EMDR Therapy Quarterly

The standard EMDR protocol is essential and usually sufficient 

The presenters at this year’s annual conference in Glasgow were all good communicators who knew their subject and connected well with the audience. They created a welcoming and supportive environment for learning. They drew on their extensive clinical experience to provide practical examples and case studies that illustrated the concepts they were presenting.  

The overarching theme was that the standard protocol (SP) is essential and usually sufficient in EMDR therapy.  With a few adaptations it can be effective in treating psychosis, challenging ego states, and people with autism spectrum disorder (ASD).  

Integrating aspects of polyvagal theory into the SP 

Rebecca Kase took the floor on the first day. She is a clinical social worker and psychotherapist who has dedicated her career to understanding the neurobiology of trauma and exploring evidence-based interventions for trauma-related disorders. In recent years, she has been at the forefront of integrating eye movement desensitization and reprocessing (EMDR) therapy with polyvagal theory (PVT), a neurobiological framework developed by Dr. Stephen Porges (1995). 

When I spoke to her afterwards and asked her what she hoped the audience’s single take home message would be she replied that “the therapists’ body is their main tool”.  Her presentation and workshop made it clear why she thought that way. 

Polyvagal theory: Overview and key concepts

PVT is based on the idea that the nervous system is constantly monitoring the environment for safety and danger, and that our physical and emotional responses to the world are shaped by the state of our autonomic nervous system (ANS). 

According to PVT, the ANS has three distinct divisions that operate in a hierarchical fashion. The first is the sympathetic nervous system, which is responsible for the ’fight or flight’ response. The second is the parasympathetic nervous system, which is responsible for the ’rest and digest’ response. The third is the social engagement system, which is unique to mammals and is responsible for our ability to connect with others and form social bonds; this is also our first line of defence when under threat. 

EMDR therapy and polyvagal theory: The connection 

One of the key insights of PVT is that the nervous system is constantly scanning the environment for signs of safety or danger. If the nervous system detects a threat, it will activate the sympathetic nervous system, which can lead to a variety of physical and emotional responses. If the threat is perceived to be too great, the nervous system may shut down, activating the parasympathetic nervous system and leading to feelings of dissociation, numbness, and disconnection. 

EMDR therapy, with its focus on bilateral stimulation and the activation of the brain’s natural healing processes, can be seen as a way of helping the nervous system move out of a state of threat and into a state of safety. By activating the social engagement system through the therapeutic relationship, the therapist can help the client feel more connected and regulated, which can in turn support the processing of traumatic memories. 

Kase asked us all to consider what it is that psychotherapists treat? The various responses from the audience were along the lines of depression, trauma, anxiety; but the answer she was looking for was that we treat the nervous system. Kase described the disorders that we are familiar with as simply “flavours of suffering” that derive from neurophysiological processes and went on to outline how PVT can be integrated with the SP. Before she went into detail it struck me that most of us would already be integrating the two theories into our practice – perhaps some more consciously than others. Therefore, if we understood why we were doing this we would be better able to target our interventions. With that in mind, here is what I took away from the presentation: 

Kase renamed Phase 1 as ‘safety and case conceptualisation’. Safety with respect to safety in life, in the therapeutic relationship and in the body. Phase 2 she called the preparation and integrative phase which aims to build resiliency. She described a preparation hierarchy that includes trusting the process, feeling and flexing, noticing and naming (interoception), and feeling safe enough to feel. 

She described how mapping states through psychoeducation around the window of tolerance, hyperarousal and hypoarousal, can assist in emotional regulation. 

The aim of Phase 3 (assessment) is to turn on the autonomic response and to make what is implicit become explicit.  Kase defined the negative cognition, as “the cognitive expression of the felt sense of the ANS”. Something I had not thought of before is that the SUD tends to capture sympathetic activity, so if it appears that a client is in the dorsal vagal state, and they are numb then including a zero to minus 10 measurement in the SUD will give some indication that the client is moving out of this state. When installing the positive cognition, it is interesting to observe that the narrative changes alongside the autonomic state. Phase 6 body scan is simply scanning the ANS for any residue and in Phase 7 closure, the aim should be to leave the client in the ventral vagal state – fully alert and calm. The re-evaluation phase is actually focused on tracking changes to the client’s defence responses (i.e., symptoms). 

Relating a clients’ presentation to the vagal neurobiology can assist in informing more precisely targeted interventions. 

Adapting the SP for psychosis

Adaptations to the SP were necessary in the “improving early intervention for psychosis using EMDR” (EASE) trial. Gita Bhutani, David Keane, Debra Malkin and Filippo Varese presented the encouraging results of their feasibility study. Their presentation was a masterclass in how teamwork, planning, preparation and flexibility can lead to positive outcomes; both in the execution of the trial and benefits for clients. 

The SP was used throughout their study and fidelity to the protocol was measured using the Modified EMDR Fidelity Checklist (Cooper et al., 2019). 

Because of the nature of the client population and the 16-session limit, particular attention was given to structure and containment. There was an enhanced focus on psychoeducation, grounding and client preparation techniques. A goal-oriented focus was maintained throughout therapy and assessment and therapeutic work around sub-clinical threshold trauma symptoms was undertaken to familiarise clients with the EMDR approach.

The findings from the trial were that it was feasible to conduct remote therapy with this client population and that there was a ‘promise of efficacy’ at 6 months – certainly enough to move ahead with plans for a full-scale trial. 

Adapting the SP for for people with autism spectrum disorder

The second keynote and workshop of the conference was run by Naomi Fisher and Caroline van Diest. They continued the theme of adapting the SP specifically for people with ASD to make it more accessible. Such adaptations often manifest in being flexible and creative about sessions and using BLS.   

For people with ASD the demands of everyday life provoke extreme anxiety and their immediate response to requests is frequently a containing “no”. This can be interpreted as pathological demand avoidance (PDA) or oppositional defiant disorder (ODD) but may actually demonstrate their behavioural expressions of distress. Therapists should be aware of this and should not attempt to treat this distress in a behavioural way. 

There are many overlapping features between developmental trauma and ASD including sensory processing difficulties. The presenters indicated that the diagnostic label matters less than how the individuals are treated. Sensory processing difficulties arising from ASD or developmental trauma can have significant impacts on daily functioning and are unlikely to respond well to behavioural interventions.  

One of my questions about late (i.e., after childhood) ASD diagnosis is: How helpful is it? The presenters observed that it provided an alternative to the narrative of self-defectiveness that is frequently compounded by trauma. 

Special adaptations of the SP for challenging ego states

Much of the final conference day was taken up with a clinical workshop on essential skills for working with challenging ego stages in the preparation/stabilisation and early processing phases of the SP. Michael Paterson and Bridget O’Rawe showed how the process of history taking and resourcing needs to be repeated, often many times, to accommodate the different parts that might show up to therapy and the challenges that occur when they do. In a similar vein, the psychoeducation aspect of the SP may need to be repeated frequently due to dissociative amnesia which is common in this client group. 

Summary

Experienced EMDR therapists at the conference will have had confirmed that the SP is sufficient for most client presentations. Furthermore, their willingness to be flexible and creative within the protocol is actually to be encouraged as it widens accessibility to what might be seen as more challenging client groups. 

More recently qualified therapists will perhaps have come away understanding more about why the SP is so important and why it is so rigidly taught. It is the evidence-based framework that holds this therapeutic modality together and upon which research is based and validated.