IMPLEMENTING EMDR THERAPY: REFLECTIONS AFTER TRAINING WITH FRANCINE SHAPIRO
Some years ago, I had the distinct privilege of spending several days training with Francine Shapiro at Sea Ranch, California along with other trainers-in-training for EMDR Trauma Recovery/HAP. Roy Kiessling of EMDR Consulting was an EMDR HAP trainer at the time and recommended me for this experience. Nerve wracking and exhiliarating all at the same time, I greatly benefitted from learning from her as well as other expert EMDR clinician educators in the field.
We all know Francine is brilliant and not surprisingly, she has a razor sharp mind. It was an incredible honor to be with someone who has changed the world and truly sees EMDR treatment as a path to world peace. She sustains the capacity to be moved by successful EMDR treatment stories and continues to deal with the 'politics of science' to clarify and broaden the understanding of EMDR psychotherapy. Her goal was to assist us in being as clear as possible about our language and the Adaptive Information Processing model, the basis of EMDR therapy and application to specialty populations.
Several of the trainers in training were active military. These fine men were able to share the wonderful work they are doing with EMDR to change the lives of so many who suffer with PTSD. Not surprisingly, they often find unprocessed adverse childhood memories as the foundation for later development of trauma symptoms in the military.
Yes I enjoyed being in California by the ocean (what Iowa woman doesn't!) but what did I take away from that experience? Here's a brief recap that may also serve as a review for others as it did for me. I learned greater clarity on the AIP model, the foundation of EMDR psychotherapy. The Adaptive Information Processing Model states that the cause of pathology is unprocessed memories from disturbing life experiences and the agent of change is reprocessing those memories to adaptive resolution. 'Adaptive resolution' means learning that results in functional behaviors and mental health.
I was reminded that Phase 4 of the standard protocol is accelerated learning as bilateral stimulation keeps information moving. This, to me, is the primary way EMDR can be a more brief therapy approach. The use of the phrase ‘disturbing life experiences’ as recommended by Francine instead of ‘trauma’ addresses the broader application of EMDR to unprocessed memories from past life experiences that dysfunctionally manifest in the present. We truly do not have a choice about our responses that arise from unprocessed memories that remain unlinked to our adaptive memory networks.
Francine emphasized a clear understanding of and adherence to the Adaptive Information Processing theory of EMDR work. . She discusses therapists’ avoidance of the processing phases every time I have heard her speak. By this, she indicates concern that this is a key factor in less effective EMDR work that some report. It also appears to be part of why some newly trained therapists do not continue to implement EMDR into their practice. In the AIP model, if the reason for pathology is unprocessed memories, then the change agent is reprocessing those memories. We need to do Phases 3-6 reprocessing work!
It is an 8 phase protocol so we can begin EMDR work with all of our clients at Phases 2 Preparation and Phase 1 History Taking, titrated as needed. Phase 4 reprocessing, however, is where we will see the most change in reduction in symptoms and increase in adaptive functioning. We can choose to do EMD (restricted) or EMDr (contained processing) to get started or deal with acute stress, or EMDR (unrestricted standard protocol) as Roy's Processing Processing Continuum descibes. The most powerful and effective treatment comes from the full protocol and this is what we want the majority of our clients to receive.
As I reflect on that experience and many more since working with Roy Kiessling, here are some thoughts I'd like to share. Don’t be afraid of the reprocessing phase of EMDR treatment, it’s the power tool! We learn to use power tools effectively with ‘good enough’ preparation (Francine’s words), rather than avoiding their use out of fear of the hyperarousal or dysregulation that may occur. Clinicians inexperienced in EMDR therapy fear that they are ‘triggering’ their clients in reprocessing targeted memories. But triggers occur spontaneously, often without the client’s awareness, not by their choice and are overwhelming as they are experienced alone. Processing is begun only when a therapeutic alliance has been established and the client is prepared for the processing phases of EMDR. It is an experience we have the honor of sharing with and supporting our clients through. It is the client’s choice and always has a stop signal built in. It is ‘pain with a purpose’ that is distinctly structured. Processing includes and connected to the client’s adaptive information that is developed and strengthened in the preparation and history taking phases. The question Francine posed to 3000 of us at an annual conference was “whose affective tolerance are you concerned with, yours or the client’s?”
I have had more than one client who never got to reprocessing for various reasons, usually due to the fear of the fear or chronic instability. They did, however, benefit from an EMDR informed treatment perspective that focuses on core negative beliefs As one trainer put it, ‘we are always doing our thing.” This is evident right at the beginning of learning EMDR psychotherapy in Basic training. When clinician-trainees practice EMDR with partners, we notice their core beliefs showing up in their reactions to EMDR. Therapists who are excessively worried about their therapist partner getting tired or being a difficult client are displaying distorted beliefs about being a burden to others. Those excessively worried about ‘doing it right’ often have an irrational belief they have to be perfect. Those fearful or even convinced EMDR therapy won’t work for them often have deeply held beliefs of failure or defectiveness. These are examples of past unprocessed memories impacting present functioning. Even reactions to EMDR therapy are frequently not about EMDR therapy!
As an EMDR clinician, be careful about accepting a client's perspective that there is nothing in their past informing their present difficulties. Remember how most of us believed this ourselves before our first EMDR experience in Basic Training? It's our job to sort through the maze (Kiessling, 2015) to assist our clients in finding what from the past laid the foundation for their present symptoms and issues. Even though targeting those early touchstone memories will clear out later memories most effectively, clients may not be willing to start there. They often have a later, working memory to target that was worse than the early adverse, often pre verbal memories. We can, however, continually educate clients about the link between their present difficulties and past adverse life experiences in preparation for later processing. We start this in our intake by asking those skillful AIP questions such as “when did you feel/think/react that way before?” when clients present their current symptoms and issues.
