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Trauma unwound: EMDR therapy uses eye movement to process pain

EMDR therapy

Recovering from trauma is never a walk in the park, but one of the most powerful tools to help patients do so, EMDR therapy, sure started out that way.

EMDR — Eye Movement Desensitization and Reprocessing — is the brainchild of psychologist Francine Shapiro, who began her career as an English teacher before being diagnosed with breast cancer in the late 1970s. After she recovered, she moved across the country and settled in rural California, where she taught communication at San Jose State University.

According to her obituary, published in the British newspaper The Guardian [1], “She had become interested in health, especially in the interaction between mind and body, and on a walk in May 1987 noticed her eyes moving rapidly from side to side, while at the same time disturbing thoughts in her head became less intrusive. She said: ‘The thoughts weren’t as bothersome. I wanted to see if it would work if it was deliberate, so I brought up something that bothered me, moved my eyes in the same way and saw the same thing happening.’”

From that fateful walk was born a powerful psychotherapeutic tool that’s been tested in a number of trials and is now practiced around the world. It’s an innovative technique to help patients deal with traumatic events, experiences and memories that continue to have a negative impact on their mental, emotional and physical health and well-being.

Trauma and the Brain

EMDR therapyThe role trauma plays on the mental and emotional states of those who experience it has been the subject of recurring, and sometimes fierce, debate in psychiatric circles. Writing for the journal Psychiatric Clinics of North America in 1994, a trio of physicians wrote [2] “Although the traumatic memories that haunt people after experiencing overwhelming terror have always been a central theme in literature, psychiatry has suffered periodically from marked amnesias in which well-established knowledge was forgotten abruptly, and the psychological impact of man’s inhumanity to man was ascribed to constitutional or intrapsychic factors alone.”

It wasn’t until the 19th century, when medical practitioners began to consider the unseen injuries of the most complex of human organs, that psychiatry was born, “when 13 asylum superintendents assembled to form a guild that is now the American Psychiatric Association. They published their proceedings in the American Journal of Insanity. While the name may sound quaint and politically incorrect, it is remarkable that the issues they discussed are virtually the same as those being discussed by psychiatrists today: the classification of mental disorders, asylum care, international approaches to mental illness, prevention of harm, and somatic therapies.” [3]

Two decades later, the American Civil War would give rise to a notable number of injuries that weren’t caused by bullet wounds or battlefield injuries. There were, notes the publication Trauma-Informed Care in Behavioral Health Services [4], a publication of the Substance Abuse and Mental Health Services Administration (SAMSHA), “accounts described the effect of battle conditions on soldiers; ‘soldier’s heart’ and ‘nostalgia’ were the terms for traumatic stress reactions used during the American Civil War.”

As the 20th century dawned, two neurologists in particular — Pierre Janet and Sigmund Freud — were “exploring a condition that affected both mind and body and that left no detectable trace in brain tissue: hysteria. The symptoms included wild swings of emotion, tremors, catatonia, and convulsions,” according to a piece in The New Yorker [5]. “Janet contended that patients ‘split off’ memories of traumatic events and manifested them in an array of physical symptoms. He advocated hypnosis as a means of accessing these memories and discovering the causes of a patient’s malady. Freud believed that traumatic memories were repressed and consigned to the unconscious. He developed an interview method to bring them to consciousness, interpreted dreams” and advocated sexual repression as a source of mental disturbance.

While both men advocated their various approaches based on what medical and psychological means they had at their disposal at the time, both points of view, interestingly, touched tangentially on what would later be implemented as part of standard EMDR therapy.

Trauma in the Modern Age

World War I made the prospect of mental injuries due to warfare a hot-button topic of mental and medical health professionals, so much so that a schism, of sorts, developed between the faction that insisted there was a biological cause for brain ailments and those who believed them to be more psychological in origin. According to The New Yorker [5], “the biological camp embraced the idea that microbes in the intestine, the mouth, or the sinuses could release toxins that impaired brain functions,” while the other side began to lay blame at the feet of mothers in American society: “Mothers bore the brunt of this new diagnostic scrutiny,” which “replaced Freudian tropes with a focus on family dynamics, especially the need for emotional security in early childhood.”

