EMDR stands for Eye Movement Desensitization and Reprocessing. It relies heavily on scripts, which makes it easy to research. A multitude of studies show that it works just as well as other easily researched approaches for trauma confrontation while being more gentle for both Ts and patients. Why exactly EMDR works is not fully explained. It is considered to be more on the reprocessing side instead of pure desensitization. The hallmark of EMDR is bilateral stimulation that is supposed to help with dual focus as well as building bridges within the brain to access dissociated material.
I will walk you through the 8 Phases of EMDR so you will know what to expect from your therapist and to make sure that you recognize if your T is making major mistakes. There are tools they might use when you somehow got stuck that I will not explain in detail, that’s not what I mean. Sometimes bilateral stimulation is used wildly outside the official script, with a high risk of re-traumatization and I want to you be able to recognize it, if it happens to you.
The 8 Phases of EMDR
The 8 Phases don’t happen in one session. Some is preparation for the exposure, then there is the exposure itself that goes through several phases and the weeks and months after the exposure make another phase.
Phase 1: History and treatment plan
First your T will listen to you. They will check if your life situation is safe and stable enough for processing, if this is a good time to do difficult work and assess your personal resources and regulation skills. It is best practice to let you do the DES to screen for dissociative symptoms right at the beginning to see if maybe a different script and more preparation, including an extended stabilisation phase, is needed. This will be the case for most people with more than a simple shock trauma. If you have DID your T needs special training how to apply EMDR, they can’t just use the standard script. There is specific training for DID available.
Phase 2: Preparation
Your T will give you time to get to know them and build a solid working relationship. If you are too self-conscious to do eye movements in their presence or feel the need to withhold your experience during processing, you are not ready yet. With cPTSD trust is not built within one session. Ts who swear they can heal you within 10 sessions or less are lying and you will probably experience harm.
Your T will teach you at least basic grounding, containment, the Safe Place, and sometimes breathing exercises to make sure that you can calm yourself during the exposure. You need solid self-regulation skills and capacity before you can continue. With complex trauma a thorough stabilisation phase protects you from greater struggles later. A good support network is recommended, otherwise it is safer to have EMDR while inpatient.
When you are ready your T will explain the technique used for exposure, the risks, how it could affect you and that it seems not to work for about17% of the people in studies. You only ever do exposure when giving informed consent. Do not let a T push you if you truly feel that you are not ready. You should be invited to ask questions.
Phase 3: Assessment
Now your T will help you define a target for processing. A target is often chosen by looking at a recent event that was dysregulating, identifying the trigger and the memory that was triggered. It is usually best to do this in the session before the exposure. If you can, it might be helpful for both of you if you tell the T what happened beforehand. But the special thing about EMDR is that you don’t have to. If speaking is not available you don’t have to. The T doesn’t have to know the details to help.
Your T should let you try out the eye movement (they move their fingers in front of your face and you follow them with your eyes) and offer you options for other kinds of bilateral stimulation (like a buzzer in each hand, a moving light bar to follow with your eyes if a hand or pen in front of your face is triggering, sounds via headphones or tapping). A study shows that eye movement gets slightly better results than other options. Your T is supposed to adapt to your needs. You can tell them if it is going too fast or it’s too close. Always make sure to say something in case your eyes start to hurt!!
Not everyone is capable of dual focus, that means paying attention to your memory and following the bilateral stimulation at the same time (usually because of a neurological problem that causes other problems in life too, you would know). In that case EMDR is not recommended!
Your T will ask you about a signal you can give them when you need a break. It is important to pick something you can do, even when you are stressed. For some, speaking or raising the hand is not possible during intense dysregulation. Using eye movement is preferred because it makes it easy for the therapist to see when a patient disengages by looking straight ahead (or dissociating).
If you struggle with the memory a lot, it might help to do the full assessment the session before the exposure, but the rest of it is often done at the beginning of it. Exposure sessions usually take 90 minutes.
A closer look at the target
A target memory consists of an image, a positive and negative cognition, emotion with disturbance level and sensation.
- Image: you pick an image or short sequence from your memory. It doesn’t have to be a full scene, EMDR works with fragments as well.
- Negative cognition: You define a core belief about yourself concerning that image. This is about your very personal interpretation, it is not supposed to be a description of what happened. Usually the negative cognition is an “I am….“ sentence + a self-assessment, like ‘I am worthless’ or ‘I am helpless’. These beliefs often express shame, being responsible, lack of safety or lack of control. But you have to look at your own memory to feel the core belief that got stuck with it.
- Positive cognition: Now you pick a desired cognition that is true today. It should be realistic and within your control, so things like ‘it never happened’ or ‘nobody is going to hurt me ever again’ don’t qualify. Try to find a positive statement, like ‘I am strong now’ or ‘I am safe now’ instead of saying ‘I am not weak anymore’. This is the cognition you will try to activate more later. It is quite common that during processing a stronger positive cognition shows up, but you need a place to start. Positive cognitions are then rated with the VOC (Validity of Cognition) scale from 1 (false) to 7 (completely true). Try not to think too much and guess how true it feels to you right now.
- Emotion: You think of the image + the negative cognition, just for a moment, and then rate the feeling that comes up in SUDs (Subjective Units of Disturbance) from 1-10, with 10 being unbearable. Make sure to rate your feeling about it today, not how bad it felt while it happened. SUDs are only used for emotion, not for thoughts. If there are several emotions it might help to rate them separately, your T will help you with that. Basically the idea is to get the SUDs down, but sometimes the quality of an emotion changes instead. So eg hatred might turn into disgust, then righteous anger and finally become sadness.
