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EMDR: Rewiring a Traumatised Brain

Light beam used in EMDR therapy

Eye Movement Desensitisation and Reprocessing (EMDR), is a type of psychotherapy which was primarily designed to effectively process traumatic memories, whilst disassociating from the feelings of distressed they are connected to. The Adaptive Information Processing (AIP) model, on which EMDR was developed, suggests that the patient's current issues have their origins in past events that the brain has incorrectly retained and therefore must be reprocessed in a safe and efficient way. EMDR allows the brain to access memories that may otherwise be unreachable for an individual with PTSD, through the use of rapid eye movements. When successful, the treatment can achieve a newfound positive belief system, reduced anxiety and mood issues previously triggered by memory and sensory stimuli and a reduction/complete stop of flashbacks, intrusive imagery and nightmares.

EMDR therapy has been named as a successful therapeutic approach in the treatment of trauma disorders such as Post Traumatic Stress Disorder (PTSD) by the majority of worldwide practice guidelines. In comparison to other therapeutic interventions for trauma, for example Trauma Focused CBT (TF-CBT), although they are still effective treatments, EMDR has been found to take the least time to show positive changes.

The post-trauma response

Studies have shown that 80% of people will experience at least one traumatic event within their lifetime, however only 10% will go on to develop PTSD. PTSD occurs when trauma is not processed properly due to the activation of the fight, flight, freeze or fawn response. When an event which threatens a person's safety, life or threatens little to no chance of escape, it can be too much for the brain to comprehend. The brain essentially 'shuts down', entering a state of dissociation and depersonalisation which consequently causes the memories to become 'stuck' and prevents memories from being able to process in the usual way. Reliving and avoiding the memories alternate biphasically in PTSD. Reliving is the process by which ingrained experiences recur in your consciousness as intrusive thoughts, nightmares, or flashbacks. A sight, sound or smell can trigger a memory to resurface. The content of the patient's most frequent thoughts and imagery, also referred to as 'hotspots', will best guide the clinician on what to focus on during EMDR. Research has shown that it is believed that concentrating the aforementioned hotspots through imaginal exposure will alter the significance they hold, which is necessary for a decrease in symptoms associated with PTSD.

A neurobiological view of trauma

The hippocampus integrates context and perceptual patterns to process memories. It is able to differentiate between anxiety and danger for example in traumatic events that happened many years ago compared to those that have occurred more recently. People release endogenous stress hormones in response to extreme stress, which affects how well memories are consolidated. In 1994, Bessel van der Kolk found that a key factor contributing to the lasting intensification of traumatic recollections is the large release of neurohormones during the trauma. He further supports his findings by quoting LeDoux's work "the norepinephrine's input to the amygdala is a major facilitator of this phenomena".The amygdala is overstimulated, which impairs hippocampus function and prevents cognitive, analytical experience assessment and semantic interpretation. Then, memories are retained in physical experiences, visual images, and sensory and motor functions, which restricts the potential for unified episodic remembrance recollection in the future.

The process of EMDR

EMDR has eight stages of treatment:

Stage 1: The clinician will take a full history of the patient trauma(s) in order to gain a full understanding of their experiences, gain a clearer understanding of the patients current mental state and identify any notable hotspots to address during treatment. The clinician will create a treatment plan, outlining goals for change with the intention of these being met by the end of treatment. EMDR has shown to be effective after just 5 hours of treatment in single trauma victims. However, where multiple or prolonged traumas have occurred, the patient may require a longer treatment timescale, though this does not equate to their symptoms being any less treatable.

Stage 2: The clinician will complete a phase of stabilisation work with the patient. This involves the patient being provided with the necessary coping strategies and tools to put them in the best position for managing the inevitable feeling of distress that accompany having to address the traumatic events head on during EMDR and between sessions. For example, the patient may be taught grounding techniques to help them remain psychologically present when recalling trauma.

Stages 3-6: The patient is now ready to begin EMDR. During the reprocessing, the patient responds to emotionally distressing content whilst keeping their attention on an outside stimulus. The most typically utilised being lateral eye movements coordinated by the clinician, however additional methods such as hand tapping can alternatively be employed. Focusing on rapid eye movement, the clinician will set up a light beam directly across from the patient. The beam shows a coloured light, which can be set to green, red, blue or white depending on the patient's personal preference. The light will travel across the beam from left to right at a series of speeds controlled by the clinician throughout the processing. Rapid eye movements will repeatedly stimulate the left and right hemispheres of the brain, literally moving memories across to process traumatic memories just as the brain would process everyday memories.

The clinician begins by asking the patient to bring the image of an earlier identified hotspot to the front of their mind. The patient will then be asked to follow the travelling light with their eyes whilst letting the starting image of the hotspot play out in their mind. The clinician will then pause the light frequently and ask the patient what they are remembering. It is important to remember that it does not matter if the imagery is playing out in order, as particularly for complex trauma patients, it may jump to different periods of their life. However this is just the brain trying to process different memories that have become stuck and entangled over time. A patient may also have what are referred to as blanks or blocks in their memory, a type of amnesia where the brain has found parts of the experience(s) so traumatic that the patient is not able to recall them. Such blocks are likely to be recovered during the reprocessing stage of EMDR, but within a safe environment can be digested and worked through with the support and guidance of the professional present.

Throughout this process, the patient will then be asked to address what negative beliefs about themselves are attached to these memories. Often individuals with PTSD report feelings of guilt, grief, anger and shame associated with their hotspots. These intense and uncomfortable feelings can lead avoidance and low self esteem which in turn creates further anxiety and feelings of loneliness. Further into the treatment once the target memory no longer holds feelings of distress for the patient, the clinician will ask them to name a preferred positive belief about themselves related to the hotspot. For example the belief may change from "I feel it was my fault" to "it was not my fault, I did everything I could". Scaffolding this shift in self-belief on the first memory, will allow the clinician to help the patient transfer this to other memories as the work continues.

Alongside identifying imagery and shifting beliefs, the clinician will ask the patient what emotions and sensations are happening for them during this process. The patient will be encouraged to just notice what they are feeling and to simply let themselves experience this. The brain can often automatically avoid experiencing these feelings, therefore it is important to re-teach the brain there is no longer a threat in the present. By doing so, the brain learns that it doesn't need to trigger a fear response when memories occur, which can help to differentiate between the past and the present.

Stage 7: Achieving Closure. Outside of the EMDR sessions, the patient will be asked to keep a diary of anything that may arise for them outside of sessions, such as nightmares or trauma memory activation. The clinician will encourage the patient to use the stabilisation skills learnt in stage two to practice effective coping strategies which they can refer to and use successfully in everyday life.

Stage 8: Progress will now be assessed by the clinician and a plan will be drawn up focusing on what skills have been helpful for the patient throughout this process and how they can now take these with them to use in the future and continue progressing.