Transcript Emdr - Florida Alcohol and Drug Abuse Association

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