and complicated. But she was able to handle that and therapy at the same time with adequate resources.
Many drugs change the brain, and inhibit the ability to make meaning out of things, even when the client has adequate mental resources. This is why drugs can dull problems, but are never a solution. in the case of marijuana, the change can last for several weeks after the client is no longer actually high. Unfortunately, research has shown that legal drugs, such as Clonazepam, Valium, and Xanax, dull emotion artificially to the point that it's nowhere to be treated, and while life is more livable, there is no development of meaning, and quite often panic attacks still occur uncontrollably. However, most SSRI mood stabilizers (Wellbutrin, Prozac, etc.) and ADHD meds are a major aid to EMDR therapy.
One thing I should mention, as many clients have read about it: psychadelics are being used by therapists and researchers (or native cultures with thousands of years of experience) in highly specific and supervised ways to get around parts of the mind that have low mental energy to access parts that have adequate resources and mental energy. I have seen, however, that psychadelics used by clients in unsupervised ways, are not helpful and very often make things worse. Even when used properly, there is a risk to psychadelic use--I heard one Ketamine-clinic client refer to his experiences as "trips to Hell." I have a blog post or two on my skepticism regarding psychadelic use in therapy.
5. Lack of life balance, social support, or external stressors: these things, such as housing instability, use up so much of the mind through literal survival needs, that there is an inadequate mental level to engage in any therapy. Again, as with the client above that I mentioned, adequate mental energy and the development of powerful internal resources, can balance out life chaos. It's not "bigger fish to fry," but rather massive mental multitasking, that lowers brainpower.
As you can see, foster children often suffer from all five of the above issues. That's why I tell participants in EMDR Basic Trainings that are specialized for child/adolescent work, that one of them needs to write a book called, "The Treatment of Structural Dissociation in Adolescent Foster Care Males." Specialized methods for EMDR for this population would change America and cause the closing of most prisons.
The long and short of it
The above reasons, all of them, are why it is important when using EMDR to examine all aspects of a client's life, history, and relevant belief and support systems, and to address deficits affecting mental level with assignments and cognitive therapy. Some clients say, "EMDR works, I know--just wave your fingers in my face so I can end my nightmare." But I have to explain that EMDR needs adequate mental level, or it's just going to be another therapy fail that destroys hope all the more. As well, addressing mental level in all of the ways described above is healing in itself, and an invariably positive experience for my clients. Phase 2 of EMDR (there are 8 phases) is Preparation, and includes all of the above solutions. Above all, EMDR therapists try to care for the whole client, like any good therapist--they simply have faster and more effective methods for producing change at levels that are beyond the capacity of talk therapy and self-care.