EMDR Therapy Quarterly

© This article was first published in Therapy Today, the journal of the British Association for Counselling and Psychotherapy (BACP). It has been modified slightly to fit this experienced EMDR audience.

In February 2022 an article had appeared in Therapy Today (the journal of the British Association of Counselling & Psychotherapy) about fads in therapy, and EMDR was singled out for criticism (Wotton & Johnston, 2022). The research that was referenced was outdated and heavily biased towards CBT and it prompted a big response from the EMDR community. Sally Brown (Editor, Therapy Today) suggested that if someone would be willing to write an article about EMDR, she would consider publishing it. Several times in the past I had thought about doing this and subsequently I had a conversation with Sally and agreed to write something which did not focus solely on the standard protocol. The name of the client and identifiable details have been changed.

An EMDR-informed approach offers a time-efficient way to work with attachment trauma

Liam was in his late 20s when he first came to see me for help with trauma symptoms, which he linked to the death of his girlfriend in a motorcycle accident 14 years previously. He described feeling hypervigilant and anxious and experiencing flashbacks, nightmares, intrusive thoughts and an exaggerated startle response. These symptoms were certainly consistent with post-traumatic stress disorder (PTSD), but as we talked, I began to get a sense that the real trauma had happened long before the accident.

For people like Liam, trauma forms part of daily life growing up, in the form of neglect, abandonment, rejection and abuse. It results in attachment trauma or complex PTSD (C-PTSD). In addition to PTSD symptoms, a client with attachment trauma or C-PTSD is likely to present with poor affect regulation, negative self-concept and difficulty in establishing and maintaining healthy interpersonal relationships. This certainly applied to Liam. His childhood memories were patchy, suggesting he had developed a defence of dissociation, he described not knowing who his biological father was, and that his mother had a series of often abusive partners. He recalled one shouting in his face when he was aged three or four. In his mid-teens, he was sexually groomed by an older man and went on to experience a string of difficult adult relationships, including multiple, casual, sexual liaisons with both men and women.

When I first worked with Liam, he was in a relationship but lived alone, and his eight-year-old son Jack stayed with him regularly. It became apparent that he was a loving father to Jack and was determined to play an important role in his upbringing, although he described a fractious relationship with Jack’s mother.

Self-healing

The rationale for my work is based on Francine Shapiro’s adaptive information processing (AIP) model, which proposes there is an innate self-healing quality in all human beings that can be inhibited by negative experiences. Trauma becomes frozen in time, but by activating the memory and adding bilateral stimulation, the client is assisted to create new, more adaptive neural pathways (Shapiro, 2018). Since being developed by Shapiro in the late 1980s, EMDR has progressed from a basic desensitisation technique into a psychotherapeutic approach that has been successfully used to address a wide range of clinical problems, most notably PTSD (Laliotis et al., 2021),

In the case of a single event trauma, the EMDR process follows Shapiro’s eight-phase protocol, but in cases of multiple trauma like Liam’s, particularly those rooted in the client’s early years, a more relational, holistic approach is necessary. Most EMDR therapists who consider themselves to be psychotherapists are treating complex developmental trauma, so rather than simply treating the client’s symptoms, the work addresses formative attachment wounds to facilitate developmental repair. This necessitates a different stance on the part of the therapist, both in and out of memory reprocessing, which is more relational (Laliotis et al., 2021).

Implicit memories

In phase one in the standard EMDR protocol (SP) the client’s history may be obtained by completing a timeline of traumatic events, but with attachment trauma, it is often necessary to initially establish a therapeutic relationship and a safe environment. As US trauma specialist Janina Fisher puts it:‘”Therapists understandably want their clients to trust without always realising how difficult it is to trust anyone when every instinct in your body is saying‘“Danger, danger – do not believe this person – do not trust’” (Fisher, 2021).

I could see that Liam appeared to be in a state of hypervigilance. This made it difficult for him to self-soothe, and he described feeling anxious much of the time. Themes emerged of shame, abandonment and rejection, so it felt important not to rush through phase one. As with most of my clients, psychoeducation played a large part in the early work I undertook with Liam, to help him feel validated and see that, under the circumstances, his actions and reactions were entirely normal. I was also very conscious that I was old enough to be Liam’s father and that he had been groomed by an older male whilst in his early teens.

When I suggested there may be a connection between his earlier experiences and his feelings of not being good enough and being ‘to blame’, Liam responded by saying it made sense but that an irrational part of him did not believe it applied to him. I reframed this in terms of adult perspective versus the perspective of a child whose needs had not been met. Identifying core negative beliefs is an important part of EMDR history-taking because they are often brought into use when subsequently working with traumatic memories.

