Introduction to EMDR

Transcript lightly edited for readability.

1. What is EMDR?

Hello, and welcome to this short introduction to EMDR, which is designed to help you decide whether you might want to train as an EMDR therapist.

I'm Dr Naomi Fisher. I'm a clinical psychologist and an accredited EMDR Europe trainer. So let's start off by talking a bit about what EMDR actually is.

EMDR is a trauma therapy. It was developed in the late 1980s in the United States by Francine Shapiro. It now has a solid evidence base and is used around the world. It's included in the NICE guidelines in the UK, as well as other international guidelines for trauma therapies.

Essentially, it's a powerful evidence-based therapy which helps people recover from trauma.

It has an origin story, like so many other things. In 1987, Francine Shapiro was walking through a park while thinking about some disturbing things that were happening to her. At the same time, she was watching birds fly back and forth. At the end of the walk she realised that she felt better, and she wondered whether this was related to the eye movements she had been making while thinking about her distressing experiences.

She went away and explored this further. She asked people to think about difficult things that had happened to them while following her fingers with their eyes as she moved her hand from side to side.

She went on to develop the standard procedure for EMDR that we still use today. Initially the process focused very much on desensitisation, and she called it EMD. It was later expanded to EMDR because Shapiro and others realised that more than desensitisation was occurring.

EMDR has come a long way since those early days. It now has a robust evidence base from research around the world and is recommended in trauma treatment guidelines internationally.

So what do we do when we do EMDR?

Essentially, we trace present-day symptoms that a person might be experiencing back to unprocessed memories from the past. Difficult things happen to people, and sometimes they struggle to make sense of those things. That can lead to problems in the present day.

With EMDR, we aim to help people's brains process disturbing memories, with the idea that this will help resolve problems in the present day.

The thing that makes EMDR different from other types of therapy is that we ask people to remember what happened and pair this with some form of bilateral stimulation — movement from one side to the other.

This is usually, but not always, eye movements. Sometimes we might use tapping, buzzers or sounds alternating between the ears. Eye movements don't have to involve following a therapist's finger either; sometimes people use a light bar.

There are many different ways to achieve this dual attention between bilateral stimulation and emotionally activated memories. Holding those two things in dual attention is really what makes EMDR distinctive.

2. Our brains have evolved to keep us safe

Let's take a step back and talk about why this might be helpful.

We know that having traumatic things happen to you can leave some people in distress, even years later. Sometimes when people talk about things that happened to them in the past they become very upset or very angry. It's as if the emotions are still there and unprocessed. They haven't managed to put what happened into the past.

One way to understand this is to think about how our brains have evolved to keep us safe. That is our brain's bottom line: keeping us safe and keeping us alive.

In order to do that, one of the most important things we need to be able to do is detect danger and act when we need to protect ourselves. We have to look around the world, identify when something might be a threat to us and then respond appropriately.

We have two small almond-shaped structures deep inside our brains called the amygdalae. They act as part of our alarm system — a bit like a smoke detector. They're looking out for something being wrong, and when they detect a threat they activate our survival system.

That might involve flight — running away. It might involve fighting, freezing or playing dead.

It's a very quick system, and it needs to be. Imagine our ancestors having a close encounter with a lion on the African savannah. You don't want to have that sort of encounter twice.

Your brain is going to remember everything about it and look out for things in the future which might resemble that lion. It might react to a lion-shaped bush, for example, because your brain's priority is keeping you safe.

The system needs to work faster than conscious thought. You can't sit around thinking, "I wonder if that lion is really dangerous, or whether it's really going to attack me."

That means the survival system can often be activated before a person is consciously aware of what's happening. Sometimes this is called an amygdala hijack: before somebody is even aware of what's going on, they have a very strong response.

This is normal and useful. Our alarm systems learn from experience. When something traumatic happens, the memory is stored in a particular way, and those memories of times when we felt under threat can then be used as clues to identify when the survival system should be activated in the future.

If you think again about the lion, your brain will remember aspects of that encounter because it doesn't want the same thing to happen again. In future it will scan for matches between that experience and things in the environment which might indicate danger.

This isn't a sign that anything has gone wrong. It's the way our brain protects us. The survival reaction is functional and useful, but it can be triggered too easily. It isn't under our conscious control because, when we're under attack, we can't afford to take time to think about it.

When we're under direct threat, we don't have that many options. We can try to get away. We can fight. We can freeze if we're unable to escape or fight. Or we can cut ourselves off from the experience — we can dissociate. If we're completely trapped, our only option may be to psychologically remove ourselves from what's happening.

