EMDR therapy: A pathway for trauma-focused care

When I had two years sober, I wanted to stay sober.

I also wanted to die.

Sound like a total paradox?

My active addiction was about trying to destroy myself. Even though I learned the skills to stay sober and ultimately to better my life, that desire to destroy myself never totally went away. At two years sober, I noticed the suicidal thoughts intensify as I was working on my counseling internship and watching how young children were being mistreated in the residential mental health unit where I was placed. A trusted colleague of mine suggested more therapy. But even though I knew something had to be done, the thought of going back into counseling after getting sober and actively working a 12-Step program troubled me.

I protested, “I know everything the counselor would say; I know that I’m good enough and that I need to let go of the past.”

From going to so many meetings and working with two excellent sponsors in my early years, I quickly learned healthy solutions to my problems, yet I felt powerless to implement them. To add icing on the cake, I was a counseling student, learning “technique” and being schooled in all of the right things to share with people who were suffering. Yet I still wanted to destroy myself.

I went to a local counselor who was recommended to me because of her reputation for approaching therapy in a new and innovative way. In our first session, she recommended Eye Movement Desensitization and Reprocessing (EMDR) because of my history of trauma and dissociation. I was willing to give anything a try that didn’t seem like the same old clichéd therapy practices challenging me to confront my thinking errors or to write more gratitude lists to help me stay positive.

History of EMDR

EMDR therapy traces its origins to the late 1980s, when California-based psychologist Francine Shapiro took a now famous walk in a park. Shapiro, a cancer survivor who became interested in mind-body medicine as a result of her own experiences with treating chronic disease, began to notice some distressing thoughts during her walk. Keen on experimenting with her own mental and somatic processes, Shapiro also noticed that her eyes began to move back and forth, rapidly and diagonally, as she noticed these thoughts.

Later in the walk when she brought up the same thoughts again, they simply did not carry the same charge. Curious about whether that process she had engaged in with her eyes had anything to do with her shifts, she began informally experimenting with colleagues, eventually developing and researching an early protocol that was published in 1989 in the Journal of Traumatic Stress Studies.

I learned from my own EMDR therapist that EMDR did not rely on eye movements alone to work. For instance, she gave me the choice of using one of various forms of bilateral stimulation. Because I found the eye movements annoying and even painful, I was relieved when she was able to control a machine that made relaxing pulses in my hand in a back-and-forth manner. In a way, it felt like drumming!

In the early years of EMDR, Shapiro and other clinicians discovered that eye movements could not be tolerated by everyone and could even be risky for people with seizure disorders or other medical concerns. Thus, they developed the two main alternatives: alternating audio tones and alternating tactile stimulation. To this day, debate remains among EMDR therapists over whether the eye movements work best just because they’ve been the modality most likely to be used in research studies, or if clients should be able to self-select the bilateral modality of their choosing based on preference and comfort.

After I selected the tactile modality for myself and engaged in some prerequisite stabilization, grounding and relaxation exercises to help me handle what the process might reveal, my EMDR therapist led me to focus on certain representational memories behind my “hot button” negative beliefs. “I’m not lovable,” “I’m permanently damaged,” and “I’m not safe in the world” were all early targets that we explored, as we might have done in standard talk therapy. However, there was much more of a somatic and mindful focus to the way she asked me questions about these memories. I didn’t have to recall specific detail. I didn’t have to analyze. My job was simply to notice my experience, my emotions and my bodily sensations as she applied the bilateral stimulation.

For me, EMDR therapy was cathartic, draining, yet empowering all at the same time. Within a few sessions, the main reason why I presented for counseling again in the first place—the suicidal ideations—lifted. I stayed connected with the EMDR therapist off and on over the next two years as the process helped me through graduate school, sustaining my first long-term relationship, and ultimately achieving a greater degree of wellness overall as I built my career.

A mainstream practice

Once written off as a fringe or even “new age” therapy, EMDR therapy is now in the mainstream, appearing on the Substance Abuse and Mental Health Services Administration's (SAMHSA's) national registry of evidence-based practices for the treatment of post-traumatic stress disorder (PTSD) and as one of two preferred trauma therapies recommended by the World Health Organization.

