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Gil Levin July 12th, 2004 04:35 AM

A Dialogue with Francine Shapiro
This forum grew out of an interview of Francine Shapiro by BOL Editor, Gilbert Levin. That interview, which took place in July, 1997 is reprinted here in order to orient newcomers to the forum. The entire interview, including contributions from many others, is available in the EMDR Forum Archive.

BOL EDITOR: Hi Francine, I am glad you have joined us here at Behavior OnLine for this dialogue on EMDR. Let me begin by asking you to provide a brief and concrete description of the EMDR method. -Gil

FRANCINE SHAPIRO: EMDR stands for Eye Movement Desensitization and Reprocessing. It is a complex treatment methodology which combines various aspects of the major theoretical orientations (e.g., psychodynamic, behavioral, cognitive, physiological, interactional and client-centered) in addition to a dual attention stimulus. It turns out that the method was badly named because in addition to eye movements, handtaps or tones can also be used--and the term “desensitization” is a limiting concept. EMDR is best conceptualized as a method that helps to reprocess dysfunctionally stored experiences. So far, there are fourteen controlled studies on the use of EMDR with posttraumatic stress disorder (PTSD). The most recent four rigorously controlled studies demonstrate that 84-90% of single-trauma victims no longer retain the PTSD diagnosis after only three sessions. Although some people have the mistaken impression that EMDR is a simple technique, in fact it is a complex method that consists of eight phases, numerous procedural elements, and a set of protocols designed to address specific client complaints.

Treatment outcomes include a cessation of pronounced symptoms, as well as the achievement of insights, cognitive restructuring, and a shift to more ecological emotions. Therefore, beyond the application to PTSD, EMDR is being used by clinicians to address the disturbing life experiences that contribute to a wide range of problems. However, EMDR should be used within a comprehensive treatment plan by adequately prepared clinicians who have experience working with the clinical population in question.

BOL EDITOR: You have said a lot in a few words. I am intrigued by your reformulation of EMDR as "reprocessing dysfunctionally stored experiences". And soon I will invite you to spell out the theory of information processing implied in that phrase. First, though, lets go into the eight phases of EMDR. What are the initial phases?

FRANCINE SHAPIRO: An EMDR treatment session consists of eight essential phases. EMDR should always be used within a comprehensive treatment plan and is never to be attempted without appropriate training, preparation, and the opportunity for reevaluation. The following is brief delineation of the critical phases for EMDR treatment.

Phase One: Client History and Treatment Planning

Effective treatment with EMDR demands knowledge not only of how to use it, but when to use it. Therefore, the first phase of EMDR treatment includes an evaluation of the client safety factors that will determine client selection--including the client's ability to withstand the potentially high levels of disturbance engendered by the reprocessing. For clients selected for EMDR treatment, the clinician takes the information needed to design a treatment plan. This part of the history-taking evaluates the entire clinical picture including the dysfunctional behaviors, symptoms, and characteristics that need to be addressed. The clinician will then determine the specific targets that must be reprocessed and the order in which they will be attempted.

Phase Two: Preparation

The preparation phase also includes establishing the appropriate therapeutic relationship, briefing the client on the theory of EMDR and the procedures it involves, offering some helpful metaphors to encourage successful processing, and training the client in a variety of self-control techniques in order to deal with the disturbing information that may arise during and between sessions. EMDR is an interactive model that strives to invest the client with a sense of empowerment and control. Since avoidance behavior is clearly a part of the PTSD configuration, it is mandatory to prepare the client to maintain the dual-awareness of present safety and dysfunctional material from the past which is arising internally.

Phase Three: Assessment

Assessment is the third phase of EMDR treatment, during which the clinician identifies the components of the target. Once the memory is identified, the client selects the image that best represents the memory. Then he chooses a negative cognition that expresses a dysfunctional, maladaptive self-assessment related to his participation in the event. These negative beliefs are actually considered verbalizations of the disturbing affect and include statements such as "I am useless/ worthless/ unlovable/ dirty/bad," etc. The client then identifies a positive cognition that will be used as a replacement for the negative cognition during the installation phase of processing (Phase Five). These statements should incorporate an internal locus of control, when possible, such as "I am worthwhile/ lovable/ a good person,/in control" or "I can succeed." Then the client assesses the validity of the positive cognition equals using the 1-to-7 Validity of Cognition (VOC) scale where 1 signifies "completely false" and 7 signifies "completely true." The negative emotion that accompanies the target is delineated and measured on the 0-to-10 Subjective Units of Disturbance (SUD) scale. A rating of 10 means the greatest level of disturbance the client can imagine and 0 means calm or emotionally neutral. Next, the client identifies the location of the physical sensations that are stimulated when s/he concentrates on the event. The assessment stage offers a baseline of response regarding to the target memory, and the specific components necessary to complete processing. The alignment of the individual components of memory and appears to facilitate the processing of the target information.

