The Emdr Procedure

Shapiro (1999) describes the eight phases of EMDR treatment. The first of these phases is 'client history and treatment planning'. The history taking is undertaken with the same degree of thoroughness that any good mental health clinician would employ when considering a client for psychotherapy. Particular emphasis will be placed on the nature of the client's psycho-pathology and the client's suitability for EMDR. Contraindications such as suicidal ideation, organic problems that could interfere with processing, and motivational issues, are assessed. Secondary gain factors accruing from the psycho-pathology are identified and may be addressed in the treatment plan. Suitable targets are identified for processing in the treatment phase. Such targets for processing or reprocessing are usually traumatic events or disturbing incidents seminal in the clients presenting problems. Present stimuli that trigger emotional disturbance in the client will also be targeted, as well as anticipated future situations that could elicit disturbance. The EMDR assessor will be particularly listening out for examples of trauma or critical incidents in clients' histories, as well as paying particular attention to the words clients use to describe themselves in relation to others and the world in general. These self-referential beliefs will give clues as to negative and positive cognitions in the assessment phase.

Phase two is called the 'preparation' phase. During this phase the emphasis is on establishing an appropriate therapeutic relationship, educating the client with regard to the effects of trauma and around reasonable expectations of EMDR, and teaching the client self control techniques. The use of metaphor is usually introduced at this stage to facilitate the creation of a manageable 'distance' for clients to reconnect with their traumatic material. This is part of a 'mindfulness' process (Teasdale, 1999) deliberately aimed at helping clients become their own observers. Emphasis is placed in the preparation phase on creating a sense of control and safety in clients, and in this regard clients are taught the use of a 'stop signal' to use if they wish to stop the procedure at any time, and also a 'safe place' is elicited and elaborated with the use of bilateral stimulation. This 'safe place' may be returned to from time to time during the procedure to give the client a sense of wellbeing and control.

The third phase is named the 'assessment' phase. During this phase the first memory to be reprocessed is targeted. A visual image or picture that represents the worst part of the traumatic memory is elicited. Next a negative belief or cognition associated with the identified picture is elicited. This negative belief needs to be meaningful in the present as well as in the old memory. Next a positive or preferred belief or cognition is elicited that the client would like to be able to believe. This positive belief is then rated on the 'validity of cognitions' (VOC) scale (Shapiro, 1989), which is a seven point semantic differential scale from disbelief to full belief. The emotions associated with the targeted memory are identified and the disturbance level in relation to the traumatic incident is rated on the SUD scale (Wolpe, 1958). Finally physical sensations and their location in relation to the targeted traumatic memory are elicited.

Each stage of this assessment stage is very deliberate. Traumatic memories may be held in any one of three modalities - visual in the form of visual memories and images, cognitive in the form of disturbing or negative thoughts in relation to the trauma and sensory in the form of physical sensations associated with the trauma. The EMDR assessment protocol is designed to tap into any one and all of these modalities in order that all traumatic feeder channels are accessed for reprocessing. Furthermore during this assessment protocol, the client is progressively brought into closer and closer connection with the whole traumatic experience, and it is only after the visual image, the negative and positive cognition, and the emotions associated with the trauma have been elicited that the disturbance levels (SUDS) is measured at maximal intensity. Finally the elicitation of a positive cognition is designed to point up the possibility to the client of irrationality in the negative belief and create an expectation of adaptive change. Identification of the physical sensations associated with the trauma is vital in that for some clients the physical sensory element may store the memory of the trauma most powerfully and be most closely connected to affective responses. Sometimes in EMDR clients are asked simply to notice their physical sensations as a means of facilitating processing or avoiding being overwhelmed by disturbing images or thoughts.

The next three phases of EMDR involve bilateral stimulation usually by means of sets of eye movements but possibly by auditory or tactile stimulation. Phase four is called the 'de-sensitisation phase'. To commence, clients are asked to focus on the visual image, negative belief, and associated physical sensations around the trauma, while following the eye movements but they are also instructed to just notice their experience and are informed that things may change. This injunction to just 'notice' their experience - a kind of 'mindfulness' -facilitates typically a free associative process across sets of eye movements in which the client will move in and out of exposure to the disturbing traumatic target. Sometimes unexpected material may arise, but all the clients experiences are accepted as associated in some way with the reprocessing and desensitising process, and as long as new information is appearing and there is movement of information, the desensitisation phase is kept going. Occasionally where clients get stuck or 'loop' (keep returning to the same material without reprocessing it), then an intervention called 'cognitive interweave' is used to introduce functional information into the clients' awareness to 'jump start' the reprocessing. However, in general one of the remarkable aspects of EMDR is that the therapist largely stays out of the desensitisation process and allows the client's adaptive and instinctive movement of information from dysfunctional to functional to occur spontaneously and naturally. Movement away from the traumatic target during EMDR desensitisation and reprocessing is not considered avoidance, but rather an essential part of 'cleaning out' feeder channels to those targets. De-sensitisation and reprocessing are continued until the targeted traumatic material no longer causes any disturbance at all, as measured on the SUDS scale, which will be down to 0.

Phase 5 is the 'installation' phase, during which the positive cognition is now paired with the original traumatic image, and belief in the positive cognition is strengthened with successive sets of bilateral stimulation and measured on the VOC scale. This phase finishes when the positive belief is rated 6, or ideally 7, on the VOC scale.

Phase 6 is the 'body scan' phase, in which clients mentally scan their bodies for any remaining physical signs of disturbance that may need reprocessing.

Phase 7 is the 'closure' phase, during which clients are re-introduced to self-control techniques and the safe place to give them a sense of wellbeing at the end of the session. In this phase the client is instructed as to keeping a diary of experiences following the session and up until the next session.

The final eighth phase is the 're-evaluation' phase where additional targets for reprocessing may be elicited.

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