From a young age Liam had self-harmed by superficially cutting, using drugs, getting into fights and intermittently engaging in bouts of binge drinking to the point of blacking out. Nonetheless, a lot of these behaviours had gradually diminished, and Liam displayed a good level of self-awareness. He told me that he knew that much of this had been about shutting down overwhelming emotions. In the recent past, Liam had engaged in dialectical behaviour therapy (DBT), which helped him learn to regulate his emotions and to resist using impulsive behaviours as an anaesthetic. He demonstrated an ability to apply these skills throughout our time together. Initially, binge drinking continued to be an issue but not to the same extent as in the past.

It is worth considering that clients such as Liam come to therapy not only with an inbuilt neurobiological need to attach but also with implicit and explicit aspects of their trauma. Often, early childhood memories are implicit and stored in such a way that the client does not have a clear link to specific events. Nevertheless, the trauma is present and can manifest as both emotional and physical symptoms. For this reason, it is important to assess for dissociation. Liam had completed a DES-II dissociation questionnaire (Bernstein & Putnam, 1986) which indicated a moderate level of dissociation but not to the point of preventing trauma processing. We discussed some of the DES-II questions in more detail and Liam showed a good level of insight into his current situation and its connection to the past. It is important for people to begin to understand the links between their current presentation and past traumas because it helps them to normalise their behaviours and recognise triggers. Additionally, this process is relational because the client starts to feel listened to and understood. I use Fisher’s psychoeducational tools, which are largely diagrammatic, and they assist clients to externalise their symptoms (Fisher, 2021). Also, crucially, with attachment trauma, much of what the client is experiencing is likely to be pre-verbal, so diagrams can help bridge the gap where there are few or no words.

Understanding versus fixing

Having spent 30 years working in health and social care, mostly as a therapist in the NHS, I have witnessed how easy it is to pathologise and medicalise clients. One of the most powerful lessons over the past few years has been the shift that comes when viewing clients through the lens of ‘What happened to you?’ as opposed to ‘What’s wrong with you?’- a subtle difference of meaning that moves the therapist from the expert view of ‘I’m OK and there’s something wrong with you that I am going to f’ix,to ‘I’m going to try to understand what’s happened to you and work with you to seek a solution.’

At the start of my work with Liam, as with all my clients, I used Santos’ EMDR formulation tool, which is diagrammatic and gathers information in six distinct categories: traumatic/adverse life events, triggers, resilience, intrusions, negative cognitions and symptoms/behaviours (Santos, 2019). The traumatic/adverse life events category forms the basis for a trauma timeline, but the formulation tool allows the clinician to gather information in any order and avoid asking direct questions about trauma memories. To do so is often very triggering, and more so if the client presents with dissociation and patchy memories. Importantly, Santos’ formulation tool also focuses on the client’s resilience and is collaborative because it can be shared with the client.

Liam demonstrated his resilience in the way that he continued to apply DBT skills and in his plans for the future and his relationship with his son Jack. It was important for me to acknowledge this throughout our time together and to use it as part of the EMDR therapy, especially when thinking about his future aspirations. In this way of working, information about traumatic events tends to emerge as the therapeutic relationship develops, but one of the benefits of EMDR is that it does not require the client to provide a detailed account of traumatic memories. What I was aiming to do with Liam went beyond purely resolving a range of trauma memories, and instead I used the therapeutic relationship as a vehicle for positive changes in his wider life (Laliotis et al., 2021).

I taught Liam about the concept of the ‘window of tolerance’ (Ogden, Minton& Pain, 2006). This helped him to understand the difference between hyper-arousal and hypo-arousal and that for effective trauma work to take place, he needed to be in a zone where he could continue to regulate his affect sufficiently.  I assessed his ability to self-soothe, and initially achieved this by use of a safe/calm place visualisation, strengthened by the addition of brief sets of slow eye movements or bilateral taps. Liam identified his safe/calm place as part of the coast where he went kitesurfing, his main hobby, and he began to practice visualising being there when he wanted to feel calm between sessions.