Phase Four: Desensitization

The fourth phase is called "desensitization" because it focuses on the client's negative affect as reflected in the SUDs rating. This phase of treatment encompasses all responses, regardless of whether the client's distress is increasing, decreasing, or "stuck." During the desensitization phase, the clinician repeats the sets, with appropriate variations and changes of focus until the client's SUDs levels are reduced to a 0 or 1 (when ecologically valid). This indicates that the primary dysfunction involving the targeted event has been cleared. However, the reprocessing is still incomplete and the information will need to be further addressed in the crucial remaining phases. It should be emphasized that the reduction of distress is only a by-product of the reprocessing, and during this phase the client also gains insight, awareness of associative patterns, increase of efficacy, and new sense of self.

Phase Five: Installation

The fifth phase of the treatment is called installation because the focus is on "installing" and increasing the strength of the positive cognition that the client has identified to replace the original negative cognition. For example, the client might begin with an image of her molestation and the negative cognition "I am powerless." During this fifth phase of treatment, the positive cognition "I am now in control" might be installed. The caliber of the treatment effects (that is, how strongly the client believes the positive cognition) is then measured using the Validity of Cognition (VOC) scale.

Phase Six: Body Scan

After the positive cognition has been fully installed, the client is asked to hold the target event in mind, and identify any residual tension, in the form of body sensations. These somatic feelings are then targeted for reprocessing. Evaluations of thousands of EMDR sessions indicate that there is a physical resonance to cognitive process that allows dysfunctional material to be effectively targeted. Positive treatment effects are evaluated, in part, on the basis of physical responses, a strategy that is compatible with conjectures by van der Kolk and others that functional memory storage resides in the declarative memory system while state-specific physical sensations are manifested in nondeclarative memory.

Phase Seven: Closure

The client must be returned to a state of equilibrium at the end of each session, regardless of whether reprocessing is complete. A variety of self-control techniques may be used to close the session. In addition, the client is briefed on what to expect between sessions, and in the use of a journal to report on the experience.

Phase Eight: Reevaluation

The eighth phase of treatment includes the additional targeting, reaccessing, and review necessary to ensure optimal treatment effects. After any reprocessing session, a reevaluation of effects should be made at the beginning of the following session. The reevaluation phase guides the clinician through the various EMDR protocols and the full treatment plan. Successful treatment can only be determined after sufficient reevaluation of reprocessing and behavioral effects over time.


Gil Levin July 12th, 2004 04:37 AM

Dialogue, continued
BOL EDITOR: You have spelled out the EMDR procedure with exquisite clarity and completeness.

I just visited the EMDR Website and was impressed with the acknowledgements there from some of the leading people in our field. It is a marvel to me that you have been able to gain wide acceptance for a method that on its face appears "too good to be true". How did you discover/invent EMDR? And how on Earth were you able to overcome the resistance it evoked.

(As I write, I am reminded of Don Nathanson's observation that you can indentify the pioneers by observing the arrows in their backs)

FRANCINE SHAPIRO: In 1987, during a walk one day, I noticed that disturbing thoughts I was having were suddenly disappearing, and when I brought them back they did not have the same charge or level of disturbance as before. Because I had been using my own mind and body as a laboratory since a bout with cancer ten years earlier, I wondered what I had been doing to cause the change, since generally that type of thought took deliberate engagement to alter or dismiss. I started paying close attention to what I was doing and noticed that when that kind of thought entered my conscious mind, my eyes started moving in a certain way: a very rapid, ballistic, flicking movement. I noticed that when the eye movement started, the thought vanished from consciousness, and when I brought it back it was less valid and disturbing. It was not a moment of great epiphany, but simply interesting and intriguing. I thought I had stumbled upon a natural physiological process that influenced thought.

Since I viewed it as a natural body/mind phenomena, I decided to see if it would work if deliberately instigated and therefore I brought disturbing thoughts to mind and then moved my eyes in the same manner. The same thing happened. The thought shifted from consciousness and when I brought it back it was less disturbing. After finding that it worked consistently for me, I then experimented with other people to see if there was a similar effect for them. I found that I had to use my hand to guide their eye movements since it was difficult for them to do it on their own. Then I discovered that the disturbance would start to decrease for everyone, but for most people it would stop prematurely and I had to develop procedures around the effects of the eye movements to get consistent effects.

