David: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host. On today's show we'll be talking about EMDR or Eye Movement Desensitization Reprogramming with my guest, Dr. Francine Shapiro. Francine Shapiro, Ph.D. is the originator and developer of EMDR which has been so well researched that it's now recommended as a frontline treatment for trauma in the practice guidelines of the American Psychiatric Association and those of the Department of Defense and of Veteran Affairs. Dr. Shapiro is a senior research fellow at the Mental Research Institute in Palo Alto, California. She is also executive director of the EMDR Institute in Watsonville, California and founder and president emeritus of the EMDR Humanitarian Assistance Programs, a nonprofit organization that coordinates disaster response and pro bono trainings worldwide. She is a recipient of the International Sigmund Freud Award for Distinguished Contributions to Psychotherapy of the city of Vienna and the Distinguished Scientific Achievement and Psychology Award presented by the California Psychology Associaton. She was designated as one of the cadre of experts of the American Psychology Association and Canadian Psychology Association joint initiative in ethno-political warfare and has served as advisor to a wide variety of trauma treatment and outreach organizations and journals. She has been an invited speaker at psychology conferences world wide and has written and co-authored more than 60 articles and chapters and books about EMDR including Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures; EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress and Trauma; EMDR as an Integrative Psychotherapy Approach; and The Handbook of EMDR and Family Therapy Processes. Now here's the interview.
Dr. Francine Shapiro, welcome to Wise Counsel.
Dr. Shapiro: Well thank you for having me.
David: You are the developer of an approach to psychotherapy known as EMDR. Can you describe that treatment for our audience and how it works?
Dr. Shapiro: Well it's a form of psychotherapy that blends a variety of different elements. The primary person of it is to identify memories that people have that are causing them problems. We don't even necessarily realize how feelings of not being good enough or of feelings we have of depression or failure, etc., are really based on earlier memories that are stored in the brain and whenever something in the present happens that's similar, it can trigger thoughts and feelings and emotions that were there at that earlier time. So what we're really doing is fighting the past. And what EMDR does is help to access those memories, identify them with the client and to process them so they are digested, if you will, and what's useful is incorporated and people learn from it, and what's useless--the negative feelings, the negative thoughts, the negative emotions--are all able to be discarded.
David: It almost sounds a little Freudian when you talk about the impact of the past and feelings that are left over from the past.
Dr. Shapiro: Well in Freudian psychology there is a notion that there are these earlier events that have had an impact and certainly I would say that just about any form of psychotherapy would agree that things that have happened to us in the past have had an effect on us. But where EMDR is different from other forms of therapy is that we're looking at it as the memory itself is stored in the brain because it was not able to be processed.
We have an information processing system that is geared to take in all the information around us and link it up with memories we already have to be made sense of. So if we have a fight with someone at work we can get disturbed and our bodies get disrupted and we have negative thoughts and we get shaken up by it. But then we walk away and we think about it and we talk about it and we go to sleep and we dream about it and the next day it doesn't bother us any longer. We recognize "oh, he was having a bad day" or "oh, I've had other good experiences with him." So we decide what we're going to do and the negative feelings are able to go away.
But sometimes things can be so disturbing that they disrupt this normal processing and the event is held in the brain and is stored in memory in the form that we experienced it. And so for instance, if it be a rape victim or something that might have happened to us in childhood it really gets locked in the brain, unprocessed, so it has those emotions and physical sensations that continue to emerge.
So in Freudian psychology they might ask you to talk about it over a long period of time to arrive at insight about it or where cognitive behavior therapy might, say, give tools to try to deal with the disturbance when it comes up, in EMDR we actually go in to access the memory and stimulate the information processing system so that it becomes processed and it is no longer disturbing so we don't have to worry about it being triggered by things in the present. Those feelings of not being good enough or not being able to succeed or I'm going to be abandoned or I'm unlovable-all of that is basically gone.