Additionally, I taught Liam a range of mindfulness exercises to reinforce his DBT skills and Shapiro’s ‘four elements exercise’, which uses the symbolism of earth (grounding), air (breathing), water (calming) and fire (igniting the imagination) to change mood (Shapiro, 2012). With Liam, as with many clients who present with attachment trauma, I introduced elements from Schwartz’s internal family systems theory to provide a framework to explore the client’s inner relationships and reveal inner conflicts that could become obstacles to progress (for example, that parts of him might want things to change, but parts were holding him back through fear) (Schwartz & Sweezy, 2019). I then used Jim Knipe’s ‘loving eyes’ technique to help Liam visualise the adult part of him looking at the childlike part that holds the trauma (Knipe, 2015).

The primary reason for this was to teach Liam to observe his trauma rather than relive it, because for EMDR to be effective, he needed to remain psychologically in the room. Particularly with childhood traumas, I was worried that if Liam reverted to a child state or started to relive the trauma, he might leave his window of tolerance.

Past, present and future

Overarching the eight-phase EMDR protocol is the concept of a three-pronged approach of past, present and future, which can help to maintain a sense of direction in therapy.

With an awareness that early memories were driving Liam’s current behaviours, it was necessary to process the earlier events before any substantial positive changes would occur (Shapiro, 2018).  This is why a thorough history-taking and case conceptualisation plan is so crucial to the EMDR process. The first memory we agreed to work with was Liam’s earliest, aged three or four and his stepfather screaming in his face because he had put his underpants on the wrong way round. To work with this memory I used the Standard Protocol and Liam processed the memory within approximately 30 minutes, with no significant obstacles. This, I believe, was a testament to thorough preparation and a trusting therapeutic relationship.

Using the therapeutic relationship as a vehicle for change

Working in the same way, we progressed through several other significant childhood memories previously identified on Liam’s trauma timeline, including being sexually groomed as a young teenager. This memory was significant because it was tied into the death of Liam’s former partner, who was eight years older and who had prompted him to run away from home in his mid-teens. We discussed further EMDR processing and talked about the memories related to his partner’s death. Liam stated that, at the time, he had no one to share his grief with so he locked it away, although he recognised the need to deal with it. For Liam, this had been the reason he originally presented for EMDR, but because he had already worked through several early trauma memories and formed a good therapeutic relationship, the processing of this memory was no more difficult than any of the others.

Trust in the process

It often happens that once the protocol of EMDR is established, the work tends to gather momentum as the client experiences the effects and begins to trust the process. After approximately 20 sessions, having worked his way through a list of historical traumas, Liam began to report positive changes in his relationships, and that he was more assertive at work and not engaging in binge drinking or casual sexual liaisons. It was clear that the emphasis in our work had now shifted to the present moment, and we began to use EMDR to address current triggers and future anxieties.

Liam told me that he had excelled academically at school but he felt that, due to events in his late teens and early 20s, he had missed the opportunity to study in higher education. He spoke about the possibility of applying for university the following year. He knew he was academically clever enough, but there was a part of him trapped by fear, which held him back. Liam said this conflict had manifested at various times throughout his life, but he could not be specific. I therefore decided to use a ‘float back’ adapted from Watkins and Watkins’ ‘affect bridge’, which connects the client with an earlier somatically held memory (Watkins & Watkins, 1997).  On this occasion, Liam floated back to a memory aged eight, when he struggled with maths and asked to go into a lower set. He expressed a sense of shame and thought that people were making fun of him. We agreed to use this memory for EMDR processing, which he did successfully. Liam subsequently processed similar fears about work.

Several weeks after Liam’s sessions ended, we arranged a follow-up so he could update me on events since we last met. He said he continued to feel in a good place emotionally and was in the process of starting an access course for university while applying to do a degree, starting later that year. Liam said that his relationship with his partner was progressing well and he remarked how novel it was to ‘take things slowly’ with someone instead of feeling the need to ‘rush in’.

It is a privilege to witness such personal growth in a client, and there is no doubt that the development of the therapeutic relationship between Liam and I was the foundation that enabled this to happen. Although EMDR is not a panacea, what it can offer in cases of attachment trauma is speed and efficiency, in this instance allowing multiple layers of traumatic memories to be processed over just 20 sessions. Clients can begin to feel the effects in the form of noticeable change after just a few sessions. Long-term psychotherapy is not practical or affordable for many clients, and nor indeed culturally acceptable. EMDR offers a structured and time-efficient way to bring about long-lasting, transformative change at the deepest levels of a client’s self-concept.

• Ian Plágaro is an EMDR Europe accredited consultant and supervisor based in the north-east of England. He has previously worked in the NHS and social services but now works in private practice, where he specialises in working with clients with complex PTSD, dissociation and abuse and attachment issues. He also provides EMDR supervision and training. http://www.emdrtherapy.uk