The underlayers of NeuroAffective-CBT

Just a snapshot look at Google scholar would reveal that CBT therapies, including third-wave CBT (e.g. mindfulness, acceptance and commitment therapy, etc.) are by far the most researched and evidenced methods of psychological treatment. When it comes to trauma at least, EMDR does not stray too far either (Bisson et al., 2013). In a recent article, I discussed EMDR’s efficacy in spite of what it can only be described as a sketchy evidence-base (Davidson and Parker, 2001). Neuroaffective-CBT (NA-CBT) on the other hand is a much younger therapy falling far behind in research, nonetheless a reliable transdiagnostic model which shares all fundamentals and evidence-base with the family of cognitive and behavioural therapies. The approach was developed by Daniel Mirea in response to a growing subclinical population of undiagnosed affective disorders that fall under the umbrella of shame and self-disgust. Since the treatment of such phenomenon crosses the boundaries of clear diagnostic criteria, the therapeutic approach has to be both comprehensive and strategic. NA-CBT therefore, relies on a clearly prescribed modular toolkit that aims to disrupt all mechanisms that predispose, perpetuate and precipitate shame, guilt, self-disgust or indeed chronic low self-esteem.

Through exploring the underlayers of NA-CBT, this article aims to look at the overlapping mechanisms that underpin a range of cognitive and behavioural methods and review some of the evidence supporting the skills and interventions relied upon during treatment.

The assessment

In keeping with the cognitive-behavioural framework, the NA-CBT therapy process starts with a comprehensive history taking which leads to a case conceptualisation, uniquely termed as the ‘Pendulum-Effect’ case formulation. NA-CBT proposes that just like the pendulum of a traditional clock, people oscillate or swing between maladaptive coping mechanisms without always being aware of this and in doing so, they reinforce deeply rooted negative views about themselves and others – which are ultimately responsible for their shame and self-disgust, e.g. “I am unlovable and unattractive and nobody wants me”.

Staying with the above (pendulum) metaphor, this core schema would very much be at the centre of the clock’s face, it represents in fact, the very central mechanism behind it. The centre mechanism would not turn the clock if it wasn’t for the oscillating movements – in other words the affect of shame (and therefore chronic low self-esteem) is reinforced by compensatory mechanisms designed and rehearsed over years (e.g. avoidance or surrendering or over-compensation) as well as the relationship that the such coping mechanisms have with each other through the swinging-effect action or the oscillating-effect.

Shame related beliefs

swing

Overcompensating – Surrendering – Avoiding

Case study [1]

To illustrate how a victim of shame oscillates between the three main reinforcing mechanisms (i.e. overcompensating, surrendering and avoiding) let’s consider Sarah’s case. Sarah is a successful paralegal in the City who struggled with shameful feelings most of her life. She is a natural ‘overcompensator’ by making herself available, useful and liked by everyone in spite of being completely exhausted and burnt out by this. She hates letting her colleagues down and therefore at work her efforts are very much appreciated. Sarah is aware of this but she attributes her popularity to very hard, exhausting work, long hours and not being able to say ‘no’ ! Typically as Christmas was approaching and lots of party invitations started to arrive on her desk, she would ‘surrender’ into self-criticism (i.e. I am not going to perform well, I drink too much to calm my nerves, I’ve put on a lot of weight this year, nobody likes me ‘for me’ anyway) and ‘avoidance’ (i.e not reading the invites, not following up, not responding to invitations, etc.). All actions taken (before various Christmas parties are due) are in order to ‘avoid’ social situations she feels likely to fail and would be supported and justified by an exaggerated set of predictions about social embarrassment or other ‘social disasters’. As such, the ‘surrendering’ or the ‘giving up’ mechanism would involve fortune telling, images of social awkwardness and also rejecting a colleague who offered to accompany her to one of those events. The insisting (and very single) colleague in this case, happened to be interested in dating her, and this will become evident later during the course of therapy; though her surrendering attitude and actions would not allow her to see the true nature of his intentions at the time. Such surrendering strategies will justify the avoidant behaviour and the eventual withdrawal which would inevitably lead to feelings of isolation, loneliness, guilt, self-disgust, and more self-criticism which ultimately would reinforce her shame-related beliefs.

