EMDR Therapy Quarterly

Background

Compelling evidence from the outcomes of recent clinical trials into psychedelic-assisted therapy has sparked public interest (Carhart-Harris et al., 2021; Cavarra et al., 2022).  It seems that we are now facing a renaissance of the healing potential of psychedelics. Therapeutically, things have moved on significantly since the first wave of psychedelic-assisted therapy techniques in the 1960s (Carhart & Goodwin, 2017).  During this 40-year hiatus, trauma-informed practice has revolutionised contemporary therapy practice (Van Der Kolk, 1989; Seigel, 1999; Porges, 2011; Levine, 2015). 

EMDR has the potential to build an important bridge between psychedelic therapy and effective, evidence-based, trauma-informed practice.  Legislative changes are already happening as these compounds enter large-scale, multi-site Phase 3 clinical trials in clinical populations across the world. Research into the efficacy of therapeutic modalities when working with psychedelic material needs to keep up with this expanding field. Developing an EMDR protocol for psychedelic preparation and integration is an unfolding process. Herein, we explore how the tools used by EMDR practitioners merges with best practice in psychedelic preparation and integration therapy. 

Psychedelic preparation and integration therapy has been informed by historic and contemporary studies in psychedelic-assisted therapy (Read & Papaspyrou, 2021), methods used at legal retreat centres in South America (Ruffell et al., 2021) and the Netherlands (Open Foundation, Netherlands, – https://open-foundation.org/); evidence from practitioners working underground during and since the hiatus (Jade, 2018; Bourzat, 2019); and indigenous, shamanic practices (Harner, 1992; Metzner 1998).  Predominantly, the interventions utilised for this case study were a combination of the standard (Shapiro, 2001; Shapiro, 2017) and attachment-informed protocols (Parnell, 2013) from EMDR therapy along with psychoeducation about harm reduction (Gorman et al., 2021) and elements of the ‘Accept, Connect, Embody’ (ACE) model (Watts & Luoma, 2020) developed in early psilocybin trials (Carhart-Harris et al., 2021).

Introduction

This 32-year-old client presented with a problematic reaction to a relationship breakdown, manifesting as an intense fear of abandonment. The client reported numerous adverse childhood experiences (Anda et al., 2008).  They had previously attended long term (seven years) traditional narrative-based psychotherapy but had become frustrated at “not covering any new ground”. This intervention was part of their “ongoing personal development”. This case study will describe how Eye Movement Desensitisation and Reprocessing (EMDR) was applied to preparation and integration therapy for their psychedelic treatment at a private retreat centre in the Netherlands. 

Psychedelics are a Class A restricted substance in the UK (Misuse of Drugs Act, 1971). To ensure legislative compliance, the client made arrangements with a Netherlands (NL) retreat centre as a private provider of the psychedelic component of this work. The centre offered a group psychedelic experience combined with preparation and community-based integration sessions. This was accessed in addition to the EMDR intervention.  The psychedelic sessions were held by English speaking guides, all of whom had therapeutic training (psychotherapists, psychologists, psychiatrists).  The psychoactive medicine used was 33g of fresh (ground) psylocibin ‘High Hawaiian’ mushroom truffles (legal in NL) served as a tea infusion. Ginger was added to the tea to help with nausea.  As is customary, participants met in a shop in Amsterdam where they purchased their own truffles in advance.

This case study describes the process of an in-depth clinical interview to determine case dynamics, and formulation and diagnosis of the real issues, as well as the applied Attachment Informed (AI) EMDR Protocol, and treatment outcomes and follow-up. It will conclude with reflections on the success of the intervention, wider issues relating to psychedelic-assisted therapy, and legislative limitations.

This case study was co-created with the client to ensure they were satisfied with the volume of detail/anonymity and that it was a true representation of their experience.  They were given the final draft to read and the opportunity to edit before submitting to the journal. As is customary in a private practice, subjective ratings and qualitative material are the primary means of assessment. In this case material, additional psychometric measurements were not taken; an evaluation of which will be addressed within the discussion section.

This case study provides an illustrative example of how an underwhelming psychedelic experience can be worked with using EMDR to elicit meaningful therapeutic change. 

Course of therapy

Phase 1: History taking

Adverse experiences reported during the detailed history taking are shown in Table 1.

