EMDR: Where did it come from? Whatis it? Where is it going? EMDR: come from? What is it? Where is it going? Gary Peterson, M.D. Chapel Hill, NC Carolina House Symposium The Washington Duke Inn Durham, NC ‘August 23, 2013, Carolina House Symposium Workshop with Gary Peterson, M.D. Objectives | cc ~ Explain the origins of EMDR + Describe the eight phases of EMDR ~ Name the three prongs of the basic treatment protocol Orientation towards EMDR EMOR Is one of a wide variety of methods under ‘the rubric of Power Therapies’ that target speettic Issues and problems, almed at rapid resolution. These methods generally employ attunement to a problem including the emotions and somatic component, and apply a dual attention task with a physical sensation that supports resolution of the clients negative emotional attachment to the target Issue. Active Ingredients Project Efficient Therapies of PTSD (Figley, 1995) ere eed «Eye Movement Desensitization and Reprocessing (EMDR) + Thought Field Therapy (TFT) * Visual/Kinesthetic Dissociation (W/KD) » Traumatic Incident Reduction (TIR) Active Ingredients Project Data | cc [Method |Subjects [ireatment Follow-up time (min.) [SUD lemon [6 172, 2.64 [TFT 14 63 3.60 WOK 1 113 3.30 [TR 9 254 567 The Washington Duke Inn Durham, NC Epigenetics | cc * Environmental influences affect the genetic expression of DNA * Epigenetic modifications can be Inherited from one generation to the next. August 23,2013 Pg 1EMDR: Where did it come from? Whatis it? Where is it going? Epigenetic Mechanisms | cc + DNA methylation and histone modification can regulate gene ‘expression without altering the underlying DNA gene sequence. Carolina House Symposium Workshop with Gary Peterson, M.D. Epigenetic Modification Epigenetics and Environmental Stress | cc ‘The genome dynamically responds to the envionment. Stress, diet, behavior, toxins and other factors activate chemical switches that regulate gene expression. ‘The lousy childhoods or excellent adventures of our ancestors might change personally, bequeathing anxiety or resilience by altering epigenetic expressions of genes in the brain Epigenetic effects | cc + Asenvironmental influences affect the genetic expression of individual traits, many effects can occur. + Inaddtional to emotional and behavioral Issues, altered gene expression can atfect cardiovascular status and can be associated with risk of cancer. The Washit Epigenetic Inheritance | cc DNA sequencing of genes is unchanged. Some epigenetic tags remain in place from generation to generation. The new embryo's epigenome is not completely erased and rebuilt from soratch. ington Duke Inn Durham, NC Epigenetics and psychotherapy | cc + “Successful psychotherapy may activate epigenetic mechanisms in brain circuits to reduce psychiatric symptoms by improving the efficiency of information processing in these circuits, just like effective drug therapy is thought to do.” Jn Pharm Ther 2012 p52 August 23, 2013 Pg2EMDR: Where did it come from? Whatis it? Where is it going? Intergenerational effects of smoking Carolina House Symposium Workshop with Gary Peterson, M.D. Autonomic Nervous System Stress and the HPA Axis Polyvagal Theory Sequence Porges’ View of the ANS ee "the metaphor st safe Trauma Treatment Overview Phase or Stage Oriented Approach . Safety, stabilization, and symptom reduction p Processing traumatic experiences 2 Integration or fusion, and rehabilitation The Washington Duke Inn Durham, NC ‘Trauma Treatment Overview 4. Stabilization Phase ~ Safety from self injury, drugs, promiscuity, destructive relationships Stabilization of mood, atfect tolerance, functioning in dally life, relationships ~ Symptom reduction, learning to self- soothe, containment of re-experienced traumas August 23,2013 Pg 3EMDR: Where did it come from? Whatis it? Where is it going? Trauma Treatment Overview 2. Trauma-Processing Phase * Re-experiencing, abreacting, desensitizing, and detoxifying traumatic events © Reframing context of the abuse + Tolerating feelings of helplessness, grief confusion, shame, horror, terror, anger and rage Carolina House Symposium Workshop with Gary Peterson, M.D. Trauma Treatment Overview 3. Integration, Fusion, Rehab