A simple chain-analysis of her behaviours would suggests that Sarah overcompensates until she burns out, then she falls into self-criticism by surrendering which is then followed by withdrawal and other types of avoidance. This completes a trap which represents the mechanism that enables the back and forth ‘swing of the pendulum’ through all these emotions and associated behaviours over time. These behaviours could be best understood as emotion-driven behaviours.

The pendulum is meant to act not only as a timekeeper but also as a regulator (figure 1).

PENDULUM

The above statement proposes that the pendulum metaphor can be equally used as an emotional regulatory tool by disrupting the behaviours that are part of the swinging mechanism (or the emotional trap). There are of course, several similar reinforcing mechanisms at play, which would be clearly described by the pendulum-effect (formulation). When all these mechanisms are fully understood, they would be further examined, modified and/or finely tuned 9with the patient in a strategic but compassionate manner, throughout the therapy over five flexible and interchangeable treatment modules:

(1) Psychoeducation and motivation, (2) Physical Strengthening, (3) The integrated-Self, (4) Coping Skills Training (including Self-Regulation) and (5) Skills Consolidation & Problems Prevention (figure 2).

Figure [2]:

  • Initial consultation : Clinical Assessment & The ‘Pendulum Effect’ Formulation
  • Module 1 : Psychoeducation & Motivational Enhancement: including building motivation, enhancing self-efficacy, problem solving skills training. How to use the Pendulum Effect to your advantage !
  • Module 2 : Physical Strengthening: TED’s your best friend ! Physical conditioning, grounding and self-regulation. Further information provided here.
  • Module 3 : The development of an integrated-Self: cognitive reframing (appraisal-reappraisal). Traumatic memories processing (through bilateral stimulation, narrative exposure or reliving. At this stage, the Vygotsky method acting can be used in order to embody a desired attitude or even character trait.
  • Module 4 : Coping Skills Training (incl. Self-Regulation): including further training in Mindfulness, Self-hypnosis and/or Relaxation Skills Training; also introducing the concept of EDRB’s (Emotion-Driven Reinforcing Behaviours: Overcompensatory, Avoidant and Surrendering Actions.
  • Module 5 : Skills Consolidation and Relapse Prevention or future plans !

The underpinning fundamentals of the approach

Several essential mechanisms underpin NA-CBT and each treatment module attracts a particular set of skills, none more relevant that the skill of building a therapeutic alliance. I coined the term empathic mentalisation to highlight therapist’s skilful ability to connect with his client in a way that would allow the therapist to not just hear and understand at a pre-frontal level, patients’ vulnerabilities but instead to allow himself, to feel his client’s pain in a way which will help the client feel felt.

Whilst some attachment-based therapies would perhaps claim to engage the patient in a similar manner, this is where the similarity stops because in NA-CBT, the therapeutic relationship is no longer used as transference or countertransferential medium of communication. The therapist remains aware of client’s goals and he is in full control of the agenda. Thus the therapist guides the relationship and the (collaboratively agreed) agenda throughout the therapy process. The transference & countertransference processes are viewed as opportunities for open dialogue and learning. Challenging, restructuring and reframing irrational self-beliefs into adaptive beliefs, installing new coping skills and disrupting unhelpful strategies stays at the core of this therapy.

Psychological education is another NA-CBT fundamental. Clinical experience and trials indicate that psychoeducation does not only establish trust in therapist’s expertise but also in the therapy itself. Research has shown time and time again that psychological education, therapist’s clinical experience and knowledge of psychopathology, therapist’s confidence and style, as well as treatment integrity are all associated with improved treatment outcomes (Donker et.al.,2009 and Podell et al., 2013).

NA-CBT offers an excellent platform for the application of neuroscience and in particular neuroaffective research that has taken place over the last 30 years and remains largely ignored or segregated by different schools of thought [1].