Traumatic events happen to all of us. Big ones and little ones are part of life. Usually, when the event is over, we're eventually able to make sense of what happened.

We might think, "It wasn't a lion, it was just a rock," or, "I'm safe now. It was a near miss, but I'm okay." Even after a very difficult experience, we might reach a point where we can say, "That was horrible, but it's over now. It wasn't my fault."

When we're able to integrate an experience like that and make sense of what happened, the memory no longer feels as distressing. Effectively, we integrate it into our life story.

One way of thinking about this is that memories of threat can initially be stored in a very emotional, sensory and fragmented form. As memories are processed, they become more organised and feel more clearly like something that happened in the past.

For example, I can think about taking my GCSEs. I know that I was very stressed when I took them, but when I think about them now, I don't experience that stress again in my body. That's an indication that the memory has been processed.

Processed memories are things we know happened, but when we think about them it doesn't feel as if they're happening again.

Unprocessed memories can be different. The emotional content can still be there and feel similar to how it did at the time. The narrative may be unclear. Memories can be fragmented and accompanied by bodily sensations.

Somebody might remember breaking their leg, for example, and feel something that resembles that pain again, even though the injury happened years ago.

Sometimes the normal process of making sense of experiences doesn't happen. That might be because there is simply too much to cope with, because somebody is living with a prolonged sense of threat, or because an event completely shatters their worldview.

Repeated frightening experiences without periods of safety in between can accumulate. The way somebody responds to their own distress can also make processing more difficult. Someone may feel extremely distressed after a traumatic event and think, "This must mean I'm losing my mind."

When these experiences remain unprocessed, they can contribute to symptoms associated with post-traumatic stress disorder: flashbacks, intrusive thoughts, numbing, avoidance, physical reactions, emotional reactions and dissociation.

But EMDR isn't only used for post-traumatic stress disorder. It is also used with other mental health difficulties which may be related to traumatic experiences, because people respond to trauma in many different ways and not everybody develops PTSD.

So, to recap: our brains have evolved to keep us safe. Our alarm systems use memories of previous threatening experiences to help detect danger. Usually, over time, we integrate difficult memories and they become less emotionally charged.

Sometimes that process doesn't happen. When that happens, people can be left feeling unsafe or in danger much of the time. They may experience flashbacks, intrusive thoughts or hypervigilance, constantly scanning the world for danger.

It's important to be clear that this is a psychological model — a way of understanding what might be happening — rather than a literal description of the neuroscience.

3. The EMDR model and what happens in a session

EMDR uses a model called the Adaptive Information Processing model, usually shortened to AIP.

The basic idea is that we are naturally able to heal from things that happen to us, just as our bodies naturally heal from physical injuries.

If you injure yourself, doctors can clean the wound, stitch it and give you antibiotics to prevent infection, but the actual healing is something your body has to do. AIP suggests that our brains have a similar capacity to recover, although sometimes things get in the way.

When this process works, distressing memories gradually become integrated. We make connections, re-evaluate what happened, talk to other people and receive new information. All of these things can help us process an experience.

You can think about it as a traumatic event followed by a process of adaptive information processing, eventually leading to resolution and integration. This doesn't necessarily happen immediately. It can take months or even years.

One important idea is that memories are dynamic. Sometimes we imagine memories as being like videos stored in our heads, but they're not. They change over time and interact with what we already know. Our past experiences also act as a filter for how we experience the world in the present.

Memories are often fragmented and may not have a clear narrative. They can change when we receive new information.

You may be able to think of something from your own life which used to upset you when you remembered it, but doesn't any more. Or perhaps you've learnt something new about an experience which changed the way you understood it.

We update memories all the time. Most memories can naturally move towards adaptive resolution. We make links between new experiences and past memories, and we make sense of what happened to us.

When a memory has been processed, it feels as though it's in the past. We can remember how we felt, but we don't necessarily experience those feelings all over again.

I think Adaptive Information Processing is often about finding personal meaning in what happened. Something happens, and then we have to find a way of understanding what that means about ourselves and the world which enables us to move forwards.

If something bad happens — perhaps a road traffic accident — and the meaning you take from it is, "The world isn't safe. I'm not safe," that can lead to you continuing to feel in danger.

In EMDR terms, "adaptive" means finding a meaning which enables us to continue living our lives in the way we want to. "Maladaptive" refers to something which blocks us or stops us being able to move forwards.

If you've had a road accident and continue to feel unsafe and in danger, that is completely understandable. But if it means you can no longer drive or live your life in the way you want to, the response has outlived its usefulness.

That's where EMDR comes in.