David: Well of course we know so much more now about the brain and about brain processing than Freud did or than people knew in Freud's time, so there's a lot more specificity that's coming to pass around these kinds of processes. You referred to rape and I'm under the impression that initially when you developed this, you were really targeting it towards people who had suffered from rather distinctive traumas such as rape. Is that right?
Dr. Shapiro: Yes, initially in wanting to test it out in research, we'd look at a diagnosis of people that would be clearly disturbed by old memories and that would be rape victims or combat veterans or accident victims--the types of very large events that you would need in order to diagnose post-traumatic stress disorder which has been in the news quite a lot of course because of the Iraqi and Afghanistan war. So when I tested the EMDR I used that population. But what we've discovered over time is that it's really not limited to those major events. It can be any kind of event that has left a lasting negative effect upon ourselves, would be called, by dictionary definition, a trauma. So the more ubiquitous kinds of events. The kinds of things like childhood humiliations; or shaming; or maybe having a learning disability early on and having that sense of not being good enough; or being humiliated by amongst the group of people might leave us unable to deal with groups in the present and not able to socialize; or being pushed away by parents at different times might give us a sense of not being secure and potentially of being abandoned; or not being able to count on anyone. Those types of experiences which are much more common can really be at the bottom of a variety of different problems that people have, from self esteem problems to depressions or different types of chronic pain. So it really has a wide range of application.
David: Yes, I've been looking at a couple of books on EMDR and I was really surprised to see just how widely it has spread it terms of being able to target a wide variety of mental health problems, if you will. Having grown from that initial focus on trauma--let's step back a moment. I think the most distinctive thing about EMDR at least from the title, it's Eye Movement Desensitization Reprocessing, and it's that eye movement. When I first heard about it and I got a very rudimentary description, somebody said, "Well, the therapist moves their finger back and forth in front of the person's eyes and their eyeballs track that finger movement."
So I'm kind of interested in that piece of it. How did you get on to that piece of it?
Dr. Shapiro: Well, it actually happened back in 1987. I was walking along one day and I noticed that disturbing thoughts I was having were suddenly disappearing and I hadn't done anything in order to cause them to go; they were the kind of thoughts you usually have and try to deal with to get them to not bother you. But I found they were just disappearing and when I went to bring them back, they just didn't have any charge anymore. So I wondered what had been going on and I started paying very careful self-attention and I noticed that when that kind of thought came to my mind, my eyes spontaneously started moving in a certain way very rapidly and I noticed again, the thought shifted and when I brought it back, it didn't have the same charge.
So, then I wanted to see if it would work deliberately. So I brought up something that bothered me and move my eyes in the same way and found that it had the same affect. Then, I went to see if it would work with other people, and during that time of experimenting with it, I would find that for most people, there would be some change but then it might stop. So, I had to develop a set of procedures around it to maximize the effect, and that set of procedures all these past 20 years has now become a form of psychotherapy in its own right and the eye movement is one aspect of it.
It's believed by certain researchers that it links into the same processes that occurred during rapid eye movement in sleep, and during that period of time, it's felt that people process the experiences that they've had during the day. But once again, we see that for instance, a combat veteran who's suffering from post traumatic stress disorder, instead of the dreams resolving problems, they often wake up in the middle of the nightmare, things like the disturbances to eye disrupts the REM state. So the notion is that in the therapist's office, we're able to bring the person further along then they would be able to occur in the natural dream state, so a very rapid movement of the memories to one where they simply aren't bothering you any longer.
David: That's fascinating. I didn't realize that it had been linked theoretically to the REM state--the rapid eye movement--that's associated with sleep. That's really fascinating to me to hear because I had intended to ask you what do you think might be the underlying role or brain processes and I think you've addressed that. After saying when I first heard about this, and I told you it was kind of one of my colleagues I think or a student maybe who was exposed to it, was describing it. My initial reaction was pretty skeptical, and I gathered that you encountered some skepticism along the way. What was the initial reception by the way?
Dr. Shapiro: Well, it was varied. There were some people who were open to it. Joseph Wolpe was one of the fathers of behavior therapy...