Approximate age	Adverse experience
Prior to birth	Mother had ectopic pregnancy – surgery for removal.
Birth	Hospital delivery. First live birth delivered. Post-natal depression.
Age 2	Sister born – maternal overwhelm and post-natal depression
Age 5	Moved house. Client unhappy and unsettled by this.
Age 6	Family dog died. Big impact on mother. Dog replaced with ‘bad’ puppy, contributing to parental overwhelm.
Age 7	Cousin (maternal) died in RTA. Mother emotionally absent. Mother initiated a new relationship online. Possibly in reaction to complex grief. Mother left the family to live with new partner in America.
Age 8	Their school placement was based on their mother’s employment at the school. So, they started at a new school, losing many attachments and friendships.
Age 8-14	Various new partners introduced by their father. Pattern of broken attachments.
Age 12-14	Peer attached, exhibiting many problematic antisocial behaviours.
Age 14	Informed they were visiting their mother in America for a half-term vacation but upon arrival they were told that they would not return to the UK. Begged to come back and returned for one month. Problematic behaviours continued and they were sent back to America.
Age 15	Younger sister joined them to live in America.
Currently	Now lives between both countries. Stays up to nine months in England, and six months in America. They tend to live in impermanent accommodation.

The client chose EMDR alongside psychedelic-assisted therapy after listening to a podcast by an American therapist discussing the potential benefits of combining the approaches. After years of talk therapy, they were interested in the neuroplastic potential of psychedelics on the brain. They described their issues as “in my body” and “beyond talking”. In this piece of work, they wanted to address the “physical as well as the biographical.” They were “desperate for change” and “single and getting extremely triggered when dating”. Friends said they were showing “similar relational patterns to childhood”.

Case Conceptualisation

From an AIP perspective, an emotionally absent mother and early disruption to the main attachment relationship led to an internalised sense of self-defectiveness (Kohut, 1971). This was compounded by the mother physically leaving, triggering further disruptions to their interpersonal relationships (Knipe, 2018) and further attachment rupture from unexpectedly relocating to America. The feelings of abandonment triggered in response to their interpersonal relationships as an adult appear to be rooted in these early relational traumas.

It is worth noting that numerous adverse childhood experiences (Felitti et al., 1998) were reported. It is widely accepted in the field of trauma that attachment severance during childhood impacts the development of later patterns of attachment (Schore, 2003; Schore, 2008; Schore, 2021; Siegel, 2001; Cozolino, 2014). Therefore, the attachment informed (AI) EMDR approach was chosen for this treatment.

Following the clinical interview, a treatment plan was agreed on and is detailed below.

NB Sessions before the psychedelic experience are referred to as Session – 6 to Session -1.  Sessions after the psychedelic experience will be referred to as Session +1 to Session +6. 

Phase 2 Preparation: Risk minimalisation and resource development

After our initial assessment, six preparation sessions were offered in advance of the psychedelic retreat. These were used to:

Develop the therapeutic container

This is necessary to contain a potentially overwhelming psychedelic experience and develop confidence in supporting the client’s return to the ‘window of tolerance’ (Seigel, 1999).  Breakthrough psychedelic experiences that include ego dissolution (Nour, Evans, Nutt & Carhart-Harris, 2016) and full mystical emersion seem to have the most therapeutic benefit (Rucker, Ko, Knught & Cleare, 2022). The removal of psychological defence mechanisms has the potential to destabilise the client in the short term, so a robust therapeutic container and tools to enhance the window of tolerance are essential.

Psychoeducation and risk reduction (harm minimalisation)

Consideration of ‘Set and Setting’ are seen as good practice for robust and effective psychedelic preparation (Hubbard, Maclean, & Macdonald, 1961; Dalgarno & Shewan 2005; Read & Papaspyrou, 2021). Clear, predefined expectations of the ‘Setting’ are essential.  The client needs to have a clear understanding of the psychoactive drug being used and a pre-agreed dose, along with group size, facilitator roles and group / facilitator gender. The client should be confident that the space holders are suitably qualified. Ideally, the group should also be offered community-based group preparation and integration sessions to process the whole group experience. Combining horizontal (peer based) and vertical (medicalised) models of care is seen as best practice in avoiding over medicalisation of healthcare provision (Thomas, 2008). Discussions should include how other participants’ processes may affect the group experience. It could also be useful to develop an awareness of how group dynamics may play into familiar family dynamics (Kettner et al., 2001). The client is also encouraged to check that the external provider has good credentials and is operating legally.

