How Does EMDR Therapy Work?

The first question I get when I talk about EMDR Therapy at a party is, “How does it work?”  I must confess this topic always seemed above my pay grade, but recently I took a look at some of the answers to the question as I prepare to deliver Basic EMDR training to a group of new therapists. Here for your reading enjoyment are a number of theoretical possibilities about how EMDR Therapy might work. None of these possibilities has been proven. And remember, it took 40 years to figure out exactly how penicillin works too.

1. Francine Shapiro, the creator of EMDR Therapy, at first thought something like Rapid Eye Movement sleep was at work. Our eyes refocus left to right during sleep, making it look like they are moving beneath our eyelids. She thought the fact that muscles in the eye relax during REM sleep, and the fact that EMDR seemed to mimic REM sleep, might mean that a relaxation response was being induced during the therapy. Inducing that response paired with trauma memory retrieval, she thought, might account for the resolution of trauma memories. Other researchers pursued this idea and suggested that various REM-like neurobiological mechanisms could facilitate activation of episodic memories and the integration of those memories into cortical semantic memory. But this explanation doesn’t account for how tones and tapping seem to work, judging from clinical practice, in addition to eye movements during EMDR Therapy.
2. Another thesis suggests that the part of the brain that performs working memory (i.e. our cognitive system with limited capacity responsible for temporarily holding information available for processing, like memory in a personal computer) gets overtaxed in EMDR Therapy. Pairing inner attention to the target memory and external attention to the bilateral eye movements has the effect of disrupting working memory, impairing the target visual memory, and reducing the vividness and emotionality of the traumatic memory.
3. The Orienting Response theory is another possible explanation of how EMDR Therapy works. The orienting response is something we all have that occurs when our attention is drawn to something of interest, a new stimulus. The theory goes that since the orienting response in EMDR Therapy is elicited by the alternating eye movements or tones at a time when there is no real danger, the ordinarily alarming reflex is then followed by relaxation. This makes it possible for the person to access and process traumatic memories without avoidance.
4. One intriguing theory comes from Ulrich Lanius and Uri Bergmann in Ulrich F. Lanius, Sandra L. Paulsen, and Frank M. Corrigan,Neurobiology and Treatment of Traumatic Dissociation: Toward an Embodied Self (2014). They propose that the sensory stimulation and sensory awareness built into EMDR (Eye movements, tapping, and sound tones) directly affect activity of the part of the limbic brain known as the thalamus. The thalamus consists of 50 groupings of nerve cells, neural tissue, and fibers in the limbic brain.  It is the main source for the external stimulation of the cortex, i.e. it is the sensory gateway to the cortex. Lanius and Bergman note that the thalamus acts as a relay station mediating processing from the top down, i.e. information from the cortex, and from the bottom-up, i.e. information from the brainstem. And they note the thalamus plays a key role in the integration of information across the three main parts of the brain. Lanius and Bergman suggest that the sensory stimulation and sensory awareness of EMDR Therapy affect thalamic activity, thus enabling the passing of previously dissociated, unprocessed memory material to the cortex for processing and formation of narrative memory.
5. Shapiro in her 2017 book, Eye Movement Desensitization and Reprocessing [EMDR] Therapy, Third Edition, notes these other factors of healing, which while not detailed neurobiological explanations, are important too:

• Small amounts of exposure to a past traumatic memory, carefully managed, have long been proven to facilitate healing from trauma
• The perceived mastery of repeatedly evoking and dismissing a memory improves self-efficacy
• Attending to somatic experience in the EMDR Therapy protocol creates an awareness of the changeability of experience. It creates some distance from the experience and so also increases self-awareness and self-efficacy.
• The cognitive reframing implicit in naming the negative cognition allows for an awareness of the impact of a memory and the irrationality of some beliefs
• By asking specific questions about the memory, the person is helped in reconnecting behavior, affect, sensation, and knowledge about an event.
• Free association elicited by the repeated question “What’s coming up now” gives access to aspects of experience not yet fully in consciousness and allows for possible integration
• The mindfulness instruction “Just notice” after each set helps counteract the fear of inner experience by encouraging people to notice their experience

Stay tuned as the search goes on to understand what effective mechanisms of EMDR Therapy are at work as we “Go with that” and “Just notice.”