In my work as an EMDR educator and specialist, I am often asked, “How soon is too soon for someone in recovery to do EMDR therapy?” To answer this question, I must explain that EMDR therapy is more than simply having people identify their most distressing negative beliefs and memories and then having them dig in to the emotions and the experiences while following alternating stimulation. Although emerging neurobiological research continues to show that this process can affect how the brain stores memories (1), it is important that EMDR therapists first determine whether or not a client can tolerate this process.

Although EMDR therapy is often described as less invasive than other forms of trauma therapy because a person does not have to narrate specific details of an event, EMDR still taps into a great deal of body sensation and emotion that many in early recovery can find overwhelming. Fortunately, the EMDR approach to psychotherapy includes two phases that precede the specific targeting of traumatic memories: client history and preparation.

In many ways, client history looks like other forms of therapy in that therapists get to know and build rapport with their clients. However, in EMDR, it is done with an open ear for listening to the impact of trauma on a client’s presenting problems. Shapiro generally describes trauma as any adverse life experience that can leave a legacy of problematic symptomatology. Sometimes these symptoms qualify for a DSM-5 diagnosis of PTSD, and other times these adverse life experiences show up as other diagnoses, medical conditions or general problems of living.

In phase two of preparation, a client develops a set of skills that can be implemented for distress tolerance. EMDR therapists may choose to implement a slower variation of bilateral eye movements or other forms of stimulation in this phase.

In addition to teaching techniques for grounding, stabilizing, holding space for emotion, and relaxing or resting, I continue to encourage that those in recovery build a set of resources such as 12-Step or other mutual help meetings. Stephen Dansiger, an EMDR trainer and clinical director/co-founder of Refuge Recovery Centers in Los Angeles, explains that he built the idea of EMDR therapy as a total approach, not just as a traumatic memory targeting technique, into how his staff delivers services:

“EMDR therapy treats trauma, and in its first two phases it prepares the sufferer to do so. So at Refuge Recovery we use our addictions expertise to guide people through stabilization and relapse prevention, helping them develop mindfulness and other skills, all the while preparing them to reprocess trauma with the later phases of EMDR. Not all clients will be able to do that during their stay. But all clients can become prepared, develop the language and knowledge base, be sent to the correct aftercare referrals in order to then get what they need—trauma reprocessing. We have seen this be particularly effective with chronic relapsers, as we find out that often the sticking point is the untreated trauma.”

The comorbidity between untreated trauma and addictive disorders has long been established, and unaddressed PTSD has both formally (2,3,4,5) and informally been identified as a relapse risk factor. Since the early years of EMDR, the trauma targeting and re-evaluation phases have successfully been implemented with those in addiction recovery with unhealed PTSD. (6,7,8,9,10)

The research specifically on using EMDR therapy to treat addictive disorders alone does not exist, and in general, the research on offering EMDR therapy to survivors of trauma with co-occurring addiction disorders is not as substantial as the research with PTSD alone. However, with the comorbidity between PTSD and addictive disorders well established in the context of EMDR therapy’s reputation as an effective treatment for PTSD, EMDR therapy has long been implemented in many treatment programs around the country, particularly as a relapse prevention or recovery enhancement measure. Refuge Recovery is one of many treatment centers prominently featuring EMDR availability in their marketing.

Keys to successful implementation

In my work spent receiving EMDR, clinically offering EMDR, teaching it, researching it and consulting other clinicians, a major factor of importance in discussing targeting trauma with EMDR therapy involves how it is implemented. This implementation also means that the therapists conducting the EMDR with clients in recovery must have some understanding of addiction in general.

I’ve had the good fortune to be involved with the two major studies in the literature that examine the how, the implementation of EMDR therapy in addiction treatment. The first, my own dissertation research, investigated 10 women who experienced EMDR at some point during their extended engagement at a long-term treatment facility (intensive outpatient plus supportive housing services). All participants recognized that EMDR was a major factor in helping them to stay sober by promoting vital shifts in thinking and lifestyle, in addition to helping them heal issues they described as emotionally core. However, all but one recognized that it wasn’t only the EMDR that helped them achieve long-term recovery—other services offered by their center, such as supportive life skills groups and accessibility to 12-Step meetings, were also important. (9)

One of the newest studies on EMDR (11) explored the impact on long-term recovery, using standard protocol EMDR and some of the newer and less researched but more innovative spins on EMDR for treating addiction. These innovative approaches include protocols for targeting urges and cravings (12) and for targeting and hopefully shifting positive feeling states around addiction. (13) In this study, spearheaded by April Wise as part of her dissertation research, she was open to exploring one of the controversial issues around EMDR and addiction: Does a person have to be totally abstinent for EMDR therapy and its related techniques to work? She ultimately discovered that no, total abstinence was not required. However, she concluded that these judgment calls about whether to proceed with EMDR trauma targeting with someone who is still using on some level must be made by an EMDR therapist who is already skilled and experienced in treating addiction, in order to fully understand the nuanced clinical decision-making involved.

