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Section 11
Steps in EDMR

Question 11 | Test | Table of Contents

In the last section, we discussed the eye movement technique that can be used by your PTSD client as a quick distraction and a way to gain temporary relief from distressing thoughts

In this section, we will discuss the technique Eye Movement Desensitization and Reprocessing (EMDR). While this is probably a review for you, it may be helpful to brush up on the basics of EMDR as you share the technique with your PTSD clients.

To begin, I would like to discuss the fact that the "eye movement" part of EMDR is a bit of a misnomer. Originally clients were asked to move their eyes back and forth as they focused on a specific traumatic image. However, there are several more bilateral or two-sided stimulations that can be used. To name a few, your client can tap both sides of their body, hear tones in alternating ears, or experience the tingle of buzzers from tactile pulsars in alternate hands.

I have outlined the steps of EMDR below. This summary outline is intended to act as a quick, helpful reference for you as well as for your client as you teach them the technique.

EMDR steps:
1. Begin by going over client history. I began the EMDR process with Taylor, 30 years old, who was active duty in the army for four years. Taylor explained that he sought counseling because, "I was getting tired of drinking, breaking down, fighting, and generally feeling like I wanted to strangle someone at all times. I just got a new girlfriend and I didn’t want to subject her to my breakdowns." When we began counseling, I helped Taylor realize that his experience in the army has led to his PTSD and the subsequent outbursts he was having.

Taylor recalled, "It is just that civilian life is so different from my four years in combat. I have never been shot at in my civilian life. I have never been blown up in my civilian life. I haven't lost an "adopted" child to a suicide bomber in my civilian life. And I haven't had to listen to a man's death over the Med-Evac frequency in my civilian life. I somehow lived through each of these events during my service."

2. Work together to identify a distressing traumatic event or image to target for treatment. These can include any events or images from your client’s past that seem to be related to their current source of distress. For Taylor, this distressing traumatic event was watching a child be blown up by a suicide bomber.

Taylor recounted to me, visually disturbed by the event, "I was headed for the child since we knew the bomber was in the area and we were tasked with securing the area. The child was sobbing, sitting in the middle of the road. I was shouting to him to come over when another person appeared. Everything went into slow motion as I watched the limbs of the child sever from his body. There was nothing left of him when we looked through the rubble. He couldn’t have been more than 10 years old."

3. Clients identify their most negative image along with the negative belief about themselves that this image has come to mean. The negative believe that Taylor held about himself that the image of the dead child came to mean was that he was helpless to effect change in the world. Taylor stated, "Not being able to save that child’s life just symbolizes how I felt the entire time in the army, I was just one tiny ant in a chaotic human world."

Clients then identify emotions and body sensations that their image evokes. When going through this step, Taylor acknowledged that each time he returned to the image of the child, he would tense up, clinching his jaw and feeling all his muscles tighten. Taylor also acknowledged that he felt upset each time the image returned.

4. Walk through with your client rating each individual part of step 3 (the image, negative beliefs, emotions, and body sensations) based on their intensity. This is best done on a numerical scale, 1 meaning least intense and 10 being the most.

Taylor stated that the intensity of the image he held wasa 9. He acknowledged that the belief was less intense at an 8 but that the emotions and body sensations were a 9 in intensity. Taylor stated, "How I feel and what is going on in my body is all consuming."

5. Clients then focus on their image while they move their eyes back and forth. Typically, you can help your client do this by moving your finger across his or her field of vision for twenty or thirty seconds or more. Shapiro, who developed the method, refers to this as "dual attention"- focusing on the image and the external stimulation.

If the eye movement is not the best suited for your client, you can assist him or her in trying different bilateral stimulation such as a light bar, hand or knee tapping, auditory tones, or others. Taylor found hand or knee tapping more effective than following my finger so we switched to doing tapping.

To clarify, both a light bar and auditory tones are equipment that can be purchased that do the work of creating a bilateral stimulation. A light bar consists of a series of lights that will alternate lighting up, in a back and forth motion. Auditory tones alternate various tones in the left and right ear while the client is wearing headphones. I have included some resources that may be helpful to explain the bilateral stimulation to your client.

EMDR + Audio Bilateral Stimulation: https://www.youtube.com/watch?v=t_nMaJyfYmU

Helpful EMDR App: http://emdrelite.com/

6. After this, you can encourage your client to let his or her mind go blank and just notice whatever thoughts, body sensations, and emotions come into his or her awareness. Again, assist your client in rating and note each aspect of this experience. For example, Taylor initially rated his image a 9 but after several dual attention sessions he rated the same experience a 7. He also noticed his emotions and body sensations were not as powerful and rated them a 6. As he distanced himself from his image, the belief of helplessness he felt, he rated a 7.

7. These steps are repeated until the client experiences no distress or significantly reduced distress from the image. When I went over this with Taylor, he became frustrated when he still felt distress in association with the image of the death of the child civilian by a suicide bomber. I stated to Taylor, "While it is upsetting to still feel distress arround this particular image, it is important to realize that the distress you are feeling has diminished since we first started based on your ratings. This is a step in a positive direction."