One way to think about trauma is that our normal ways of adjusting to difficult events have broken down. Memories remain unprocessed and continue to be triggered by things in our environment.

When we think about these memories, we may experience the emotions and bodily sensations again. They can also be triggered automatically by similarities in our environment rather than because we consciously decided to remember something.

So, in the AIP model, we have a traumatic event. The information processing system becomes overwhelmed for one of many possible reasons. The memory is stored in an unprocessed form, which contributes to ongoing distress in the present.

That can then lead to coping strategies. If somebody is highly distressed or feels unsafe much of the time, they may use alcohol, drugs, self-harm or other strategies to cope with overwhelming emotions.

Different people can make very different meanings from the same sort of experience.

After a road traffic accident, one person might think, "I'm not safe," and become unable to drive or avoid busy areas. Another might think, "I'm a bad driver. It was my fault," and respond by taking an advanced driving course.

That's one of the key things about the AIP model: it's idiosyncratic. It's about the individual. Every person makes sense of their memories differently. It isn't a formulaic approach.

Unprocessed memories can contribute to many different difficulties in the present. These might include flashbacks, intrusive thoughts and bodily reactions. People may become flooded with emotion unexpectedly or find themselves reacting in ways they don't understand.

They may also be using survival mechanisms that were developed in childhood and made sense then, such as dissociating when escape wasn't possible, but which have persisted into adulthood.

These responses may have been highly adaptive at the time of the trauma, but they're no longer helping in the present.

The AIP model assumes that we all have a capacity to heal. Processing is happening naturally all the time as we integrate what happens to us with our other memories and make sense of events in the context of our lives.

Sometimes that process gets stuck because we're overwhelmed.

For example, after a difficult birth, somebody may have very little opportunity to psychologically process what happened because all of their attention is focused on caring for a new baby.

This is where EMDR comes in. The aim is to facilitate Adaptive Information Processing by helping connect adaptive information with the unprocessed memory network.

We do this using dual attention. We activate the emotional memory while also using bilateral stimulation. This might involve eye movements, tapping or sounds alternating between the ears.

The idea is to help somebody keep one foot in the past and one foot in the present. They are remembering what happened and allowing themselves to experience some of it, but they aren't completely disappearing back into the experience because we're also keeping one foot in the present.

During EMDR, memories can change in quality. People often report that negative images, thoughts and emotions become less vivid. Positive images, thoughts and emotions may become more vivid. Memories can start to feel more firmly located in the past and fade in intensity.

Sometimes memories themselves change and sometimes they don't. People's evaluation of what happened to them may also change.

So essentially, somebody experiences a traumatic event and is left with an unprocessed memory. In EMDR we pair that emotionally activated memory with bilateral stimulation, with the aim of facilitating adaptive resolution and integration.

Hopefully this then leads to changes in the person's experience of the world, allowing them to live their life in ways they couldn't before.

The AIP model views current difficulties as being connected to stored responses or memories of past events. Present-day reactions are understandable in the light of previous experiences, but may no longer be useful or functional.

EMDR suggests that we can identify those past experiences, help the person process them, and potentially help them respond differently in the present.

It focuses particularly on the meaning somebody has made of what happened to them. We're trying to understand what it is about an experience which means somebody continues to have these feelings today.

So another quick recap: memory is a dynamic process. We all have the capacity to process memories, even memories of highly traumatic events. Not everybody who experiences trauma will need trauma therapy; some people will recover naturally.

When we're very highly aroused, however, we may not process events effectively. This can contribute to maladaptive memory networks which cause difficulties later.

EMDR works with those memories and aims to connect them with more adaptive networks, using dual attention between the present day and emotionally activated memories.

What are the recommendations for EMDR?

The International Society for Traumatic Stress Studies gives a strong recommendation for EMDR for children and adolescents with clinically relevant post-traumatic stress symptoms, and for adults with post-traumatic stress disorder.

NICE guidance in the UK recommends EMDR for adults with PTSD or clinically important symptoms of PTSD in particular circumstances. For children and young people, EMDR may also be considered in particular circumstances.

So you may be wondering what EMDR sessions actually look like.

The important thing to know is that they don't all look the same. EMDR is a whole therapy. It isn't simply trauma processing or eye movements.

It begins with history taking and formulation. Then there is a preparation phase in which we may help people develop ways to soothe and regulate themselves. We may need to help them change things in the world around them if they aren't currently safe.

We're also forming a therapeutic relationship. It's a very important part of EMDR that the person feels safe with you, that you feel safe with the person, and that you have a good therapeutic alliance. All of that happens before getting anywhere near trauma processing.