Developing the set (mindset)

Exercises using symbolism help to support and develop a psychological mindset. Material from the psychedelic session may include (but is not limited to) archetypal content such as animals, colours, shapes and human/non-human forms. Integration therapy seeks to accommodate and assimilate meaning from the (often quite abstract) psychological content. EMDR resourcing imagery exercises provide an opportunity to practice working symbolically with such psychological content. 

Additionally, establishing a clear intention can support and direct a psychedelic experience (Watts, 2020).  The client did not have a clear intention for this retreat during our -1 preparation session. However, during the review of this case material, they later shared an excerpt from their personal journal which detailed their intentions as to…

“Show what is holding me back, Allow me to feel whole, worthy and good enough,  
See what I need to see in relation to childhood/my mother wound and  
See how I can best serve the world with the insights/gifts I receive.”

Resource development

A safe/calm place was established. Protective figures, nurturing figures and a wise figure were installed using BLS following the AI-EMDR protocol. These were tested for effectiveness and tolerance using content from a reactivation experience on a recent flight between UK and America. Self-regulation and re-stabilisation into the window of tolerance was established.  

Tools and strategies

Rehearsal of phrases to overcome belief-blocking and looping such as ‘trust, let go, be open’, ‘lean in’ or ‘in and through’ were used as processing prompts during the preparatory Phase -4 reprocessing abreactions (discussed later), along with traditional EMDR prompts “notice that”, “feel that”, “go with that”. These mantras (widely attributed to psychedelic veteran Bill Richards [Watts, 2021]) are useful preparation for the psychedelic session. Resourcing experiences of letting go and bravery were installed using BLS. The popular EMDR metaphor of ‘the tunnel’ was used to remind the client that the ‘fastest way to get through difficult content is to put your foot on the accelerator to get to the other side’. Journaling, which supports adaptive information processing, was used as an adjunct to therapy. The client was encouraged to journal throughout the course of treatment and keep a note of any new material that emerged in between sessions. This information was then used in re-evaluation (Phase 8).

Phase 4 Re-processing – used as preparation for psychedelic dysregulation

An initial Phase 4 EMDR re-processing session was offered for one (-3) preparation session, leaving the -2 and -1 sessions available for further containment if required.  This ensured plenty of opportunity for stabilisation immediately prior to the retreat.  This preparatory Phase 4 session was based on current content – the present context of the three-pronged approach (Shapiro, 2008). It was used to establish tolerance of emotionally intense material that may emerge in the psychedelic session. It also served as a preparation for post-psychedelic EMDR integration therapy. Emergent childhood content was bracketed off to avoid destabilisation.

Phase 3 Assessment: Treatment goals

One week after the retreat, an initial EMDR integration session (described herein as Session +1) allowed the experience to be communicated, forming a narrative. Free association of the experience was supported using BLS (tapping). This served as a debrief as well as an assessment of the emergent themes (Shapiro, 2007). Care was taken to not edit or judge the relevance of any material that came up. Psychedelic content can be viewed as a rare and valuable insight into the usually deeply defended content of the deep psyche. Radical acceptance (Watts, 2020) of any unconscious material reported is crucial.   In this case, the client described having a disappointing experience. They did not experience any visionary material that is synonymous with a psychedelic experience.  They described a harsh inner critic judging them throughout, that they were “doing it wrong”. They reported somatic experiences of discomfort in their jaw, neck, and lower body. They described how much time, effort, and money they had invested in the experience and their deep sense of disappointment. The high expectations set by the marketing and media around psychedelic-assisted therapy were defended against by a shutting down of feeling; replaced by the emotional tone that they had “done something wrong.”