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Hillbilly Elegy by J.D. Vance: A Review

Hillbilly Elegy by J.D. Vance is the story of growing up in a massively complicated, loving, and dysfunctional white family in Ohio and Kentucky at a time when good-paying jobs were disappearing. He also shows how his family suffered the transgenerational effects of addiction and violence.

Vance’s memoir is, in part, a love story portraying his relationships with hisgrandmother, “Mamaw,” who gave him stability and encouraged him to learn, and with his older sister Lyndsay, who parented him when his mother was in her addiction. He writes an hysterically funny account of what Vance calls Hillbilly culture. Mamaw, for example, threatened to run people over at regular intervals for various offenses.

Most interesting to me was his showing the bi-directional connections between family violence/addiction/alcoholism and the economic implosion of the Rust Belt against which all this dysfunction occurred. He shows how economic collapse and family collapse can feed on each other. He calls out his own people for what he sees as flaws, not taking responsibility for trying harder to pull things together. But the book is fundamentally one of thanks for his cultural inheritance, one that grounded him in a kind of family cohesion and dense connection that we all need to be whole and healthy.

Hillbilly Elegy is a a searing, endearing, life-affirming read. Thanks to Fareed Zakaria for recommending it!

Am I dissociating? Does it matter?

Do I dissociate? Yes, we all do. Some forms of dissociative behavior are a part of everyday life. Getting absorbed in a book or movie, or even a walk, can sometimes be considered dissociative. But if you are having more significant types of dissociation, it can be important to seek help. These are signs that your mind has had to be very creative to help you get through some very tough times in your life. Sometimes dissociated aspects of experience can slow down or halt normal development through life and really get in the way of having a good, productive, and meaningful life.

Examples of dissociation: For example, if you have stretches of time in your adult life that you cannot recall, and they are not related to substance abuse, it can be a sign of significant dissociation. Or, if you have “out of body” experiences in which parts of your body or the world seem distorted or not real, then it is important to get help. If friends describe your behavior in ways you don’t recognize or you find unexplained items in your possession, these too may be significant signs of dissociation. Flashbacks of smells, visual images, or thoughts that interfere with normal life are also examples of dissociation. Internal negative chattering of Internal voices can represent dissociation as well.

How can therapy help? Integrating dissociated aspects of oneself can increase personal power and effectiveness. It can increase your ability to focus and function. Through therapy the annoyance and pain of not being able to be focus and function in your life can be addressed so that you become more present and productive. In cases of dissociated identities, different parts of oneself also learn to work cooperatively together with psychotherapy. Remember, dissociation is treatable, and healing can happen!

Finding a Trauma Therapist

If you are looking for a therapist to help you work through childhood trauma issues, it is important to find someone experienced in trauma work. You want someone with whom you feel very comfortable. But chemistry is not everything! You want to know if a potential therapist has a good understanding of the importance of the preparation phase of therapy, i.e.grounding and resourcing, safety, and relationship building. Also, you want to know if the therapist is in a position to continue to offer you services, at a price you can afford, over time.

Sample questions to ask in choosing a trauma therapist:

• What portion of your practice is trauma?
• Do you consult with other trauma therapists?
• What methods do you use to process traumatic memories?
• What professional associations do you use to stay up to date on trauma studies?

A good therapist will not mind answering questions like this.  Asking these questions will help you assess his or her level of interest and expertise in the trauma field. Other questions to ask are:

• How do you prepare a client for trauma work?
• What cautions do you take in beginning memory work?
• How do you handle a client who is dissociating?
• What is you experience treating dissociative clients?

If alcohol and drugs are part of the picture of how you have coped with trauma, it is also very important that a therapist understand and have experience in these areas too. Don’t hesitate to shop around until you find someone you believe can truly help you.

