Recently, someone wrote to me at my Tumblr and shared how helpful her EMDR trauma therapy was. In particular, she was pleasantly surprised to find that she could process her childhood trauma even though her memories weren’t very clear or organized. She wanted to know about my experience as an EMDR certified clinician. I responded:
The ability to work with an incomplete or highly fractured narrative is one of the things that I really like about EMDR. Here are some others:
More attention is paid to somatic experience
In our culture, we aren’t really taught to listen to our bodies. But trauma, like most mental health experiences, has physical symptoms. We generally respond to physical discomfort by ignoring it, resisting it, trying to push it away. We know from mindfulness studies that these only exacerbate pain, and that, instead, mindfully observing the pain is helpful. So it makes sense that teaching people to notice their physical responses to trauma while doing the trauma narrative, and having them observe their responses, is part of what is healing about the exposure.
There is no homework
In EMDR, all processing happens while in session. This is ideal for complex trauma survivors, for whom one of the symptoms is emotional disregulation, and not unusually, self-destructive coping behaviors.
In Prolonged Exposure therapy, a tape recording of the trauma narrative is made and then must be listened to daily. The evidence indicates that this is generally helpful, so despite the fact that intuitively this sounds terrible, in many cases, it’s worth it. But anecdotally, I’ve heard from clients that found this distressing, and there haven’t been any studies that really look at whether it’s harmful—what happened with drop-outs and people who didn’t report improvement?
If there is a therapy where clients only do processing in session in the presence of their therapist who can monitor them for safety, and the evidence says it’s equally effective, that’s the one I want to use.
Use of Negative and Positive Cognitions
Humans are creatures of narratives. Think about it: you tell yourself stories about who you are, why things happen, and why other people do the things they do. People from different cultures have different ways of crafting these explanations, but there’s no documented culture without stories that express values or explanations for why things happen.
Part of the power that a trauma event has is the belief behind it: I’m not safe, I’m not loveable, I’m a bad person. These negative cognitions aren’t adaptive. Part of the preparation work is to identify the negative beliefs around the event and then develop counter-beliefs that would be more helpful: I did the best I could, I was just a little kid, people do care about me. They are used to assess how well the exposure is working, in addition to the scale of distress that those familiar with CBT would recognize.
Naming negative cognitions are especially helpful when working with a client who has a long and varied history of trauma. It’s not practical to process every single event but it can be really overwhelming to know which ones to process. With one client, after we made her very extensive timeline of her abuse history, we discussed themes in her traumatic responses using negative cognitions. We identified themes of (not having) safety, competence and wholeness. From the themes we were able to select the most potent memories and process those.
More awareness of the client’s present experience
Having done TF-CBT and EMDR (as both therapist and client), the primary difference is that the clinician is far more in tune with the client in EMDR. This is because there is much less describing the story out loud (the client is re-experiencing it internally) and instead the reports are more focused on the client’s internal experience. This is where that extra somatic and cognitive preparation comes in handy: clients and clinicians are much better equipped to observe the processing experience. In any trauma processing there is a natural pendulation (rise and fall of arousal)—but in EMDR, more attention is directed to this process and subsequently, I think clients feel more in control. This is especially important to individuals who dissociate, or have other problems with emotional disregulation.
To sum up, EMDR is an evidence-based treatment that is used in a variety of settings and is endorsed as a top-rated practice by ISTSS, the largest and most revered international organization devoted to traumatic stress studies. I completely understand that it’s not a perfect fit for all clinicians or clients, just as prolonged exposure isn’t. Because all clients and their issues aren’t identical, I’m glad that there is more than one option for evidence-based practice in trauma therapy.