Dr. Shapiro: ...and he was actually quite open to it.
David: Yes, I immediately thought of him as I was reading about this system. But go ahead, I'll come back to that.
Dr. Shapiro: Right. He introduced that to the Association for the Advancement of Behavior Therapy as a breakthrough back at that time. But then others were quite skeptical because they didn't believe that anything could be that rapid. At the time I published the first controlled study of it, it was reporting the facts with a single session in being able to reduce the distress that people have with their memories. So people were quite skeptical that anything could work that rapidly or that well, and there were talks "Well, it's just placebo. Well, it's non specific affects."
So over time though over these past 20 years, there are now close to 18 randomized controlled studies of EMDR. In comparison to other forms of therapy for trauma, for instance cognitive behavior therapy, you might be looking at the same type of symptom reduction but it would take 40-100 hours of hallmarking the cognitive behavior therapy in order to achieve the same results.
What we're looking at is the applications at this point, we mentioned the wide variety of problems that seem to be quite susceptible to treatment where other forms of therapy have failed. For instance, we have a recent study on the treatment of phantom limb pain where, and of course that has application to combat veterans and many accident victims who lose limbs. And you can have up to 70-80% with pain, and people used to believe that it was nerve damage and the medical treatment for it was often cutting up the limb to try to get beyond it but with very limited success.
What we found is that the pain that the person is feeling is really once again that stored memory of the accident that actually has the pain sensations stored in the brain. Once we use the EMDR to process it, the pain was able to disappear. I think that's extremely important because what it points out is that many people who are suffering from different types of chronic pain do not have to be suffering with it. There really is a way of dealing with it that doesn't involve monitoring it to try to feel better or pain medication.
David: Well, that is really exciting because I'm under the impression that up to this point, treating phantom limb pain has been fairly intractable except through medication. Yes, that's very exciting. Well, I believe that I've given an over simplified description of how it works, and I know that you've developed quite a protocol that has a number of distinct steps. Maybe you could just kind of take us through what those steps are?
Dr. Shapiro: Well, there are eight distinct phases in the treatment. One is taking a thorough history to identify what are the earlier memories that are the basis for the client's problems. Whether it be the self esteem issues or specific diagnosis, what are those earlier memories? The person might not be aware of the links but the therapist is trained to assist the client in identifying those.
We identify the earlier memories that set the groundwork for the problem and the current situations that caused the disturbance. Then, we identify what that person might need to learn for the future, different social skills for instance or a family therapy skill or any number of things that might not have been learned but that are necessary. So those are identified during the history taking.
Then there's the preparation phase where the client learns certain self-control techniques so that they know that they can stop the disturbance when they choose, whether it's during the session or in between sessions. This is kind of a bridge to make life more tolerable while the therapy is taking place because the goal is to use the processing of EMDR, to make sure that these disturbances don't come up again. But the preparation phase really sets the groundwork so the client can stay with the memories for the brief amount of time needed without undue distress.
Then during the assessment phase, we bring up--whether it's the memory or that current situation or the future--that template that's needed and identify different aspects of that image, the negative beliefs that the person might have. "I'm not good enough. I'm not in control. I'm not safe", whatever it might be. Then, the positive belief that they would prefer to have, and then the emotion that they're experiencing when they bring up the memory and where they're feeling it in their body. We take different scales of that so that we know precisely where the person is at the beginning of that treatment session.
Then the next three phases are the reprocessing phases where it actually allows the client's own brain to go where it's necessary in their memory network. So the clinician doesn't need to or try to supply the answers for the client or to lead the client because the connections that the person has in their own memory system is the one that's necessary to really bring it to a finish state. So the clinician is there more as a facilitator to guide the client when necessary but to allow them to do the processing that's necessary for them with attention to the negative emotions that they have and then the thoughts they may have and then the physical sensations. At the end of that--the three reprocessing phases--there's traditionally a closure phase at the end of each session to make sure that the client is walking out feeling good about themselves and empowered.