On the military front, trauma was one of the medical conditions of World War 2 that wasn’t discussed. Despite the fact that 300,000 men were discharged from the military during World War 2 for psychiatric reasons — 43 percent of all medical discharges — the effects “remain shrouded in secrecy … Americans who volunteered went to war on the heels of the Great Depression. They came from a social and cultural landscape that stressed stoicism and uncomplaining fortitude. As long as they could generally function in society, it was believed that they were recovered. So the servicemen who came home from Berlin or Tokyo stayed quiet, and the emotional toll of the war remained secret.” [6]

The continued involvement of U.S. forces on battlefields around the globe, however, meant that psychological injuries could hardly be swept under the rug. According to the SAMSHA publication [4], “During the Korean and Vietnam wars, approaches began to focus more on the use of talk therapy. It was not until the post-Vietnam era that interest in developing treatment alternatives started to take hold. During this time, the U.S. Department of Veterans Affairs (then called the Veterans Administration) developed group therapy for posttraumatic stress disorder (PTSD). Beyond being cost-effective, the technique was well suited to the symptoms of the veterans and fostered socialization and reintegration.”

By 1980, Post-Traumatic Stress Disorder became an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM), and the next several decades saw an expansion of that definition to included traumas suffered outside of military service. In 1995, Dr. Karen Krinsley and Dr. Frank Weathers, writing for the publication PTSD Research Quarterly [7], noted that “there is a growing recognition that traumatic stress is a complex, multifaceted construct and that its assessment entails considerable conceptual ambiguity and practical difficulty. Many investigators have called for a multidimensional approach to the assessment of traumatic life events, and new, more sophisticated instruments are beginning to emerge in response to this demand.”

EMDR therapy is born

EMDR therapyIn a 2012 interview with Time [8], Shapiro recalled her famous walk: “I noticed that some disturbing thoughts I was having were suddenly disappearing. When I thought to bring them back, they didn’t have the same charge any more … what caught my attention was that they were the kind of thoughts that you generally had to do something about [in order to make them go away]. I started paying close attention and I noticed that when that thought came to mind, my eyes started moving in a certain way and the thoughts shifted from consciousness and when I brought them back, it wasn’t that intense.”

The specific movements, she detailed were “very rapid diagonal” ones, known as saccadic movements. Using herself as a test subject, she called to mind other worrisome thoughts and moved her eyes in the same manner, and found that it reduced stress around those thoughts as well. She then approached friends and relatives, using them as guinea pigs to help relieve their own stressors, and every time, Shapiro recalled, the eye movements proved beneficial.

So excited by the concept, Shapiro rushed into an initial study that showed promising results [9]: “The results of the study indicated that a single session of the EMD procedure successfully desensitized the subjects' traumatic memories and dramatically altered their cognitive assessments of the situation, effects that were maintained through the 3‐month follow‐up check,” she wrote in 1989. “This therapeutic benefit was accompanied by behavioral shifts which included the alleviation of the subjects' primary presenting complaints.”

However, the relatively new field of PTSD therapy, as well as the radical methods involved in EMDR therapy, led to significant pushback. In her interview with Time [8], Shapiro expressed some regret for publishing her findings so quickly: “The view of field was that PTSD was pretty impossible to treat and here I published an article on a randomized controlled study showing positive effects after one session and with eye movements, which didn’t make any sense,” she said.

For Shapiro, there seemed to be a connection to the behavior of the brain during REM sleep cycles, particularly the movement of the eyes. According to The EMDR Institute Inc., founded by Shapiro, she [10] “continued to develop this treatment approach, incorporating feedback from clients and other clinicians who were using EMD. In 1991 she changed the name to Eye Movement Desensitization and Reprocessing (EMDR) to reflect the insights and cognitive changes that occurred during treatment, and to identify the information processing theory that she developed to explain the treatment effects.”