Cognitive psychology studies (Padesky C.,1997), the Interacting Cognitive Subsystems model (ICS) by Barnard and Teasdale (1989, 2008) as well as the Adaptive Information Processing model (Shapiro, 1989, 2001, 2007, 2009) propose that memories are processed and assimilated not in a random way but in a highly organised fashion, using screening templates such as individuals’ past experience and understanding of themselves and the world they live in. However, if childhood experiences are traumatic, the information processing system stores the memory in the wrong parts of the brain and in a frozen or rigid format without adequate processing and integration. This suggests that traumatic memories fail to become integrated into the individual’s life experience and concept of the self which eventually creates psychological and emotional vulnerability. As such, unprocessed, unintegrated or upsetting memories (not only traumatically charged memories) may be at the core of shame and self-disgust or chronic low self-esteem (Schore A, 1998; Gilbert P, 2006; Siegel D, 2007; Gilbert P, 2011).

During the third NA-CBT treatment module, developing an integrated-self, the patient may be asked to recall the worst aspect of an earlier shameful memory together with the accompanying and currently held shame-related beliefs and associated bodily sensations [2]. An increased attentional focus on the location of the physiological (psychosomatic) reaction is required at this stage. Simultaneously, the patient is not directed to move their eyes from side to side (like in EMDR), but instead the therapist would employ tapping as another form of bilateral stimulation. Although the research has often been challenged, more recently the evidence has been favourable to bilateral stimulation and this extends to hands tapping in particular. A number of neuropsychological, developmental and attachment studies (Kirsch et al., 2007) have pointed out the usefulness of (appropriate and therapeutic) physical touch and associations with the release of endorphins, serotonin or dopamine as well as the formation of new neural pathways which ultimately leads to an improved self-regulation (Siegel D, 2007).

It may be important to remind that the area of traumatic memories processing, would be the only domain where NA-CBT crosses paths with EMDR but unlike this method, NA-CBT is rooted in evidence-based cognitive and behavioural practices proven to work over the last 50 to 60 years. This suggests that NA-CBT is primarily a behavioural approach relying on active and progressive changing through the adoption of new and more adaptive behavioural strategies (e.g. case study 2).

Case study [2]:

John used to have flashbacks of being physically and emotionally abused every time his manager would raise her voice in the office. He started to experience less and gradually no flashbacks at all, after only 3 hours of desensitisation via bilateral sensory processing (e.g. tapping). In addition John also experienced significantly less hyperarousal. In order to decrease the possibility of a relapse and reinforce the newly formed competing memory (in-between sessions) the therapist agreed with John that when at the office, he must adopt a different attitude, a different mind-set, be more aware of his body language and mental activity, make notes and improve his body posture. He also agreed to have in place a number of responses to potentially challenging situations which would require a more assertive approach. He worked on clear strategies and detailed coping skills which would have been rehearsed (e.g. imagery rehearsal, role plays, etc.) inside and outside the therapy room and in-between sessions.

NA-CBT views narrative exposure, re-living or exposure in-vivo more appropriate forms of treatment (when compared with memory processing) for some cases of trauma – for example when a male therapist is treating a female victim of rape; therefore the integration process does not always relay on bilateral sensory input but on detailed descriptions of the traumatic event and on building evidence against associated unhelpful beliefs through behavioural experiments and other types of practical exercises.

During desensitisation, it remains important for the victim of shame to re-experience the related shameful memories whilst not feeling overwhelmed by it. Clinical experience shows that bilateral processing can at times achieve this more successfully than reliving or other types of exposure. Through the multi-tasking exercise of a focused but distributed attention [3] our brain seems to be able to access dysfunctionally stored experiences and stimulate the processing system, allowing it to transform and integrate the information much better. When fully integrated, the event and what has been learned about the event, can be verbalised however the inappropriate emotions and physical sensations (of hyper or hypo-arousal) would have been discarded and those can no longer be felt.