What is Dissociation?

Dissociation is a disturbance or alteration in the normally integrative functions of identity, memory, and consciousness. Most people have experienced it at one time or another. A common example is “spacing out” on a bus or train and missing your stop. Dissociation could also involve mentally leaving one’s body and looking at it from a distance when experiencing a trauma. Or having a blank spell that is not associated with substance use. A dramatic case would be someone who travels to a new location and does not remember how or why he arrived there.

Think of dissociation as “dis-associating” or compartmentalizing different pieces of mental and emotional experience. It is a common part of everyday experience and also nature’s way of protecting us from overwhelming pain, a natural defense mechanism that helps us to survive in very painful experiences.  Dissociation interrupts the integration of information in the human brain.  It blocks the integration of memories into the present context. It also makes it impossible for someone to integrate an experience into personal memory or identity. Examples are amnesia (memory loss), depersonalization (changes in self experience), derealization (changes in the perception of reality), fugues (finding oneself in a new location after a blank spell), identity confusion, personality partition, and some physical experiences including motor weakness and paralysis.

Sometimes people continue to use dissociation long after it is really needed. It has outlived its usefulness as an intra-psychic defense mechanism. Sometimes dissociation shows up in therapy sessions as clients begin to work through and reframe old, difficult experiences. A good therapist can help clients who are dissociating learn to re-alert themselves and move out of the dissociative pattern to be more fully present. Individual psychotherapy can help someone with dissociative patterns learn more flexible, manageable coping strategies. And, of course, therapy can help you work through and resolve the difficult memories that made dissociation necessary.

Grounding Tools for Trauma Recovery

For people recovering from traumas, the first challenge can be to turn off the intense feelings, thoughts, and images that get in the way of beginning to work on the problem. Think of it as turning down the volume on a music device. Until you are no longer distracted by the blaring volume—of intrusive thoughts and images—it’s hard to focus on what you need to do next.

Turning down the volume is what grounding for survivors of emotional trauma is all about. It may seem counter-intuitive to begin trauma work this way, since you’ve probably always heard it’s good to get into and express feelings. But for trauma survivors, that’s not usually the best first step. What I, along with many other trauma psychotherapists, teach people to do instead is distract themselves by using grounding techniques as a way to begin the recovery process. These simple tools can re-focus your attention away from the intrusive feelings and pictures that are so troublesome and prevent you from getting started on recovery.

Lisa Najavits in Seeking Safety (2002) put together a wonderful list of grounding tools. I give this list to clients almost every day. The goal is to help the person feel more aware of his/her surroundings, to be more in the room and in the present moment, less distracted by old memories or feelings. Najavits’ easiest grounding tool is to think of your favorite color and find everything of that color in the room. Say each item out loud as you find it. After a minute of this, you will almost certainly feel more alert and re-oriented. It’s best to make sure room lights are on high, notice where you are, perhaps look someone in the eye if possible. You can also describe each thing in a room out loud until you feel more in touch with the present.

Another tool is to eat something slowly and describe the flavor to yourself. Try a raisin or a slice of ginger. Strong smells can also help to come back to the present. You could purchase a pleasant, strong scent from one of the bath/body shops around and use it as a grounding tool. For more mental grounding tools, think of all your favorite movies, or clothing stores, or baseball players. You can also run your hands under warm and then cool water, alternating so that your attention goes to the sensations present in your hands and away from the intensity of emotion or memories.

All these exercises refocus and distract your mind and give you evidence that you have some control over intrusive experiences resulting from past traumas. If feelings seem to overwhelm you, take a moment and use one of the tools. Start to practice them regularly. Other similar tricks might occur to you that also do the job. Pretty soon you may begin to experience relief that you can turn down the volume of disturbance temporarily, long enough to give yourself some relief and get started on a longer term recovery plan. Of course, grounding techniques are just the first step in recovering from trauma, but succeeding at this first step can give you great hope and confidence that recovery is possible.