According to The Guardian [1], “The EMDR ‘bible’ — ‘Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures’ — followed in 1995. That year, too, she received a phone call asking for help in the aftermath of the Oklahoma (City) bombing, which killed 168 people and traumatized thousands more. The result was the EMDR Humanitarian Assistance Program. There are now over 60 ‘trauma recovery networks’ with practitioners offering free EMDR to people affected by disasters.”

What is EMDR therapy?

According to the American Psychological Association [11], “Unlike other treatments that focus on directly altering the emotions, thoughts and responses resulting from traumatic experiences, EMDR therapy focuses directly on the memory, and is intended to change the way that the memory is stored in the brain, thus reducing and eliminating the problematic symptoms.”

In psychology, trauma can manifest in two forms: big “T” traumas, such as violent or catastrophic events like military combat, sexual assault or natural disasters; and little “T” traumas, which might seem benign on the surface — rejection or public humiliation, for example — but still cause emotional harm. The brain processes both in the same manner: “The sympathetic nervous system is aroused, the body is flooded with neurochemicals like cortisol and adrenaline, certain body functions like the immune system and the digestive system are shut down, and the traumatic events are cataloged as fragmented memories, shards of thoughts, images, emotions and body sensations that can trigger a full-body response to the most benign of stimuli,” according to a 2018 story in The Daily Times newspaper [12].

EMDR therapy practitioners start with those fragmented memories in the form of a measurement known as a Subjective Unit of Disturbance, and patients are cautioned that discussion of their traumas can elicit those same physical and emotional reactions. However, they’re also instructed to focus on that agitation and tension as they begin a series of therapist-directed eye movements. As they follow a therapist’s fingers or assigned objects, they’re asked to recall the memories — not for the sake of discussion, but to simply recall them like scenes from a film.

“Patients follow the moving fingers of the therapist, which move back and forth, from left to right, across the patient’s field of vision [12]. The rapid movement of the eye serves in part as a distraction mechanism, and brain scans have shown that the pattern of electrical activity caused by the movement helps to change the emotions surrounding the trauma memory. It becomes less visceral, and patients are able to examine it with a sense of detachment that allows them to make sense of it and understand it on an intellectual level.”

The science behind it is still shrouded in the mysteries and complexities of the brain, an organ that holds its secrets well. According to a piece in the publication Scientific American [13], “EMDR proponents have invoked a dizzying array of explanations for the apparent effectiveness of the lateral eye movements: distraction, relaxation, synchronization of the brain's two hemispheres, and simulation of the eye movements of rapid eye movement (REM) sleep have all emerged as candidates. In conjunction with their therapists, EMDR clients also learn to replace negative thoughts (such as ‘I’ll never get this job’) with more positive thoughts (such as ‘I can get this job if I try hard enough’).”

EMDR therapy and addiction recovery

EMDR therapyIn the field of addiction treatment, EMDR therapy can be a game-changer for patients whose addiction and/or alcoholism developed out of trauma, or who experienced trauma while drinking and using. As the National Association of Alcoholism and Drug Abuse Counselors points out [14], “many individuals with substance use disorders also have experienced one or more traumas. Treatment for these co-occurring disorders should be integrated and the use of EMDR can be helpful for some people.”

Since Shapiro’s initial trials, EMDR has undergone rigorous testing in various medical and psychiatric settings, and the results are fairly unwavering: A substantial amount of research indicates that adverse life experiences may be the basis for a wide range of psychological and physiologic symptoms. EMDR therapy research has shown that processing memories of such experiences results in the rapid amelioration of negative emotions, beliefs, and physical sensations,” Shapiro wrote in 2014 for the Permanente Journal [15]. “Reports have indicated potential applications for patients with stress-related disorders, as well as those suffering from a wide range of physical conditions.”