Yet another interesting phenomenon seems to take place. During bilateral sensory processing (e.g. tapping) the shamed patient is assisted with navigating through the various associations that would usually arise internally. This leads to an increase in the sense of self-efficacy and mastery and specifically an increase in patient’s ability to go back and forth between re-experiencing the event and the present moment (Oren and Solomon, 2012). This does not only diminish dissociative symptoms but also improves attention-orientation skills (Goldin, 2009). A number of trauma studies indicate that physical touch undermines dissociative tendencies and contributes to achieving a feeling of safety and being grounded in the here-and-now (e.g. feeling grounded in the present, being more aware of own physical presence and the voice or the touch of the therapist, etc.).

In regards to self-efficacy in particular, Oren and Solomon (2012) propose that the experience of mastery and self-efficacy would become encoded as adaptive information into memory networks. This may in fact be in line with other studies from established clinicians, for example Teasdale and Barnard (1993), Donald Meichenbaum (2017) or even Albert Bandura’s (1989) self-efficacy theory. This might also suggest that eventually, although the traumatic event and what has been learned can be recalled, the inappropriate emotions and associated sensations of hyper or hypo-arousal would have been discarded and can no longer be felt with the same level of intensity.

One other mechanism at work in NA-CBT, relates to the training of attention through mindfulness. During the desensitisation or processing phase, patients are instructed to ‘let whatever happens, happen’ and to ‘just notice whatever thoughts come to mind’, which is consistent with principles of mindfulness (Goldin et al., 2009; Siegel, 2007; De Jongh et al., 2013).

Imagery-based desensitisation and exposure exercises (routinely used in mindfulness and clinical hypnosis) can also improve individuals’ ability to create a gap or a distancing effect according to the working memory theory. This process may be facilitated by the degradation of the working memory due to cognitive overload, which allows the individual to stand back from a shameful or an upsetting memory, observe it with less emotionality and re-evaluate their understanding of it. Even though the literature on the working memory hypothesis seems inconsistent, research on mindfulness, ICS, EMDR and even clinical hypnosis offers more clarity in this direction. Maxfield and colleagues [4] propose that ‘links are forged between the associated material and the original memory, thus transforming the way that the traumatic memory is stored in memory networks’ (Maxfield et al., 2008).

Final thoughts

In a 2018 interview with Psychotherapy Expert Talks, Donald Meichenbaum pointed out that the field of neuroscience (including gene expression and so on) is not only ‘cutting edge but highly relevant’ with the potential to further tailor interventions for patients suffering from very specific psychopathology. Research coming out of this field certainly adds value to psychological therapies and stays at the basis of models such as NA-CBT. It is my subjective view that in the near future, schools of psychotherapy will adapt and learn to focus on the body as well as the mind, which would imply a deeper understanding of bodily functions not only mind functions for all psychotherapists and psychologists. The fields of neuroscience, clinical hypnosis, psychosomatic medicine and biological treatments are only just starting to come together. NA-CBT is only one example of what could be achieved under the umbrella of Cognitive & Behavioural Therapies, an integrative school that remains best positioned, because of its empirical base, to oversee attempts to treat mental illness holistically.

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[1] For example, the Adaptive Information Processing model (Shapiro, 1989, 2001, 2007, 2009) is mostly seen as the property of EMDR whilst the Interacting Cognitive Subsystems model (ICS) by Barnard and Teasdale (1989, 2008) belongs to cognitive psychology and CBT.

[2] ICS theory and research, explains its account of emotion development and production. ICS emphasises the importance, as part of the total cognitive configuration producing emotion, of a schematic synthetic level of processing that integrates both propositional meaning and direct sensory contributions. Processing at this level corresponds, subjectively, to holistic sense or feeling rather than to thoughts or images explains the link between information processing.

[3] The term distributed attention refers to the complex exercise that involves recalling the trauma and paying attention to traumatic episode, whilst keeping oneself grounded in the present and paying attention to the here-and-now, and all at the same time with further assistance from bilateral sensorial stimulation such as hands tapping.

[4] Maxfield, L., Melnyk, W. & Gordon Hayman, C. (2008). A working memory explanation for the effects of eye movements in EMDR. Journal of EMDR Practice and Research, 2, 247–261.