Phase | © Grapple with loss, grief, mourning, loneliness + Practice new skills © Tolerate not relying on dissociation * Deal effectively with everyday problems The Adaptive Information Processing System ‘Healing isthe usual human response to untoward events Pry at eae Pejenaageal-probims esoe Learning occurs based upon constant ‘updating in response to changing environment, perceptions, ‘and knowlege. Disturbing events that are not metabolized or led off are stored in manner that precludes the usual integration that occurs with fe evens. EMDR Historical Highlights me 1987 Shapiro develops Eye Movement Desensitization (EMD) 1989 Shapiro publishes 2 EMD articles 41991 EMDR renamed EMDR, 4992 First EMDR Conference 41995 Shapiro's EMDA published 4995 EMDR International Association established 2001 EMDR, 2° Ea., published 2002 Resource Development and Installation 2007 Journal of EMDR Practice and Research begins EMDR Research hlights ed 1989 Treatment of somatoform disorder ecm) 1998 Treatmentof military veterans icxreor) 1998 EMDR equivalent to exposure therapy (van eter) 1999 Superior to routine Tx for adults with CSA (cement 2002 Positive results with children with PTSD (creme) 2002 Equivalent to CBT for adult prco overs atte) 2004 Group protocol for children ieemandee) The Washington Duke Inn Durham, NC More EMDR Research Highlights 2004 ‘As effoctve os GBT lareomally abused gi (essere) 2006 Effective treatment after 9/11 sim 2007 EMDR Reduces PTSD sx better than SSRI (vane kom 2008 Effective vs. CBT for child behavior problems (wanes) 2012 EMDR and B/SIT significantly reduced test anviety (cook vera 2012 Traumalized C&A -15 EMDR studles (cook vena August 23,2013 Pg 4EMDR: Where did it come from? Whatis it? Where is it going? Professional Organizations Endorsing EMDR include: 2013. World Health Organization (WHO) 2011 Substance Abuse and Mental Health Services Administration (SAMHSA) + 2010 Department of Veterans Affairs & Department of Defense 2009 International Society for Traumatic Stress Studies (ISTSS) + 2004 American Psychiatric Association (APA) Carolina House Symposium Workshop with Gary Peterson, M.D. The EMDR Approach «Integrated psycholhetapy approad = Based upon the Adaptive Information Processing Model +The Present isa re-marifestation of the Past © Reprocessing = Adaptive Learning + EMDR takes a complex approach to trauma, processing not only the emotion associated with the trauma, but the entire trauma ‘memory within tts network of associated memories. Case Conceptualization Bio-Psychosocial Intake Presenting Complains Targeting Plan Eight Pass ‘Three Pres EMDR Treatment Goal ed Trait Change vs. State Change Effective, Efficient & Safe 8 Phases of EMDR ed 4. Client history taking 2. Client preparation 3. Assessing target event Picture the stuation Establish negative cognition (NC) Establish posite cognition (PC) Valdty of Cognition (VoC) Subjective Unis of Disturbance (SUD) maton and somatic components The Washington Duke Inn Durham, NC Phase 1: Client history and treatment P inning + This phase usually occurs over the fst few sessions. Often the person being evaluated is ‘asked to compete an information form that includes questins about current and past ‘medical status, family and chidhood story, and current symptoms. During the interview, the cncian asks supplementary questions. These questions include facts about the person's pastas well as current and past symptoms. August 23,2013 Pg 5EMDR: Where did it come from? Whatis it? Where is it going? Phase 1: Client history and treatment planning (cont.) | Detaled information is necessary to create an independent assessment ofthe clents condtion. In ccomplcated stations, contact wih the person's family may be requested ‘The cncian wil use this information to build a treatment matric addressing present and past disturbing event For chiiren, parents are invaved inthe consutation. ‘The cncian generally shares his/her impressions wit the client and a decision about how to go about ‘neatment is agreed upon Carolina House Symposium Workshop with Gary Peterson, M.D. ‘TRAUMA/RESOURCE TIME LINE mn Phase 2: Preparation Ed lit agteed that that EMDR would be used