EMDR has eight phases. The early phases include history taking, formulation and preparation. Only once we have a good understanding of the client, have agreed what we're going to focus on, and both therapist and client feel safe to progress do we move towards trauma processing.

During those early stages you might address coping strategies which are no longer helping and help somebody develop new ones. You may also use elements of therapeutic approaches you already know.

Trauma processing itself can take anything from a couple of sessions to many sessions. I've used EMDR with people for fewer than six sessions and I've also worked with people for well over a year.

EMDR can therefore be used within both short-term and long-term models, with single-incident trauma and complex trauma, and with responses to trauma which don't necessarily look like PTSD.

People are using EMDR with psychosis, depression and anxiety, among other difficulties. The AIP model asks us to think about the difficult things which have happened to someone, the meaning they have made of those experiences, and how that might connect with what's happening in the present day.

EMDR is very adaptable. It can be made accessible for children, people with learning disabilities, people with dementia and people with acquired brain injury.

It's also possible to be creative when using EMDR. I know therapists who integrate music, art, play and drama into their sessions. If you're already experienced in another approach, you can explore ways of integrating EMDR with what you already do.

4. What does EMDR training involve?

So what does EMDR training actually involve?

My EMDR Standard Training is a seven-day training delivered in three parts. There is Part One, Part Two and Part Three, with around two months between each part.

It's a very practical and experiential training. It isn't one of those trainings where you simply sit and listen. You will be practising EMDR from day two.

You'll practise with somebody else and you'll experience elements of EMDR yourself. That experiential aspect is a really important part of the training.

There are also ten hours of case supervision built into the training. You need to be getting out there and actually doing EMDR with clients as you progress through the course.

The seven-day Standard Training is a generic training, which means it provides the basic training regardless of the client group you work with. Specialist training can then follow afterwards, particularly for people working with children and adolescents.

You might also be wondering whether you're eligible to train in EMDR.

EMDR is an adjunct therapy rather than a starting point. You need to already be appropriately trained and regulated within a mental health profession. You can check the detailed eligibility requirements on the EMDR Association UK website.

You may also be wondering whether your clients could benefit from EMDR.

EMDR can be adapted for a very wide range of people: those with severe mental health difficulties, those with less severe difficulties, people with learning difficulties, younger people, and people who may find other forms of therapy difficult to access.

It's less dependent on language than some therapies, which can make it particularly useful for people who have communication or language difficulties.

I use it a lot with neurodivergent clients.

People do need to have some level of safety and an ability to self-soothe before trauma processing, but those are things which can be developed in therapy. They don't necessarily have to arrive with those abilities already.

You are taking somebody towards some of the hardest things that have happened to them. To do that safely, you need to be confident that they can return afterwards to a place of relative safety.

One common misconception is that EMDR is only for single-incident trauma. It isn't. It can be used with many different responses to trauma, and I've used it with many people who have experienced complex trauma.

So what about you? What do you need in order to be a good EMDR therapist?

You need a willingness to go with people to their darkest memories and an ability to hold the space for that distress. That's not an easy thing to do.

Sometimes people imagine that because there can be less talking in EMDR, it isn't such an emotionally attuned therapy. In fact, it's a very emotionally attuned therapy. You're right there with your client while they revisit some of the things that have happened to them.

That isn't right for everybody. You need to be able to tolerate distress, and you need to be open to doing things differently from whatever therapeutic modality you're currently trained in.

You also need to be able to hold the structure of a session while remaining flexible and client-centred.

That's one of the things I like best about EMDR. I think it's a very structured therapy, but it's also very flexible and client-centred. We create a structure for our clients, but within that structure the process is theirs.

You need the ability to contain high levels of distress and to stay present with clients while they're re-experiencing some of the worst things that have happened to them, while continuing to provide a place of safety.

And you need to be able to integrate and make sense of what happens — both for yourself and with your client — because that's really what we're doing in EMDR. We're helping people make sense of the things that have happened to them.

So, to recap: EMDR is an evidence-based trauma therapy. I think it lends itself particularly well to a non-pathologising framework.

It's based on the Adaptive Information Processing model, which understands present-day difficulties as potentially linked to unprocessed memories from the past.

EMDR works with the meaning of an event as well as its emotional and physiological aspects. It isn't just about thoughts; it's also about bodies and feelings.

It brings together aspects of different therapies, and I think it manages to be both structured and client-centred.

I hope this introduction has helped you understand a little more about EMDR and think about whether you might like to train as an EMDR therapist.

If you think it might be for you, and you meet the eligibility criteria, do get in touch.