SHAPIRO'S CHALLENGES TO CLINICIANS IMPLEMENTING EFFECTIVE EMDR THERAPY
Francine Shapiro’s plenary addresses at the annual EMDRIA conferences every other year have not not only provided the expected updates on EMDR therapy and research, but continued to inspire and educate. Now that she no longer is able to do so, I appreciate having heard her in person as a plenary speaker in past EMDRIA annual conference. One I remember distinctly was when she shared the results of surveying practitioners (including therapists, consultants and trainers) about the most significant issues surfacing in EMDR practice settings.
Francine stated that therapists from all therapies “learn something and then drift occurs…” She cited research, for example, on CBT therapists who believed they were following CBT procedures after training, when research revealed that most were not. Her question then was: “Are we doing the clinical work that the research supports?”
It’s a thought provoking challenge to those of us who have incorporated other protocols and innovations in our practice of EMDR therapy. These ‘adaptations’ can tend to dilute our effectiveness and clarity in applying the standard protocol over time, as I am frequently reminded in follow up EMDR trainings. As experienced EMDR clinicians, we know how to make modifications and incorporate other procedures and modalities as we integrate EMDR therapy into our clinical practice. Over time, however, we need to sustain doing this purposefully and not because of ‘drift’ in our practice.
The concern, however, is not really making the decision to modify so much as it is that we lose our focus over time on doing what we learned is most effective. I've known a few EMDR trained clinicians whose EMDR work, unfortunately, has been reduced to using bilateral stimulation without most of the other components of good EMDR therapy processing. This, bluntly, is not EMDR therapy, That’s why we need updates and refreshers to bring us back to what we know works, what kept us going in EMDR, what we remember experiencing ourselves in our Basic Training. We need to stay purposeful as well as creative in our clinical adaptations of EMDR therapy.
Dr. Shapiro shared a meta-analysis of EMDR research (2002) that demonstrated the relationship between positive treatment effects and clinical fidelity (Maxfield & Hyer). She also cited recent research by Kaiser Permanente (2012) using the standard protocol for PTSD clients receiving 6 fifty- minute sessions. Outcomes showed clients no longer met PTSD criteria in 100% of single trauma and 77% of complex trauma cases. She then offered two challenges to her audience:
“Are we getting the same results?” and,
”On what basis are we not doing…the standard protocol?”
Shapiro stated that if we are not following the standard protocol that research supports, we need to give clients informed consent regarding our modifications. While she clearly supports the many researched adaptations to the standard protocol that have been published, she would view our failure to provide standard EMDR protocol on any regular basis as depriving our clients of the robust healing outcomes that are being achieved all over the world and that our clients deserve. If we are not following the standard protocol, we need to have clear reasons why and consider researching the options we are using if they do not sustain protocol fidelity.
Clearing Up Misconceptions about EMDR and the Therapeutic Relationship
One common misconception concerns Shapiro's position regarding the therapeutic relationship in EMDR. In her texts, she underscores the need for a '‘strong therapeutic alliance, specific truth telling agreements, and a therapist who can convey a message of safety, flexibility, and unconditional regard…[as] necessary but not sufficient” (Shapiro, 1995; 2001).
EMDR is a client centered therapy that emphasizes the client’s innate capacity for healing, requiring ‘minimal therapist intrusion’ for effectiveness, which ‘does not negate the importance of the therapeutic alliance’ (Shapiro, 2001). I would restate her clarification like this: she never said the therapeutic alliance was unnecessary. It is the foundation for the primary mechanism of healing: the client’s own adaptive information through spontaneous, not therapist controlled, movement. Therapist intervention should mimic spontaneous processing as much as possible.
Other misconceptions she clarifies are that EMDR is not suitable only for single trauma,. Now there is EMDR research on complex trauma and she would suggest that months or years of preparation are not needed. She reminds us of Van der Kolk’s early research (consistent with my clinical experience as well) that we can’t know from a client’s trauma history what RDI they may need in order to do state change for staying present during processing. We need to consider that some clients with extensive trauma history “also had people in their lives who built adaptive information neuronetworks” to draw from.
Do we trust the EMDR process?
She expressed concern that some therapists go to resourcing when clients abreact during reprocessing when “we don’t need RDI for every distressing experience.” Using resources during processing isn’t EMDR. This becomes therapist controlled therapy rather than client centered healing. Instead whenever possible, we need to keep our ‘foot on the gas’ with BLS until the client’s own brain does the healing.
She emphasized: “Unimpeded processing allows the full range of associations to be made throughout the targeted memory, and the larger integrated networks (Shapiro, 2011 EMDRIA Conference). She then challenged: “how much do we trust the process vs. having to fix it now…are you willing to let the affect go or do you feel you have to stop it?” EMDR/AIP emphasizes the ‘client’s innate capacity to heal,’ requiring ‘minimal’ clinical intrusion.” (Shapiro, 2001). It postulates that “the cause of the symptoms are unprocessed memories stored in networks that govern both the nonconscious and conscious” (Shapiro, 2011 EMDRIA conference). In other words, processing is change.
It’s our job to facilitate the client’s self healing and that requires that we trust the process rather than feeling the urge to ‘fix it now’ when client’s affect disturbance escalates. “What’s going on with us that hinders client processing?” We need to understand our own as well as our clients’ tolerance for affect, asking ourselves what our own tolerance is and doing self care so that our level of affect tolerance does not get in the way of EMDR processing. She mentions CD’s for clients and clinicians, meditation, physical and mental ‘tune-ups,’ and doing our own EMDR processing as self care options.
EMDR Heals and Creates Growth
A final key point Francine made is that EMDR results in measurable growth for clients. EMDR does not just eliminate symptoms of past trauma or present triggers, but “results in the emergence of adaptive affective, cognitive, and behavioral responses to new situations [as well as] trait and personality changes (Shapiro, 2011 EMDRIA Conference). She cited research assessing significant shifts in maternal bonding pre and post EMDR (Madrid, 2007; Madrid et al, 2006) as well as research in Pakistan using the ‘Post traumatic Growth Inventory to measure change in these five factors: relating to others, new possibilities, personal strength, spiritual change and appreciation for life. Their results showed EMDR to be “significantly superior…decreas[ing] PTSD symptoms and increase[ing] PTGI [factors] (from Shapiro, 2011 EMDRIA conference). Conclusion: validation by research that EMDR gets rid of symptoms and enhances personal growth.
I find myself emphasizing these very points for EMDR training and consultation. I have always appreciated Dr. Shapiro's clarity and directives and miss her presence at recent conference.. I acknowledge that this is what I heard, not exactly what Francine said, of course, and hope it inspires as well as challenges us to provide ever more effective EMDR practice.
Bonnie Mikelson LISW
Director, EMDR & Beyond