in therapy, there are several steps in reparation for the actual processing of the material A deoree of trust must exst between the cent and cncian, ‘The cincian explains the theoretical background for EMDR and describes the actual steps in the process. The clnian learns about the etints sel-sothing stil and teaches the clent new skils to increase the abit ofthe client to tolerate the processing of traumatie material Phase 2: Preparation (cont.) | ne One ofthe caming techniques used in EMDR Isto estabish a"safe place” inthe ctent's imagination to which the clent can rtum uring times of emotional disturbance. The clnian ascusses the types of lateral stimulation (BLS), and they decide what Kind of biateral attention process they will use. Salety procedures are discussed and set in place. The clents concerns and feats ate addressed. Phase 2: Preparation (cont.) The clinician might apply BLS during this phase to develop and enhances psychological resources before beginning information reprocessing (Phase 4: Desensitization). BLS for resource bulking is applied with a shart set of very slow aternating movements. Prior ta moving to the next phase (Phase 3: Assessment) the cient must be able to change emotional states from being reubledllsturbed to feeling neutral, stable, or postive. This i so the cent vil be abe 1 recover fom a disturbing state that can bccur from the reprocessing of a asturbing event The Washington Duke Inn Durham, NC Phase 3: Assessment a ls ‘The Assessment Phase begins the EMDR reprocessing session. The client is asked ‘what the target incident will be. He/she is asked what picture represents the worst part of the experience. + The client associates words that best go with the picture (or experience) that express a negative belie (Negative Cognition (NC) about sein the present time while attuning tothe disturbing event. August 23,2013 Pg 6EMDR: Where did it come from? Whatis it? Where is it going? Negative Cognition Properties | cc ~ Negative belief around target issue First person present tense (| am ...) * Statement of being (vs. doing) © Child-like perspective © Irrational quality + Generalizable Carolina House Symposium Workshop with Gary Peterson, M.D. Phase 3: Assessment (cont.) omar + Next, the client decides what he/she ‘would like to belleve about self in place of the negative thought. + The client assesses the validly of this postive thought (Positive Cognition (PC)) relative to the target experience, ‘on a seven-point scale (Validlty of Cognition (Voc) scale 1-7). Phase 3: Assessment (cont.) ed + The client then names the emotions associated with the target event and scales the disturbance level on an ‘eleven-polnt scale (Subjective Units of Disturbance (SUD) scale 0-10). + The cllent identities the location of the body sensation associated with the disturbance. Examples of Cognitions | cc Negative Cognitions Positive Gognittons. lam abad person ama good person am worthless Lam worthwhile lam shameful am honorable 11am unlovable Lam lovable |lam incompetent | can take care of myselt 8 Phases of EMDR (cont.) | cc Desensitization Installation Body scan Closure eNom Re-evaluation The Washington Duke Inn Durham, NC Phase 4: Desensitization The desensiization phase isthe core ofthe Information processing. lt bepins with the cient to holding in focus a picture of the traumatic event, a negative sel-perception and a body sensation associated with a dsturing event. +The einican then heps the cent focus on a bilateral stimulus (BLS) while helaing the target event in mind. +The stimulus may consist of rapid hand movements 1 moving Eghts inthe cents field of vision atemating tones to the ears, or aternting taps on the hands. August 23,2013 Pg 7EMDR: Where did it come from? Whatis it? Where is it going? Phase 4: Desensitization rel Na mein | These ses of ioral tention may lat rom less than a hattminut to, rare stuabon, several mnules, depending on the cen's response. The cient asked to. tng his arenes fo the ofce are fo comment on ‘hater comes in aiarnsas, “Alter ging a short description of what thought, feting or ‘experiance that eames upin the cles mind, the eent ‘oes another set of biseralebmulaton Over