Assessment

Themes of self-defectiveness that emerged during the psychedelic therapy session were explored in the subsequent integration sessions using EMDR therapy. The thoughts and somatic sensations triggered by the psilocybin were used as the starting point for the somatic bridge technique (Watkins, 1971) to identify the corresponding maladaptively stored material that had emerged (Browning, 1999). The somatic bridge landed on a memory of being “on a holiday in Italy with other children, who had arranged a water balloon fight”. While the other children were setting up the game, the client (age 5) had access to the water balloons and inquisitively began to play with them, popping them in so doing. The other children found out and were angry at them and had told them that they could not play. They described how they were “surprised to be still upset about it” and that they had “not been able to stand up for themselves”. They had gone to their tent and described how “no-one came to check that I was ok”. This highlights a potential attachment wound, pre-dating the separation caused by the mother leaving. This appeared to be the touchstone memory or ‘root node’ of the self-defectiveness memory network that we were targeting (Shapiro, 2001).

In this memory, the worst part was the boy in charge who told them that they “can’t play with them anymore”. The emotions were , shame and fear, that were felt in the chest and throat. The negative cognition was “I am unworthy/unlovable”. SUD were 10. They described a “constriction in the throat” and “not knowing what to say and so it’s best to not speak”.  On reprocessing, they described how it was “helpful to think about different perspectives” and had not realised that they had “needed someone to be there to ask what was wrong.” This shows the adaptive information emerging as the memory is reprocessed and the SUD reduced (Shapiro, 2001).

Phases 4 – 8

As the memory was re-processed and integrated within the adaptive memory networks (Shapiro, 2007; Hase, 2017) the client indicated that they were “seeing parallels in being lonely and isolated” elsewhere in their life. They described how they “keep friends at arm’s length” and that this “same narrative is applied to lots of situations in my life”. This validated the choice of target because the brain automatically made connections resulting in maladaptive interpersonal behaviours. Psychoeducation around enactment was provided to consolidate the adaptive, metacognitive (Flavell, 1979) viewpoint that was naturally developing. Given what had been shared, reparative attachment-informed interventions were conceptualised as appropriate to attempt to heal their attachment deficits in the imaginal space (Parnell, 2013).

During the re-processing, another formative memory from age 8 was revealed. The paternal grandmother, who was in a care-giving role when the mother had left, verbally attacked the absent mother, placing her as the ’bad object’ (Klein, 1926).  They identified that critical judgement had since been internalised and they tend to “judge myself before others judge me”. Using a reparative, inter-generational interweave, we explored how this ‘superego’ was ‘introjected’ through interactions with the grandmother (Freud, 1924). Finding their origins in dated religious and cultural practices, this was then processed using BLS. Imaginal interweaves were used to revisit the parental alienation experiences. Providing resources, (nurturing and protective figures) to support and patch over the deficits caused by these formative experiences, we directly addressed the critical judgement of doing things wrong. One adaptive thought expressed was “in whose eyes is the wrongdoing?”. Once again, the target was incomplete and the session finished with the child parts being taken forward in time to the present and settled into the preestablished calm place. The SUD were 4 but the client said they wanted to let the experience percolate. They agreed to reach out for containment if required. 

The theme of self-defectiveness kept emerging in the work, and each time a somatic bridge was used to identify the corresponding maladaptively stored material. Once this network was sufficiently re-processed using BLS, another theme of abandonment was revealed, which was re-processed accordingly. Throughout this process, all the main traumas identified during the history taking phases were addressed either directly with BLS or indirectly with imaginal re-scripting of touchstone attachment experiences.

Eventually, adaptive thoughts of “doing things ‘wrong’ is other people’s stuff” were accompanied by images of a “protective light bubble” and “lasers spreading out and zapping other people’s judgements”. Expressions of “not letting it hook on me anymore” brought the SUD down to 0. We revisited the different channels that had bridged from the core memory and integrated the new adaptive material that naturally emerged using BLS. The protective light bubble appeared to represent a strengthened ego and a new confidence in relationships. This can be conceptualised from the adaptive information processing perspective and will be discussed later. The age-5 target and psychedelic retreat target were cleared to a SUD of 0 and the validity of cognition (VoC) of “I am loveable/worthy” was placed at 7.  The positive cognition was installed, and body scans were positive and adaptive for both. 

Session +6 began with a re-evaluation of the target and review of Session +5. The shift of the descriptor from “I am unworthy/unlovable” to gratitude with the SUD remaining at 0 indicated target completion. They expressed a sense of gratitude for the retreat experience. On reflection, they had “received the perfect medicine”. This was installed using BLS.