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Bandura, A. (1989). Regulation of cognitive processes through perceived self-efficacy. Developmental Psychology, Vol 25(5), 729-735.

Bisson J, Roberts NP, Andrew M, Cooper R, Lewis C (2013). “Psychological therapies for chronic PTSD in adults”. Cochrane Database of Systematic Reviews. 12: CD003388. PMID: 24338345

Brown, S. & Shapiro, F. (2006). EMDR in the treatment of borderline personality disorder. Clinical Case Studies, 5, 403–420.

Davidson, P. & Parker, K. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305–316.

De Jongh, A., Ernst, R., Marques, L. & Hornsveld, H. (2013). The impact of eye movements and tones on disturbing memories of patients with PTSD and other mental disorders. Journal of Behavior Therapy and Experimental Psychiatry, 44, 447–483.

Donker, D., Griffiths, K.G., Cuijpers, P., Christensen, H., (2009). Psychoeducation for depression, anxiety and psychological distress: a meta-analysis. BMC Med. 2009; 7: 79. Published online 2009 Dec 16. doi: 10.1186/1741-7015-7-79

Gilbert P., Procter S., (2006). Compassionate mind training for people with high shame and self-criticism.: overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy, 13, 353-379.

Gilbert P., 2011. Shame in psychotherapy and the role of compassion focused therapy. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 325-354). Washington, DC, US: American Psychological Association.

Goldin P, Ramel W, Gross, J (2009). Mindfulness Meditation Training and Self-Referential Processing in Social Anxiety Disorder: Behavioral and Neural Effects. Journal of Cognitive Psychotherapy, 23(3): 242-257

Herbert, J., Lilienfeld, S., Lohr, J. et al. (2000). Science and pseudoscience in the development of EMDR. Clinical Psychology Review, 20, 945–971.

Hofmann, A. (2012). EMDR and chronic depression. Paper presented at the EMDR Association UK & Ireland National Workshop and AGM, London.

Jaberghaderi, N., Greenwald, R., Rubin, A. et al (2004). A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy, 11, 358–368.

Lee, C.W. & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44, 231–239.

Logie, R. & De Jongh, A. (2014). The ‘Flashforward procedure’: Confronting the catastrophe. Journal of EMDR Practice and Research, 8, 25–32.

Maxfield, L., Melnyk, W. & Gordon Hayman, C. (2008). A working memory explanation for the effects of eye movements in EMDR. Journal of EMDR Practice and Research, 2, 247–261.

Meichenbaum, D (2017): “Constructive narrative perspective”. In The Evolution of CBT: a personal and professional journey with Don Michenbaum. Taylor & Francis Group.

Oren, E. & Solomon, R. (2012). EMDR therapy. Revue européenne de psychologie appliquée, 62, 197–203.

Padesky, C. (1997). Schema change process in cognitive therapy. Clinical Psychology and Psychotherapy. Vol 1. (5), 267-278.

Podell J.L., Philip C. Kendall, Elizabeth A. Gosch, Scott N. Compton, John S. March, Anne-Marie Albano, Moira A. Rynn, John T. Walkup, Joel T. Sherrill, Golda S. Ginsburg, Courtney P. Keeton, Boris Birmaher, and John C. Piacentini. Therapist Factors and Outcomes in CBT for Anxiety in Youth. Prof Psychol Res Pr. 2013 Apr; 44(2): 89–98. Published online 2013 Mar 18. doi: 10.1037/a0031700

Propper, R. & Christman, S. (2008). Interhemispheric interaction and saccadic horizontal eye movements. Implications for episodic memory, EMDR, and PTSD. Journal of EMDR Practice and Research, 4, 269–281.
Ray, A. & Zbik, A. (2001).

Rothbaum, B.O., Astin, M.C. & Marsteller, F. (2005). Prolonged exposure versus EMDR for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607–616.

Shapiro, F. (1989). Eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211–217.

Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd edn). New York: Guilford Press.

Shapiro, F. (2007). EMDR, adaptive information processing, and case conceptualization. Journal of EMDR Practice and Research, 1, 68–87.