many ats of BLS, the therapist support the Sent through the processing of whatever images, though, fealngs or sensations that come ino awareness. Carolina House Symposium Workshop with Gary Peterson, M.D. Phase 5: Installation of Positive Cognition on When the processing of the disturbing memory is. complete, as measured by the amount of residual disturbance of the memary (SUD =0), the postive thought (posiive cognition) Is revisited, reconfirmed 2 appropriate and scaled as to vaidty inthe presence of the erignal experience. Ses of lateral stimulation are applied untl the Positive thought is experienced as being totaly vald (7 ona scale of 1-7), Phase 6: Body scan Yon + The clients asked to close hisiner eyes, concenirate onthe target experience and ‘mentaly scan the entire body + tsensations or lack of sensations are reported, shot sets of bistral stimulation are ‘npied unt any negative sensation subsides ‘or postive sensations are fly experienced. Phase 7: Closure _ “he cents guided 10 neta or positve emaiona state prior toloavng the session. The cent may continue to process the maleal for days ater a These experionces may foe confusing tthe cent, but they tre concord to ba continuation ofthe healing proces. The cents asked to keep a record of new sensaons and cewperionces and raped them fo the cinian a the net fection. ithe csant becomes caneeed or supingly ture, helene should et the cnc know ng ay. Phase 8: Re-evaluation TT + Atte beginning ofthe net session, the cent reviews the week, dscussing any new sensations or experiences and reveing hisiher leg. The dstubance ofthe previous session's {aige! exerience s assessed top decide on the couse of atin + Generaly, the eght-phase process is soped to pst events, cunt tigers and aniiated future events related tote target event (Three Pronged Approach The Washington Duke Inn Durham, NC August 23,2013 Pg 8EMDR: Where did it come from? Carolina House Symposium Whatis it? Where is it going? Workshop with Gary Peterson, M.D. Three Pronged Approach Points for Consideration | cc a + Informed consent during preparation phase + Past © Secondary gain i recelving dlsabity . + Ego strength to tolerate stress ofthe method eeone + Strong therapeutic relationships support the work + Future + Age may require moaliction o he protocol * Length of session ~ Insurance time lmiations wal lead to frequent closing of Incomplete sessions Medical Issues Special Protocols | cc | cc * Medication represses symptoms requiring eee ea the target to be reexamined when meds * Strengthen resources - Phobias are decreased Affect management - Dreams * Medical conation may requle spectal Single trauma event - Excessive gret circumstances. © Recent events * Couples © Hospitalization has been used to support » Emergencyroom =» Groups fragle patients who could be distressed by Drawing protocol - Children g * Blindto therapist — Somatic disorders processing * Saif care * Complex trauma Potential Obstacles for Potential Obstacles for EMDR practitioners EMDR practitioners | cc | cc * Premature/inappropriate application * Might uncover unrealized dissociation © Client preparation can be elaborate © Limited number of colleagues trained in the method (though there are hundreds of clinicians in the local community who = With incomplete sessions, residual are trained in EMDR) = The method looks so hokey that people can't believe it works! © Training is complexiexpensive * Sessions may take more than 50 minutes processing discomfort may be present The Washington Duke Inn Durham, NC August 23, 2013 Pg9EMDR: Where did it come from? Whatis it? Where is it going? A good thing! | cc All insurance companies now reimburse for EMDR treatment Carolina House Symposium Workshop with Gary Peterson, M.D. Advantages of using EMDR | cc + Established effectiveness for PTSD * Brings out strengths of cient = Can be applied to any form of clinical practice * Focuses on specific target/problem * Generalizable positive effects Integrative Group Treatment Protocol (IGTP) (Garerearigas, 2010) © Protocol © Activation with picture + SUD level © Self administered BLS + Draw another picture + SUD level + Repeat sequence + Resulted in substantial | SUD Neurobiology of EMDR | cc + Neuroanatomy + Multipronged Approach to Mechanisms of Action + Theoretical Perspectives + REM-Ike System Hypothesis «SPECT Scan Study Anatomical Planes ‘anatomy ofthe Bran The Washington Duke Inn Durham, NC August 23,2013 Pg 10EMDR: Where did it come from? Whatis it? Where is it going? Multipronged Approach to Mechanisms of Action Ceengere 38 + Theoretical perspectives * Test the predictions of a specific model - REM sleep + Top-down dismantling — what are the necessary components + Bottom-up investigation of the impact to identity the basic building blocks Carolina House Symposium Workshop with Gary Peterson, M.D. Theoretical Perspectives jergmann, 2010) oe Crienting Response Models Frontal Lobe Activation Model REM-Like Physiological Systems Reciprocal Suppression/Activation of the ‘Anterior Cingulate Models Hippocampal Neural Mapping Model Low Frequency Stimulation Model Thalamic Temporal Binding Mode! Parietal Lobe Activation Model REM4ike System Hypothesis (Stickgotd, 2002) ed "Several Ines of evidence suggest that EMDR may help inte treatment of PTSD by turing on memory processing systems normaly activated during Rapid Eye Movement (REM) sleep but dysfunctional in the PTSD patient ‘Two separate memory systems store information in the brain, One, locate Inthe ippocampus, stores "episodc' memories, the memories of actual evens in ‘ur les. The second, located inthe neocortex, stores general formation and associations, REM4Jike System Hypothesis (Stiekgold, 2002) ed LEMIR through the repttve redirecting of attention, ‘elvates bran systems normaly present dung REM sleep. Any altematin, lateraized stimulation regimen, wether eye movements, tapping, or bnaural sound, could activate these systems by frcing the bran to constantly reorient to new locations in space. In this manner, EMDR can push-stat the broken- down REM machinery that is required forthe bran to effectively process traumatic memories SPECT Scan Study Results (Levin, Lazreve and van der Kelk, 1999) tajeen Post-EMDR, the Rorschach Hypervgliance index went from postive to negative, indicating that the subject was spending les time scanning the environment for treats, and avalable ego Tesources also ncreased, as measured by the Experience Actual variable Upon recaling the traumatic memory during ‘SPECT scanning, two areas of he bran were hyperactive pos-EMDR treatment, relave to pre- tweatment the anterior cingulate gyrus and the let ‘tonal lobe, The Washington Duke Inn Durham, NC SPECT Scan Study Results (Levin, Lazreve and van der Kelk, 1393) ee ‘An Important implication of these findings is that, using EMDR, successful treatment of PTSD does not reduce arousal atthe limbic level, but instead, enhances the abilty to differentiate real from Imagined threat, August 23,2013 Pg 11EMDR: Where did it come from? Whatis it? Where is it going? Carolina House Symposium Workshop with Gary Peterson, M.D. nal and Structural Neuroimaging (Paani et al. 2013) a + EMDR. related neurobiological changes were monitored by EEG during therapy itself and showed a shift of the maximal activation from emotional limbic to cortical cognitive brain regions. This was the first time in which neurobiological changes ‘occurring during any psychotherapy session have been reported Answers to Objectives Revealed (a cc + Explain the origins of EMDR- EMDR came about after Shapiro's 1987 walkin the park. She developed the process over the next four years. © Describe the eight phases of EMDR — ‘See slides. + Name the three prongs of the basic treatment protocol — Past, Present and Future Contact Information ed Gary Peterson, MO. Southeast Institute for Group and Family Therapy Chapel Hil, NC-27517 gpeterson@seinsttute.com 919-929-1171 wirw.selnsttute.com Patients vs. Normal Controls During 1st Ses: Patients in 15t Session vs. the Last Session The Washington Duke Inn Durham, NC August 23,2013 Pg 12EMDR: Where did it come from? Carolina House Symposium Whatis it? Where is it going? Workshop with Gary Peterson, M.D. SPECT Scan Perfusion after EEG Cortical Representation of EMDR Therapy Increased and Decreased activity The Washington Duke Inn Durham, NC August 23,2013 Pg 13