For persons in recovery or struggling with recovery who are interested in exploring EMDR therapy, they should ask if the EMDR therapist they are considering has any experience working with addicted clients. If they sense a good fit during that preliminary call, scheduling an initial appointment is the vital next step. As someone who is both an addiction recovery traditionalist and an innovator, I would generally advise to proceed with caution if the EMDR therapist promises that EMDR will be the magic bullet to “cure” an addiction.

Recovery is a process, and someone with addiction knowledge who is well-skilled in EMDR can use the totality of the EMDR approach, not just the trauma targeting elements, to help someone embrace the process. For me, I am not only grateful that EMDR was there for me in my early recovery, but also that I had the chance to go through it with a therapist who knew recovery.

Jamie Marich, PhD, LPCC-S, LICDC-CS, REAT, travels internationally to teach on topics connected to trauma, EMDR therapy, mindfulness and the expressive arts. She maintains a private practice in her home base of Warren, Ohio, where she operates Mindful Ohio & The Institute for Creative Mindfulness. She is the author of four books on trauma recovery, including EMDR Made Simple (2011) and Dancing Mindfulness (2015).

References

1. Pagani M, Hogberg G, Fernandez I, et al. Correlates of EMDR therapy in functional and structural neuroimaging: A critical summary of recent findings. J EMDR Prac Res 2014;8:29E-40E.

2. Hendrickson E, Schmal M, Ekleberry S. Treating Co-Occurring Disorders: A Handbook for Mental Health and Substance Abuse Professionals. Binghamton, N.Y.: Haworth Press, Inc.; 2004.

3. Hruska B, Delahanty D. PTSD-SUD biological mechanisms: Self-medication and beyond. In Ouimette P & Read J (eds.), Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid Disorders (2nd edition). Washington, D.C.: American Psychological Association; 2014.

4. Najavits L, Kivlahan D, Kosten T. A national survey of clinicians’ views of evidence-based therapies for PTSD and substance abuse. Addict Res Theories 2011;19:138-47.

5. van Dam D, Vedel E, Ehring T, et al. Psychological treatments for post-traumatic stress disorder and substance abuse disorder: A systematic review. Clin Psychol Rev 2012;32:202-14.

6. Zweben J, Yeary J. EMDR in the treatment of addiction. J Chem Depend Treatm 2006;8:115-27.

7. Hase M, Schallmayer S, Sack M. EMDR reprocessing of the addiction memory: Pretreatment, posttreatment, and 1-month follow-up. J EMDR Prac Res 2008;2:170-79.

8. Marich J. EMDR in addiction continuing care: Case study of a cross-addicted female's treatment and recovery. J EMDR Prac Res 2009;3:98-106.

9. Marich J. Eye movement desensitization and reprocessing in addiction continuing care: A phenomenological study of women in recovery. Psychol Addict Behav 2010;24:498-507.

10. Brown S, Gilman S, Goodman E, et al. Integrated trauma treatment in drug court: Combining EMDR therapy and Seeking Safety. J EMDR Prac Res 2015;9:123-36.

11. Wise A, Marich J. (in press). The perceived effects of standard and addiction-specific Eye Movement Desensitization and Reprocessing (EMDR) therapy protocols. J EMDR Prac Res.

12. Popky AJ. DeTUR, an urge reduction protocol for addictions and dysfunctional behaviors. In Shapiro R (ed.), EMDR Solutions: Pathways to Healing. New York City; W.W. Norton & Co.; 2005.

13. Miller R. Treatment of behavioral addictions using the feeling-state addiction protocol: A multiple baseline study. J EMDR Prac Res 2012;6:159-69.

Recommended reading on EMDR

Jamie Marich recommends these books for those who do not have Eye Movement Desensitization and Reprocessing (EMDR) training and want to learn more:

Shapiro F, Forrest M. EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming Stress, Anxiety, and Trauma. New York City: Basic Books; 1998.

Shapiro F. Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy. Emmaus, Pa: Rodale Books; 2013.