Then a reevaluation phase opens up each of the next sessions in order to make sure where the memories are, how they're feeling now and to really guide the clinician through the different protocols because there are different protocols for substance abuse, for chronic pain, phobia, etc. So the reevaluation phase allows the clinician to know what steps to take. The thing is that during EMDR therapy, it's very accountable in that the client will generally be able to feel different changes, experience different changes from the very beginning of the reprocessing phases. So they're getting feedback at every session of how it's progressed. It's not the type of thing we have to wait months or years to find out whether it's going to be better or not, you know it from the beginning.
David: OK. Yes, I mentioned that I was quite... as I began to read up on it, I really thought of Wolpe's systematic desensitization except with the eye movement seem to be a new element and the SUD scale or subjective unit of distress scale where you ask people to rate on a scale of zero to 10 how aroused or fearful or panicked or whatever they're feeling in the moment. So I can see why Wolpe would have gotten quite excited about what you're doing. I see the similarity, I'm not trying to reduce it to say that you haven't made an original contribution here because I think that you have. I know there were some critics who questioned whether the eye movement was in fact adding anything specific to the effectiveness of the treatment. You report on some recent research that seems to counter that criticism. Maybe you could share that with us.
Dr. Shapiro: Yes. Well, the problem was that the earlier research that have been done on the eye movement was really not good science as the last practice guidelines for the International Society for Traumatic Stress pointed out. There weren't enough subjects in the different studies or they used inappropriate clients, for instance, they were trying to check on the effect on post traumatic distress disorder measures with combat veterans who were may have only treated only one memory when these folks of course have quite a bit more than one memories to treat.
So because it was bad times that gave indications that the eye movement did not have an effect, but since that time, since 2000, all of these studies that have emerged to have supported the eye movement. There are about eight randomized controlled studies that tested the eye movement in isolation and they found that it has an effect on the vividness of memories and on the distress that people have. Others have indicated that it does seem to link into processes during REM sleep. They've had studied it in terms of working memory.
Most recently, physiological studies have shown that the eye movement itself seems to cause an automatically relaxation response. So the notion of it being able to have an effect has clearly been demonstrated. If I were to mention one of the things that in terms of the desensitization, I actually did call it initially "eye movement desensitization" because that's what I thought was happening, that desensitization in behavioral terms is to reduce the anxiety or distress that you have associated with something.
But I eventually added reprocessing on and thought that the desensitization is really only one thing that's going on during the treatment. When you watch an EMDR session, you see the client coming to new insights, new understandings, their whole demeanor changes, the physical sensations change. So there's quite a bit more that's going on than simply taking away the distress from the memory.
What you really do see is a rapid evolution towards health. So the problem with much research of course is that it's only measuring the overt symptoms that are involved in a specific diagnosis. But what we really see is quite a bit more than that occurring, and that's why if I had to do it all over again, I would really just call it reprocessing therapy.
David: You mention the physiological studies, and certainly there are new brain scan technologies that are greatly increasing our understanding of how the brain works. Has this technology shed any light on EMDR or might it?
Dr. Shapiro: Well there have been studies that have been done - SPECT scans and PET scans - that have shown clear differences before and after EMDR treatment. What they've shown is that different areas of the brain light up or calm down. For instance, the limbic system, the one that was over activated in terms of emotional distress is calmed down, whereas, other brain elements that involve more sense of presence or awareness are more greatly activated.
There's a recent study that's actually shown growth in hippocampus after eight EMDR sessions, which is very interesting given the fact that a number of studies previously had shown that trauma has a negative effect on the hippocampus and actually shrinks it. The notion was, for a time, that post-traumatic stress disorder in chronic victims might be untreatable because there's actually organic brain change.
But here we see that after EMDR therapy, there's actually an increase in hippocampus. So it's all quite fascinating, but as with any form of psychotherapy, the whole area of neurobiology is so young. You can see pre/post- changes, but one has no actual idea what the mechanism was that caused it to occur.