Do we believe in the AIP model? Do we have confidence in EMDR therapy? It takes a while to embrace the AIP model and gain protocol confidence, but it is the most effective therapy I have done in over 40 years of clinical experience.
I started as a therapist who did EMDR therapy and became an EMDR therapist. That is, I shifted from doing EMDR therapy as one of several models of treatment to working from the AIP perspective with all clients regardless of therapy models. I was able to assist clients in their healing path prior to EMDR training' but getting that training changed my career. Eventually I learned that all of my clients could benefit from my eventual EMDR expertise, whether I did the entire standard protocol with them or not. The most powerful changes from EMDR work stem from accelerated learning occurring in the reprocessing phase of the protocol.
When you continue to see positive results from the momentary pain a client may go through in reprocessing, you become more committed to EMDR work. Clients may or may not process with abreaction, but as you see reduction in symptoms and shifts in belief about self, your confidence and willingness to get to Phase Four reprocessing will grow. This “pain with a purpose,” helps me with the challenge of accessing and activating past distress in Phase 3, in order to clear it out, rather than reducing distress through talk therapy and other means as soon as we are able. Clients also don’t need more reactions from others, particularly their therapists, that give them the message their distress is not okay, unbearable, or cannot be survived.
If I believe EMDR is effective for many issues that have not resolved by other means, I also believe it is unethical of me to withhold that treatment for which I have trained. The best way to get to that confidence, which your clients mirror from you, is to keep doing it. Keep reading, practicing, getting consultation, and participating in study groups with colleagues. To borrow from Nike, “just do it.”
Originally presented as a ‘brief therapy’, EMDR is brief as compared to other types of trauma treatment. I have had clients who no longer met the criteria for the diagnosis of PTSD after three to ten sessions, but none were DID. We still need a number of sessions over several years for complex trauma.
An example would be an early complex trauma client who was seen every 1-2 weeks for the first year, resolving nightmares, flashbacks, and suicidal ideation during that time. This was after 30 years of psychiatric treatment and multiple hospitalizations for suicidal thought and intent. I continued to work with her for several years after that, addressing marital and family issues as well as multiple health stressors not uncommon for trauma survivors.
I remember at the time wondering if I was “doing it wrong” because it was taking longer than the EMDR material I was reading or the videos we typically see in EMDR trainings. I know now that she spent a much briefer and more effective time with EMDR treatment than she had experienced with past therapy. Lesson learned: it takes however long it takes. Just keep following the protocol or have a good clinical reason for variations. Through the years, deviations from the standard protocol have resulted, as we know, in the many specialized protocols now available for our use.
Francine reminds us that we don’t know how EMDR works but the neurobiological mechanisms of change are unknown for any form of psychotherapy. Our brains are amazing in their ability to self-heal, with more and more evidence from neuroscience about continued growth and change possible throughout the life span. EMDR is an ‘accelerated learning’ process that relies on our brain’s capacity to heal itself. Isn't that amazing?! That’s what processing through to adaptive resolution means—to process through dysfunctionally stored memories so that we are free to choose adaptive present behaviors without limits from our past experiences.
Broaden your understanding of trauma beyond events that most people think of when we ask about past trauma. It is interesting that PTSD scores are higher after adverse life events than following most of the events that are generally labeled PTSD-worthy. We used to call these events small ‘t’ trauma while significant traumatic events were called big ‘T’ trauma. Francine now prefers to use ‘adverse life experiences’ and has written an excellent article for the Permanente Journal on EMDR Therapy and ACES (2014)
Clinical evidence supporting this is found in the length of treatment I have had for clients without PTSD who have experienced longer term developmental gaps with attachment disruption. These clients typically don’t see themselves as survivors of trauma. They might expect a briefer course of treatment when in fact it is just the opposite, as many of you know.
It is not only the history of adverse life experiences but also the client’s adaptive information and support/stability that impacts both length of treatment as well as readiness for processing. If it isn’t in their adaptive neuronetworks, then it has to be taught, modeled, learned in therapy so there is adaptive information to link up with the unprocessed, dysfunctional, and outdated information.
We know that maladaptive information—when the past is present—is dysfunctionally stored information as it was experienced and perceived at the time of the event. When the present is distorted by past unprocessed beliefs, thoughts, emotions and body sensations, we can agree that we have some brain ‘files’ that need to be updated (Kiessling metaphor). Through EMDR processing, we can let go of no longer useful information and retain what is useful in stored memory networks.
Francine Shapiro's self help book, Getting Past Your Past, (2014) is considered by many to be her best, most understandable writing. This wonderful resource for individuals as well as clinicians effectively and non-judgmentally discusses different psychotherapies according to what each believe to be the cause of pathology.
I wish I could adequately represent the impact of Francine Shapiro on the healing in the world. Though I have reflected on EMDR theory, information and clinical application, I came away most impressed not with Francine's intellect but with her heart. Truly a great lady who is changing our world! I know she no longer presents every few years at our EMDRIA annual conferences, but her legacy lives on in the many many clinicians she has taught, trained, and encouraged through the years.
Bonnie Mikelson LISW
Director, EMDR & Beyond