The same year, a study in the Journal of Psychoactive Drugs concluded that “PTSD symptoms can be successfully treated with standard EMDR protocol in substance abuse patients.” [16] In a 2016 contribution to U.S. News and World Report, substance abuse counselor Paige Maurer detailed [17] her own experiences with EMDR in an addiction treatment setting, stating that when EMDR therapy is used, “the uncomfortable symptoms of post-traumatic stress diminish and the client has a greater, more positive outlook of their situation. They no longer feel like a victim and are able to move forward and focus on other important aspects of their substance abuse treatment.”

Speaking to the addiction recovery website The Fix in 2015 [18], Dr. Jamie Marich said, “Since the beginning of my journey with EMDR in 2004, I've long viewed it as an effective relapse prevention/recovery enhancement strategy that truly targets trauma. It's been clear to me from the beginning of my own journey with recovery, and as a treatment provider, that unhealed PTSD and other trauma-related disorders pose a clear relapse risk. If we accept that unhealed traumatic wounds play a major role in causing or at the very least exacerbating the seriousness of substance use and addictive disorders, yes, EMDR therapy can be very effective.”

It’s a new frontier of EMDR therapy, but it’s one Shapiro was just as passionate about in the final years of her work. Writing for the book “Innovations in the Treatment of Substance Addiction,” she advocated [19] that “integrating treatments for co-occurring trauma and addiction with EMDR therapy will help resolve the traumatic experiences that contribute to addiction and restore people to the promise of a sober and healthy life.”

Across the country, EMDR is now standard protocol in many addiction treatment programs, especially when combined with other therapies like Cognitive Behavioral Therapy and Cognitive Processing Therapy, and for good reason: It is evidence-based psychotherapy that provides another avenue toward the end goal of addiction treatment as a whole: a new way to live, free of the pain of the past.

SOURCES

[1]: https://www.theguardian.com/science/2019/jul/15/francine-shapiro-obituary

[2]: https://www.sciencedirect.com/science/article/abs/pii/S0193953X18301023

[3]: https://www.psychiatrictimes.com/history-psychiatry/trip-through-history-psychiatry

[4]: https://www.ncbi.nlm.nih.gov/books/NBK207202/

[5]: https://www.newyorker.com/magazine/2019/05/27/the-troubled-history-of-psychiatry

[6]: https://www.washingtonpost.com/news/made-by-history/wp/2018/06/26/the-wartime-origins-of-a-disorder-that-plagues-rape-victims-at-even-higher-rates-than-veterans/

[7]: https://pdfs.semanticscholar.org/639c/792fea0868d5a988e2a7b7696af8c461aa1e.pdf

[8]: http://healthland.time.com/2012/04/18/getting-past-your-past-qa-with-therapist-francine-shapiro/

[9]: https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.2490020207

[10]: http://www.emdr.com/history-of-emdr/

[11]: https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing

[12]: https://www.thedailytimes.com/news/addiction-center-uses-eye-therapy-to-treat-trauma/article_6d546197-0d28-5f02-aabf-f3b7a6b6eb37.html

[13]: https://www.scientificamerican.com/article/emdr-taking-a-closer-look/

[14]: https://www.naadac.org/the-use-of-emdr-therapy-in-the-treatment-of-addiction

[15]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951033/

[16]: https://www.ncbi.nlm.nih.gov/pubmed/25188700

[17]: https://health.usnews.com/health-news/patient-advice/articles/2016-07-18/self-medicating-to-cope-with-trauma-how-emdr-therapy-can-help-in-substance-abuse-treatment

[18]: https://www.thefix.com/can-emdr-treat-addiction

[19]: https://www.researchgate.net/publication/308925851_EMDR_Therapy_and_the_Treatment_of_Substance_Abuse_and_Addiction