Shapiro, F. & Maxfield, L. (2002). In the blink of an eye. The Psychologist, 15, 120–124.

Shapiro, R. (2009). EMDR Solutions II. New York: Norton.

Schore, A. (1998). Early shame experiences and infant brain development. In P. Gilbert & B. Andrews (Eds.), Series in affective science. Shame: Interpersonal behavior, psychopathology, and culture (pp. 57-77). New York, NY, US: Oxford University Press.

Siegel, D.J. (2007). The mindful brain. New York: Norton.

Soberman, G., Greenwald, R. & Rule, D. (2002). A controlled study of eye movement desensitization and reprocessing (EMDR) for boys with conduct problems. Journal of Aggression, Maltreatment, and Trauma, 6, 217–236.

Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61–75.

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van den Hout, M., Engelhard, I., Rijkeboer, M. et al. (2011). EMDR: Eye movements superior to beeps in taxing working memory and reducing vividness of recollections. Behaviour Research and Therapy, 49, 92–98.

Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74 (6): e541–55

Why EMDR is more than just another therapy with a funny look and a strange name

When Mel B publicly announced this summer that she was going into treatment for Post-Traumatic Stress Disorder (PTSD), an unusual kind of psychotherapy started to draw attention: EMDR formerly known as, Eye Movement Desensitization and Reprocessing. Talking about her diagnosis in particular, it appears that Mel B had been self-medicating with sex and alcohol, which is otherwise not uncommon with this diagnosis. In an interview during the summer of 2018, she pointed out that “[I am] still struggling but if I can shine a light on the issue of pain, PTSD and the things men and women do to mask it, I will do […]”.

More recently comedian Adam Cayton-Holland recounts in his book (Tragedy Plus Time: A Tragi-Comic Memoir) the death of his sister, who took her own life. In an exclusive excerpt from his book, Cayton-Holland reveals that EMDR helped him recover from PTSD following his sister’s suicide.

So what exactly is EMDR, why is it getting the headlines, and does it in fact, help with traumatic experiences? If so, is this evidence-based treatment and, is there a connection with Cognitive Behavioural Therapy (CBT) the golden standard in psychological treatments?

More questions than answers..?

For a therapy that is committed to resolving traumatic re-experiencing, PTSD [1] would have been an obvious starting place for the application of EMDR. Most of the earlier work and research into this therapy, discovered by complete accident [2] by Francine Shapiro, would naturally focus on traumatic memories processing. Shapiro`s earlier research (in the late 80’s and early 90’s) would successfully demonstrate EMDR’s efficacy (Shapiro, 1989). Subsequently, numerous research and clinical trials followed, which would have culminated with a meta-analysis of no less than 38 randomised controlled trials (RCTs). The conclusions were very clear: EMDR and Cognitive Behavioural Therapy with a trauma focus (TF-CBT) are the two most effective treatments for adults with this disorder (Bisson et al., 2007). A separate review of the efficacy of EMDR for traumatised children also showed that EMDR and TF-CBT are superior to all other treatments. EMDR however, was found to be slightly more effective when compared with CBT by Rodenburg et al. in 2009.

Two further meta-analyses in 2013 found that EMDR is better than no treatment, it is similar in efficacy to TF-CBT and also that ‘the eye movements do have an additional value in EMDR treatments’ (Bisson et al., 2013 and Watts et al., 2013). However, due to high drop outs, poor quality of evidence, and significant rates of researcher bias, authors warned against inconclusive analyses and inaccurate interpretations of the results.

In spite of a work in progress understanding of all the mechanisms involved in EMDR, a few strong hypotheses have been proposed over recent years. Those theories coupled with demonstrated efficacy, have been sufficient for EMDR to secure a place alongside CBT, within the treatments recognised by the National Institute for Health and Clinical Excellence (NICE) and the World Health Organization (WHO) as the psychotherapeutic treatments of choice for post-traumatic stress disorder.