Robust and effective EMDR therapy requires a 3-pronged approach. Therefore, we took the emergent material into a Future Template. They described how an ex-partner’s family member discouraged them from having children together, saying that if they had children, they would likely re-enact their own attachment experience and “leave their own child”. This triggered a core belief, and they described how they had a “fear” about their capacity to be a parent. We bridged forwards from this – image, emotion, somatic sensation, and belief – and BLS was applied.  Eventually, they processed to a place in time at the “end of my life”, with an image of them “being elderly and not having had the experience of being a parent”. This fear superseded other people’s judgments. On reprocessing using BLS, an image of future resilience emerged – a sense of being good enough and working with whatever life brings. The protective bubble and lasers displacing other people’s judgments also featured in the adaptive thoughts processed here. Once again, gratitude featured and was tapped in. SUD remained 0, concluding this piece of work. 

Review of Therapy and Follow-up

This person’s experience highlights the importance of addressing the preverbal, transpersonal, and intergenerational content for robust EMDR target completion. Key features of this work will likely generalise out into other aspects of our ongoing work, and it is for these reasons that multiple sessions were required to fully address this specific target. This open-ended piece of work continues, and the client intends to use legal psychedelic experiences alongside EMDR to deepen the work we do.

Outcomes

In collaborative review of this case material, the client described how

“EMDR allowed me to go deeper and explore the associated memories that were connected to what came up in my (psychedelic) trip”. EMDR “allowed me to experience the difficult feelings in my body and, as I reexperienced it, it loosened its hold on me”.  It was “like a glitch in my thinking and EMDR helped me break out of it”.

Discussion

This client described how “lots of people look at it (psychedelics) as a silver bullet; you take it one time and you are cured”. Their experience on the retreat moderates this view of psychedelics. “After the retreat I was not fixed, but I set to work with the material”. They explained how “people don’t realise the importance of the work that comes afterwards”. They gave an example of how “one other retreat participant who had a similar experience to me says they didn’t get much out of it…”, but that “I have had a change in perspective as a consequence of EMDR”.  For this client, the turning point can be framed using the AIP model.  Through EMDR, the imagery of a protective light bubble appeared to represent a strengthened ego and a new confidence in relationships challenging the faulty cognition.  This generalised out into other areas of our ongoing work together and has impacted various aspects of their life –  the details of which go beyond the remit of this case study.    

The psychological content from underwhelming psychedelic experiences is often overlooked and the psychedelic treatment can be written off as unsuccessful. When participants on retreats do not have a transformative experience, an overview of the process needs to be held, trusting that you get what you need, no matter the insights. Fundamentally, it is the work that did happen, rather than what the participant wanted to happen.

It is important to remember that the psychedelic experience holds no answers. It is not a magic cure.  Retreat centres are expensive and their marketing flawless, which may serve to further fuel the notion of a silver bullet.  Letting go of expectations is, for many, the work that needs to be done. Therapeutically, we need to remain open to the possibility of the participant expecting to be rescued, believing that if they had the perfect parents and were taken care of then they would have been happier. This is then projected onto the psychedelic retreat setting and onto the therapist. This can be further compounded by the media hype around the benefits of psychedelics. This case study illustrates that the value of the therapeutic component requires further investigation. 

Retrospectively formatting this piece of work into a case study was not without difficulty.  Client consent was sought retrospectively which is not ideal, albeit their later collaboration was helpful. The efficacy of this intervention was not objectively measured. Whilst this is customary in a private practice setting, this piece of work falls short of the demands of full scientific integrity.  More extensive, objective psychometric measurements are needed to assess treatment efficacy. To ascertain the cumulative impact of PsyA-EMDR therapy, a randomised controlled trial (RCT) is needed where PsyA-EMDR would be compared against other psychedelic preparations and integration therapies such as EMBARK (Brennan & Bessler, 2022), ACE / ACT (Watts & Luoma, 2020) CBT, Jungian, and community-based interventions. Combinations of these therapies may also enhance efficacy, and needs investigating. It is likely that such studies will happen once licencing is granted. With promising early results from the Phase 3 clinical trials for MDMA and psylocibin, this might be possible in the next three to five years. Further work is needed to develop the PsyA-EMDR protocol before then. 