David: Yes. As I hear you talk about the approach, it brings up for me associations to other approaches, and it seems to me that there are elements in common with other approaches. While it is a unique and important contribution, it's certainly not isolated from other things. So I'm wondering what sort of connection, if any, do you see between things like psychodynamic-insight therapy or cognitive-behavioral therapy or the mindfulness approaches?
Dr. Shapiro: Well I think that all truth dovetails. We're very happy to see, with EMDR, it's an integration of elements of different therapies. For instance, there's a nice chapter that was written by Paul Wachtel on his view of EMDR and psychoanalysis, and what has been described as a free association process that occurs during EMDR, like free association at turbo speed. So it's really able to go very deeply into an individual's psyche to identify what the issues are and what the connections are in a way that's very understandable to those practicing psychodynamic therapy.
And in EMDR, we do use negative beliefs as they do in cognitive therapy. But the difference is in cognitive therapy, there's the notion that the belief is the cause of the problem, whereas, in EMDR, we see the belief as a symptom of the problem, but the cause is the memory that's inappropriately stored. And once we process that memory, that negative belief changes to a positive belief, and we don't have to challenge it or deliberately try to get the person to think differently, but it happens automatically.
And then in experiential therapy, we see it really as client-centered, that the client is the one in the lead, and it's not the therapist that has to give the answers. Indeed, the EMDR clinicians love doing the therapy very often because it's very much like a treasure hunt; you don't necessarily know what's going to come up. It's recognizing that the client is really the one from which the answers are going to stem, and they do beautifully, without the client having to talk a lot.
It's not like the rape victim has to delve into all the details of what happened, or that the combat veteran has to tell everything that occurred. It's something that's happening nonverbally that's going on in the mind of the client. So the client can share what they would like to, but those who don't want to talk about it don't have to. And I think that's a very important part because a lot of people are kept away from therapy because they believe they're going to have to spend so many sessions talking about things that they don't want to - in EMDR, it's simply not necessary.
David: Well there used to be a belief that talking about it was good for you, say in the case of battle trauma. If you talked about it, you would get it out of your system. But now some people are arguing, I believe, that you might actually be rehearsing it and making it stronger by reliving it. Do you have a position on that?
Dr. Shapiro: Well I know there's a form of therapy called exposure therapy, where the person needs to go over it in detail. So they'll say, "I'm feeling the blood", and it all has to be in the present and in the 'I'. And it has to be that continued description of it over and over again, then listening to audiotapes, and then going to places where they were disturbed in order to overcome it.
Now that had a long history in psychotherapy. I think the issue in terms of making people worse can be involved in the preparation or when it's tried with them. Certainly the research has indicated that when individuals are asked to do that type of thing - as they have incorrectly done in misuses of something called 'critical incident debriefing' with individuals - it has made the person worse. But that's really a misapplication because it was really supposed to be done in a group in a particular way.
So yes, people can get hurt when therapies are misapplied. And therefore, it's important to make sure you go to a therapist who's clearly licensed and trained in whatever form of therapy they're doing and has a positive track record.
David: Yes, and talking about the ways in which the approach, EMDR, has spread into a wide variety of applications, one of the ones that surprised me most was family therapy. The way that I envisioned EMDR was very much as a one-on-one process, so that surprised me. How's it used with families?
Dr. Shapiro: Well with family therapies, very often the concentration is on identifying what the problem is and trying to teach the family members different skills and ways of communicating, so that they can deal with each other in a more positive way. But what we found very often is that the reason for the disturbance are the earlier memories that the person has that's pushing them to feel that they might be abandoned by the spouse, that they are not treated well or they fear that they're not going to be treated well. And all of this, again, comes from these earlier memories that are pushing up.
So if a spouse looks at them in a way that their father did before they got hit, or had the sound of their mother's voice at a time that they felt that they were being intruded upon, those emotions are going to be coming up and they're going to be treating the spouse from that lens, from that sense of disturbance.