EMDR mechanisms explained

So how does it actually work? And what are the mechanisms and approaches involved in the treatment process? Simply put, the patient is asked by therapist to recall distressing images while generating a type of bilateral sensory input, on short bilateral processing or bilateral stimulation (the preferred terms for this article). This basically refers to side-to-side eye movements or hands tapping (though tapping is less common in EMDR). The effect is to desensitise the client to the distressing memory but, more importantly, to process the memory so that the associated cognitions and affects become more adaptive.

The EMDR toolkit is clearly prescribed but to the untrained eye, it can appear almost mechanistically applied, which makes this approach an easy target for many critics from other schools of psychotherapy, usually positioned outside the spectrum of CBT therapies.

A standardised template consisting of an eight-stage protocol is routinely employed with every traumatised patient. The treatment typically starts with comprehensive history taking and case formulation, a process that is very similar to CBT. This is followed by a preparation phase in which the client is provided with the all necessary (internal) resources to safely manage the processing of their distressing memories (e.g. stop signals, etc.).

The assessment phase involves identifying the patient’s target memory, the associated negative cognition, the desired positive cognition (this would become a therapeutic goal), bodily sensations and various ratings for the level of distress and the level of belief in the positive cognition (other immediate therapy goals would be to improve these ratings).

The assessment is followed by the desensitisation phase or the actual memory processing [3] through bilateral stimulation. The final phase would involve installing the desired positive cognition (this process is normally referred to as installation) and a final body scanning for any residual physiological symptoms before the final debrief. This work is not usually backed up by real life exposure or other behavioural exercises in-between sessions, which would usually be the case with cognitive-behavioural therapies.

The adaptive information processing model (Shapiro, 2007) suggests that new experiences are integrated into already existing memory networks. Memories are processed and integrated via sophisticated cognitive screening mechanisms based on individuals’ past experience and understanding of themselves and the world they live in (also known as schemas and/or schema processes in CBT). However, if the experience is traumatic, the information processing system stores the memory incorrectly, often in the wrong parts of the brain and in a still (rigid or frozen) format without adequately processing it to an adaptive format. Thus traumatic memories fail to become integrated into the individual’s life experience and concept of the self. For example, an individual who becomes traumatised as a result of a car accident would experience a much more global sense of vulnerability. In other words, the trauma victim would feel weak and vulnerable across a range of situations not only when he comes in contact with the traumatic stimulus (e.g. the vehicle responsible for the trauma). In PTSD, individuals continue to relive the trauma as if the event is happening all over again, in the present moment. Patients therefore become avoidant of anything that would be connected to the trauma and tend to become hyperaroused and hypervigilant.

The above formulation which simply explains some of the perpetuating and precipitant mechanisms involved in PTSD is strikingly similar to the CBT approach for trauma. In fact, not just the conceptualization of trauma, but also a range of empirically based cognitive-behavioural interventions [4] such as exposure, desensitization, meta-awareness, attention-orientation training, are all at the very core of EMDR also. Professor Paul Salkovskis a renowned UK based CBT researcher and author, pointed out in a 2002 article, that the eye movement in EMDR is completely irrelevant, and that EMDR effectiveness is solely due to having similar properties to CBT, such as desensitization and exposure (Salkovskis, 2002).

It would be fair to describe the side-to-side eye movements or hands tapping as somewhat unorthodox exercises for the traditional psychotherapist, and therefore it should be no surprise that bilateral stimulation has been the target of many debates and studies. To make matters worse, the evidence hasn’t always been favourable. Some studies compared using EMDR with and without the use of bilateral stimulation and even a meta-analysis of 13 studies (Davidson & Parker, 2001) concluded that eye movements made no difference to its effectiveness. But on the other hand, Stickgold (2002) proposes that eye movements in EMDR produce a brain state similar to the one during REM sleep. It has been shown that REM sleep serves a number of adaptive functions, including memory consolidation. Observing the parallels between REM sleep and EMDR, Stickgold proposes that EMDR reduces trauma-related symptoms by altering emotionally charged autobiographical memories into a more generalised semantic form (Stickgold, 2002). Interestingly, when investigating the neurobiological processes involved in attention training in third-wave CBT (mindfulness), Philippe Goldin (2009) also observed a shift from a rigid narrative sense-of-self to a more fluid or experiential sense-of-self aided by attention training exercises and focused breathing. Propper and Christman (2008) draw upon research suggesting that retrieval of episodic memories is enhanced by increased interhemispheric communication. Gunter and Bodner (2009) found that although vertical eye movements do not enhance hemispheric communication, they did decrease memory emotionality as effectively as horizontal movements.