- Sensation: last the body is included with all the sensations that come up with the memory. That can include somatic flashbacks you have when thinking of it, hyperarousal, tension, sensitivity and all kinds of body sensations that belong to TraumaTime. You need body awareness for this, which means that you cannot process things if you are still stuck in chronic dissociation.
While it takes some time to explain, all this it actually only takes a few minutes during the session. Your T will guide your through it and take notes about everything. There is no need for over-thinking, it doesn’t have to be perfect and everything can be adapted during the processing.
Phase 4: Desensitization/Processing
Now your T will start the bilateral stimulation, choosing intervals between 20 seconds and up to a minute, more if that seems helpful. This will naturally result in something like titration. You focus on the image you picked while also focussing on the bilateral stimulation. You don’t keep the scene in your mind statically, instead you allow your mind to drift, noticing whatever comes up in connection to the memory. That might be the emotion, then you stick to that and notice how it changes throughout the interval. Don’t hold on to anything, let it evolve. There might be details that jump out, you might suddenly remember something that was said, you might feel an old body sensation etc. Your T will guide you to stay with whatever moves to the front of your awareness through several intervals of bilateral stimulation until this specific aspect is resolved or stops changing. Then you will return to the image and see what comes up next.
I often imagine the trauma scene like an underground cave that has different tunnels for the different aspects of the experience. You follow whichever tunnel comes up to its end, then return to the cave and check out the next tunnel. Your T will constantly ask you ‘What do you get now’ after the intervals to check how things are developing and to see if maybe the tunnel is finished.
They will take breaks when you get too dysregulated and help you with orientation and grounding whenever needed. You can ask for breaks too, in case your T doesn’t notice that you need one. If you dissociate a bit that is ok, take your time for grounding. If you dissociate severely your T will stop the session and return to working on this later in your therapy. You might not be ready yet.
With complex trauma it is common to follow a tunnel and suddenly end up in a new cave, a different memory that shares certain elements with the one you are processing. Your T will help you to leave that alone for now and will take notes to address that other memory in future processing.
With EMDR it is possible that the distress about other scenes will go down even if you don’t look at them specifically, similar things might get processed on the way.
It is also common for new details of a the memory to come back to you. Sometimes that can make a huge difference.
Your T will let you rate your distress in SUDs now and then. When they are still high but nothing changes anymore they might try to do things differently, like changing the direction of the eye movement. When there are no more ‘tunnels’ showing up and the SUDs are low your T will move on.
Phase 5: Installation
Now you will try to improve your rating for your positive cognition. Your T will either use the one that was written down at the beginning of the session or one that became meaningful at the end of one of your tunnels. The bilateral stimulation continues but now you think of the scene + your positive cognition at the same time. The goal is to get to a place where you will think of the positive cognition whenever you remember the scene. Your T will ask you to rate the VOC again and when it is at a 6 or 7 they will stop. Sometimes you will need to test things out to be sure, that is why it doesn’t always have to be a 7 right away. You don’t rate the VOC for the negative cognition. It is not addressed anymore.
Phase 6: Body Scan
Your T will ask you to think of the scene and your positive cognition and then check your body for any body sensations that might be left, that can include numbness. Tell your T whatever you can feel in your body, it might not make sense yet but it is important to process it anyway to prevent this from bothering you in the future. This might get uncomfortable. Your T will continue the bilateral stimulation while you focus your awareness on the body sensation (or numbness) and notice how it changes. It is not rare for additional information to come up that explains why your body sensation made sense for that trauma situation. Your T might add techniques from body work here to support the trauma release.
Phase 7: Closure
You are done with the bilateral stimulation and your T will help you to calm down and contain the scene you worked on. It is actually not so rare to end the processing in a good mood. You will get instructions for the next few days anyway because our soul tends to keep processing things and they will most probably come up during the next week. That is not a sign that the EMDR didn’t work, so don’t despair.
If that didn’t happen the session before your T will ask you about your plans for after the session (it would be best if someone could pick you up and stay with you for some time). You will be reminded of your coping skills and the T will offer a phone call to check on you and a new appointment a couple of days later. Ts who work closely with the EMDR script will ask you to keep a journal where you write down your dreams and everything that comes up for some time. This can help to point out areas where this scene needs additional processing or to define new targets. It is not so rare to need 2 sessions to process a memory, so don’t be discouraged if that is the case.
Phase 8: Re-evaluation
During the next session your T will evaluate how things went for you, how much change was achieved, if you can leave it like that or if you should tackle that memory again. For the next few weeks they will also look for signs (and help you with) change in the present, like you managing situations differently where you got overwhelmed before. It is important to ‘walk it out’ and follow through with the change before choosing a new target for more processing. You need time to experiment with new behaviors and change your life. Healing looks like something. Once this memory seems to be fully integrated your T will return to assessing new scenes to process or terminate therapy when you are done. Being in the phase of trauma processing doesn’t mean that you will have an exposure in every session, not even every other session. It needs time to stabilize in between.
This is what EMDR is supposed to look like. If it is not used for a single shock trauma it should be integrated in the 3-phase model of stabilisation, trauma processing and integration. Just using bilateral stimulation for desensitization without using this whole script is not EMDR, it is someone taking shortcuts that are potentially dangerous for you.
You cannot do this at home for yourself. It needs a T trained in EMDR to be with you, they actually do more than moving their fingers for you. They make sure this is going well for you and that you are safe. If you try this alone you will get re-traumatized. Ts who did not get EMDR training should not use EMDR, there is a lot more to know about it than the basic script. Ts who are not trained how to do EMDR for DID should not try to do it with their DID patients. If you have DID, make sure to ask about this specifically.
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