So what we do is process these earlier memories so the person is no longer pushed into being reactive. Of course, you hear so many times, "I tried to but I just couldn't control myself." The reason that they can't control themselves is that these earlier memories are pushing those emotions and reactions. So processing those experiences first, then leaves the groundwork open to learn the skills and be able to use them effectively because they're no longer being run by the past.
David: OK. Now let me ask you, are there any conditions for which EMDR would not be applicable?
Dr. Shapiro: Well, when things are purely organic, certain forms of depression may need medications, certain forms of ADHD may need medications. But what we often found is that a child or an adult might be diagnosed with ADHD, it really is mimicking the symptoms of it but it's really this earlier trauma, these earlier events that are pushing it, that are causing the person not to be able to concentrate, et cetera. So, processing those events can drop the symptoms that cause them to be diagnosed with ADHD.
If it was actually organic, so EMDR would not stop those symptoms but it could be used to address the feelings of "I'm not good enough. I'm damaged," all of those negative feelings that the person has because of failure experiences that can be compounding it. So we really would be looking at what conditions are being pushed or contributed to by earlier memories, and if those are not there, then EMDR would not be appropriate.
David: How might a listener to this show gauge whether they should seek out this treatment?
Dr. Shapiro: It's basically identifying "What is it that's holding me back? What's pushing me to the things that I'm being pushed to do that I don't want to? Are there things that I'm prevented from doing that I'd like to do? Do I have the sense of not being good enough, et cetera?" If those feelings are there, just recognize that very often they are the products of these earlier memories. By accessing an EMDR clinician, they could find out in very short order whether therapy would be good for them because as I said, it's not the type of thing where you have to go through months or years to find out if it's going to work. Just the history taking phase with the clinician can help identify whether EMDR would be appropriate for them.
David: How would they go about finding an EMDR clinician?
Dr. Shapiro: They can access it through the EMDR Institute which is at www.EMDR.com or the EMDR International Association which is EMDRIA.org, would give a list of clinicians available throughout the United States.
David: That's great. Well, let me just close by asking you a personal question. Here you were walking along the waterfront, dwelling on a personal problem and you noticed something. So many of the breakthroughs in science have come through some observation that other people had just overlooked that could have been available to any number of people, but somebody notices something. You noticed something that seems to have been very key and it's caught on and spread like wildfire. There's a research literature and there are training programs and so much has been written about EMDR. So what's it like for you now as kind of rock star of psychotherapy?
Dr. Shapiro: Well, I don't feel like a rock star, I do feel very grateful to be a part of it. We have an EMRD humanitarian assistance program that has been able to do work of ethnopolitical violence throughout the world. They've been able to work with those who have been traumatized in a variety of ways and it's bringing people together. For instance, we're able to work in a training program in Northern Ireland bringing Catholic and Protestant clinicians together to actually work together and deal with the problems that came from the troubles.
We have trainings going on in the Middle East where Israeli facilitators have helped to train Palestinian clinicians. The notion is, that if we can help individuals overcome the effects of trauma, then it doesn't have to continue a cycle into despair and anger and violence. Knowing that that potential was there to bring people peace is just a wonderful feeling.
David: That's very fascinating. That's a direction there that would require a whole another interview. But we better wrap it up for today. So Francine Shapiro, thanks so much for being my guest today on "Wise Counsel".
Dr. Shapiro: I appreciate it, thank you.
David: I hope you found this interview with Dr. Francine Shapiro thought-provoking. As you heard in the interview, I was initially quite skeptical when I first heard of EMDR. However, I'm now convinced that enough research has been done and enough evidence of its efficacy has been collected for me at least to take this approach seriously.
Let me repeat the two Web addresses Dr. Shapiro gave out in case you wish to investigate this approach more on your own. They were www.EMDR.com and internationally, www.EMDRIA.org. I would also recommend her book "EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma", which is published as a paperback by Basic Books.
You've been listening to "Wise Counsel", a podcast interview series sponsored by CenterSite, LLC. Until next time, this is Dr. David Van Nuys, and you've been listening to "Wise Counsel".