Final thoughts…

It is my opinion that, to the traumatised patient often in distress, such clinical debates and views very little matter. Improved neuroplasticity and cognitive-behavioural changes could be achieved in a variety of different ways as shown by Golden (2009) and numerous other CBT studies. A number of additional covert factors that facilitate change are equally important. For instance, if patients’ motivation remains high and expectations from a specific therapeutic intervention are equally high, treatment outcomes would be positively influenced. This further implies that the therapeutic alliance and trust in the clinical skills of the therapist are also essential. As such, these important resources have to be given priority throughout the therapy process.

Who can get training in EMDR

In UK the more advanced cognitive-behavioural training programmes also include training or at least an overview of EMDR in the context of evidence-based treatments for trauma. However EMDR has its own accredited training organisations (via EMDR UK & Ireland) and therefore it does not placed itself under the umbrella of CBT therapies (or BABCP). Training in this method is not usually offered outside the psychological or psychotherapeutic community, which means that one would have to have a core mental health profession or to be CBT accredited before specialising in EMDR. There are three levels of EMDR competences that can be achieved and the highest level would indicate the most skilled level of EMDR application.

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[1] Post-traumatic stress disorder (PTSD) is a severe form of anxiety caused by exposure to very stressful, frightening or even distressing events. PTSD victims often relive the traumatic event through flashbacks (memories of the trauma) and they experience states of hyperarousal (intense fear), isolation, shame and guilt in different degrees. Years of clinical research have noted a range of trauma-related psychological problems that were not captured in the DSM framework of post-traumatic stress disorder until recently. PTSD, dissociation, somatization, and affect dysregulation represent a spectrum of adaptations to the traumatic experience. They often occur together, but traumatized individuals may suffer from various combinations of symptoms over time. When treating PTSD patients, it is critical to attend to self-regulation and cognitive integration of traumatic experience and to provide systematic treatment that addresses both intrusive recollections and, all the other symptoms associated with the trauma (van der Kolk et al., 1996).

 

[2] In 1987, Dr Francine Shapiro (Senior Research Fellow Emeritus at the Mental Research Institute in Palo Alto, California) was walking in the park when she realized that eye movements appeared to decrease the negative emotion associated with her own distressing memories. She assumed that eye movements had a desensitizing effect, and when she experimented with this she found that others also had the same response to eye movements. It became apparent however that eye movements by themselves did not create comprehensive therapeutic effects and so Shapiro added other treatment elements, including a cognitive component, and developed a standard procedure that she called Eye Movement Desensitization (EMD).

[3] The working memory hypothesis proposes that eye movements and visual imagery both draw on a limited capacity of the visual and central executive working memory resources. The demand and competition created by two or more tasks will impair imagery, so much so that images become less emotional and less vivid. It has been established that horizontal eye movements tend to tax working memory (Van den Hout et al., 2011). In support of the working memory hypothesis, studies have found that other taxing tasks during recall also reduce vividness and/or emotionality of negative memories (De Jongh et al., 2013).

[4] The cognitive model for PTSD by A Ehlers and D Clark, the Interacting Cognitive Subsystems (ICS) model by Barnard and Teasdale, the typical Socratic dialogue used, the psychopathological understanding of trauma and various aspects of the therapeutic alliance are common to both CBT and EMDR approaches. Another common mechanism with both approaches would be mindfulness. During the desensitisation phase of EMDR, clients are instructed to ‘let whatever happens, happen’ and to ‘just notice what is coming up’ (Shapiro, 2001) which is consistent with mindfulness methods (Siegel, 2007).

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