The integrative nature of EMDR and the ongoing adaptions being made to work with a wide-range of clinical populations mean that it is well aligned to fit into a psychedelic-assisted therapy protocol. EMDR allows for client-focused flexibility in the way it is implemented. The development of AI and IG protocols can support transpersonal development which is often triggered by psychedelic experiences. There is also scope to expand transpersonal aspects of the AIP model further, if combined with the work of Carl Jung (Jung, 2014) and Stanislav Grof (Grof, 2003; Groff, 2009). Psychedelic material often includes systemic and transpersonal content, so Jungian and Grofian theories provide a supplementary framework. 

The measurable outcomes of systemic and transpersonal change are difficult to quantify. Given the cultural impact of psychedelics in the 1960s, large scale population studies might provide some insight into the impact that individual transformation has on the collective psyche (Jung, 2014). Considered and measured application, along with robust and effective therapy, are paramount to ensure that the mistakes from the 1960s are not repeated. Learning from the mistakes of the entheogenic past, we know of the potential for depersonalisation, derealisation, additional traumatisation or retraumatisation, reactivations (flashbacks), as well as overlooking underwhelming experiences. EMDR can support the onward processing of such psychedelic content. The psychedelic therapy community needs better tools when participants have such difficult experiences. The eight phases of EMDR therapy have comprehensive, targeted tools for grounding, resourcing and safety, and stabilisation, which can be easily lent to the discipline. The AIP model guides the use of these interventions throughout the process.

The efficacy of private retreat settings can vary considerably. In addition to EMDR, this retreat centre provided one group preparation session and seven post-dose integration sessions. The client participated in this online community-based integration alongside the EMDR intervention. These sessions were offered at +1 week, +2 weeks, +1 month, +2 months, +4 months, +6 months and +9 months post dosing; the cumulative impact of which was not measured in this case material. Community-based integration groups (Thomas, 2008; Kettner, 2021) and horizontal care structures provide important ongoing peer support and can be used in conjunction with vertical models of care such as EMDR therapy.

Writing this case study has been a collaborative process.  Whilst looking back through their journal at the intentions that were set, the client acknowledged that their participation in this case study has become part of their integration process.  Our most sincere gratitude goes to them for their generosity in sharing their personal story and the details of their unfolding process. Thanks too for their collaboration in making this a true reflection of our work together. 

Summary

This case study illustrates how EMDR therapy, guided by the AIP model, can be used to explore psychological content from non-ordinary states of consciousness using attachment-informed interventions. It shows how the eight phases can be used in a targeted way to develop a container for clients accessing psychedelic-assisted therapy. The stabilisation and resourcing interventions during the preparation phases of EMDR are particularly suited to supporting psychedelic-assisted therapy clients.   Over the past 30 years, EMDR has developed into a comprehensive treatment for cPTSD, supporting those experiencing regressed ego states and those with an impaired ability to self-regulate – states often accessed during work with psychedelics. This case demonstrates how reprocessing can be used to prepare clients prior to a psychedelic treatment – activating the nervous system and triggering somatic responses and biographical content. It also outlines how psychedelic therapy compliments and amplifies the benefits of EMDR therapy.  EMDR was used to explore and integrate psychological material that emerged during the treatment, and the AI and IG protocol adaptions facilitated this. It is hoped that this article will pave the way for more robust research of PsyA-EMDR therapy and its potential as a hybrid psychotherapeutic intervention.

Further research

Legislative restrictions currently limit our capacity to investigate the impact of PsyA-EMDR. According to Home Office definitions, Class A (Schedule I) restricted substances are deemed to have no therapeutic value and therefore cannot be lawfully possessed or prescribed. This case study contributes to a growing body of evidence that psilocybin holds significant therapeutic value, undermining its position as a Schedule I restricted substance.    

Jocelyn is a psychedelic therapist working in clinical research, and training with the Institute of Psychedelic Therapy. She is also a psychodynamic psychotherapeutic counsellor, EMDR practitioner and supervisor working in private practice. Hannah is an integrative psychotherapist, clinical supervisor and researcher working in private practice. She was trained in EMDR therapy (MSc) at the University of Worcester and studied the neuroscience of psychedelics and EMDR therapy on a cognitive neuroscience masters at Cardiff University.