8. To end the process, encourage your client to think about a positive belief that he or she identifies. Your client can then focus on their traumatic image and eye movements. After several rounds your client may begin to adhere more to the positive belief. The positive belief that Taylor identified was that he had the strength to overcome his PTSD.

Keeping a Journal:
I have found it beneficial with clients going through the EMDR process to maintain a journal during the weeks following. Encourage your client to document anything else that might arise. This journal can also better help your client work through any related images or images emerging from the past or anticipating in the future that are connected with the original incident.

For Taylor, he was resistant to writing in a journal. However, due to his desire to control his PTSD and his harmful outbursts to maintain his healthy relationship with his new girlfriend, he was motivated to write daily about his PTSD.

Some insight into how EMDR works:
The goal of EMDR is to eliminate emotional and somatic distress in a very short time, while producing cognitive insights and shifts in self-perception. During the EMDR session, distraction occurs from the dual attention requirement and because of the way the session is structured clients are able to reach this goal without reactivating a cascade of traumatic symptoms.

I have found that sharing EDMR videos with clients is helpful in their understanding of the technique and how it relates to their PTSD.
Here are three videos I have found helpful:
1. EMDR explained by James Alexander: https://www.youtube.com/watch?v=cMtrwFIRaTA
2. EMDR Therapy for PTSD: https://www.youtube.com/watch?v=sWS-TADSbJ4
3. EMDR- Eye Movement Desensitization and Reprocessing: https://www.youtube.com/watch?v=hJDrMDT_ezU

Do you have a client like Taylor that can benefit from using the EMDR technique and learn to process the negative images sparked from his or her PTSD?

In this section, we have gone over a summary of the steps to EMDR. These steps are going over client history; identify a distressing traumatic event; identify most negative image; rate the intensity of each part of the image; focus on the image while moving their eyes back and forth; let your client’s mind go blank and notice thoughts, body sensations, and emotions; repeat the steps; and incorporate a positive belief into the process. We also discussed that your client may find it beneficial to maintain a journal while going through the EMDR process.

In the next section we will discuss the Emotional Freedom Technique (EFT).

Naparstek 290- 295 case study: http://gawker.com/ptsd-and-me-true-stories-from-military-veterans-1167107848

EMDR beyond PTSD: A Systematic Literature Review

- Valiente-Gómez, A., Moreno-Alcázar, A., Treen, D., Cedrón, C., Colom, F., Pérez, V., & Amann, B. L. (2017). EMDR beyond PTSD: A Systematic Literature Review. Frontiers in psychology, 8, 1668. doi:10.3389/fpsyg.2017.01668
Reviewed 2023

Update
The effect of the online eye movement desensitization and reprocessing early intervention protocol (EMDR R-TEP) for the risk groups with post-traumatic stress symptoms during the COVID-19 pandemic

Yurtsever, A., Bakalim, O., Karaman, Ş., Kaya, S., & Konuk, E. (2022). The effect of the online eye movement desensitization and reprocessing early intervention protocol (EMDR R-TEP) for the risk groups with post-traumatic stress symptoms during the COVID-19 pandemic. Frontiers in psychology, 13, 935782. https://doi.org/10.3389/fpsyg.2022.935782


Peer-Reviewed Journal Article References:
Balbo, M., Cavallo, F., & Fernandez, I. (2019). Integrating EMDR in psychotherapy. Journal of Psychotherapy Integration, 29(1), 23–31. 

Houben, S. T. L., Otgaar, H., Roelofs, J., Wessel, I., Patihis, L., & Merckelbach, H. (2021). Eye movement desensitization and reprocessing (EMDR) practitioners’ beliefs about memory. Psychology of Consciousness: Theory, Research, and Practice, 8(3), 258–273.

Jowett, S., Karatzias, T., Brown, M., Grieve, A., Paterson, D., & Walley, R. (2016). Eye movement desensitization and reprocessing (EMDR) for DSM–5 posttraumatic stress disorder (PTSD) in adults with intellectual disabilities: A case study review. Psychological Trauma: Theory, Research, Practice, and Policy, 8(6), 709–719.

McLay, R. N., Webb-Murphy, J. A., Fesperman, S. F., Delaney, E. M., Gerard, S. K., Roesch, S. C., Nebeker, B. J., Pandzic, I., Vishnyak, E. A., & Johnston, S. L. (2016). Outcomes from eye movement desensitization and reprocessing in active-duty service members with posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 8(6), 702–708. 

Shapiro, R., & Brown, L. S. (2019). Eye movement desensitization and reprocessing therapy and related treatments for trauma: An innovative, integrative trauma treatment. Practice Innovations, 4(3), 139–155. 

QUESTION 11
What are the eight steps involved in the EMDR process? To select and enter your answer go to Test.

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