Over the past ten years, as more difficult problems were accessed, the procedures have gotten more and more refined and now include aspects of all the major psychological orientations: psychodynamic, behavioral, cognitive, body-oriented, client-centered, interactional, etc. It was a process of evolution which also revealed that the eye movement is only one form of stimulation that can be used. We now know that rhythmical handtaps and tones can have the same effect as the eye movements. So the name Eye Movement Desensitization and Reprocessing is an unfortunate one. Indeed, even the term -desensitization- is limiting. The lessening of disturbance is really only a byproduct of the reprocessing of information. The client also achieves insights, connections, cognitive restructuring, enhancement of self, etc. So, if I had to do it over again, I would call it Reprocessing Therapy. However, EMDR has such world-wide recognition, that we retain the abbreviation in the same way the AT&T does, even though telegraphs are not in common use.

As to how I was --able to overcome the resistance it evoked,-- I have to say it is not completely overcome. There abounds a tremendous amount of misinformation about EMDR, as well as the inevitable attacks that come with any innovation. However, we have encouraged experimentation on EMDR since the beginning and now there are 13 completed controlled studies, which makes it the most widely researched method used in the treatment of trauma. The most recent, rigorously controlled studies all indicate that 84-90% of single-trauma victims no longer have the post-traumatic stress disorder (PTSD) diagnosis after only the equivalent of three 90-minute sessions (a review and the citations are available at the website: www. emdr. com and in my new book: EMDR -- BasicBooks).

Those who are accurately informed about EMDR, have tried it themselves, or have dispassionately reviewed the literature are certainly accepting of it. It is exciting to enter with them onto a new plateau of protocol development, investigating ways to integrate the traditional wisdom of the various modalities into a more refined, comprehensive practice. Experts in various specialty populations (such as substance abuse, sexual dysfunction, complicated bereavement, etc.) have expanded the use of EMDR to a variety of presenting complaints. However, there are still a number of individuals who refuse to accept EMDR until it can be explained by traditional theories. Unfortunately for them, however, one cannot explain three-session positive EMDR treatment effects by traditional psychodynamic or cognitive-behavioral theories. For instance, according to the exposure/extinction/habituation theory of flooding which has been advocated as the primary cognitive-behavioral treatment for PTSD, there must be 15-50 hours of exposure for positive results. Even though the controlled research on EMDR has clearly demonstrated otherwise, I have actually heard cognitive-behavioral academicians dismiss the results as placebo, even though 15-month follow-ups have demonstrated robust and lasting effects. For some, it is hard to integrate new paradigms into standard practices. Therefore, unfortunately, I have to agree with Don Nathanson. The arrows may be fewer, but they definitely exist.

BOL EDITOR: Your account of the moment of origin of EMDR sent a chill through my spine. It was reminiscent of Einstein's famous ride on the commuter train -- actually more like Gautama pausing under the Banyan tree, because of the personal significance of your moment. That would make you especially vulnerable to those arrows of skepticism and it's a great relief that none of them reached your heart.

I read your response late last night and awoke with a vivid memory from my undergraduate days. One of my most influential teachers at college was Leslie White, the distinguished (and somehat eccentric) cultural anthropoligist. White took fiendish delight in debunking myths ("What fools YOU mortals be!") and saw science as the cure for the boundless distortions that are part and parcel of the uniquely human power to make and grasp symbols. Forty years after his lecture, I can still hear White's rhetorical question/mantra uttered in a tone that would do justice to Howard Stern, "Do you REALLY suppose that an ape can believe in holy water?" This was said in a way that made it clear that the ape was on the right side of the argument. For White the essence of science was doubt and he coined a verb to describe that essence: Science is NOT-knowing.

It's clear from all you have said above that you embrace fully the scientific paradigm and the fundamental skepticism at its heart. I invite your comment (even though I know I haven't really framed a question).

FRANCINE SHAPIRO: I wholeheartedly agree that the tools of scientific investigation are crucial to eliminate error and objectively evaluate that which can be observed in order to counterbalance the possible distortion caused by subjective interpretation. However, to my way of thinking, the essence of science is investigation--not doubt. If science is used in the service of humanity, its mandate is to explore and expand the bounds of knowledge. The springboard is then curiosity and the goal is KNOWING. If doubt becomes the driving force of science then it often is subverted to the goal of debunking anything that cannot currently be measured or explained. Science then takes on the stature of religion and the dominant myth that is accepted is that one should not entertain, accept, or believe that which cannot be currently proven. Unfortunately, this eliminates from the arena all those things for which there are so far insufficient theory, measurements, and conceptual frameworks.

If one is an ape, one is reduced to that which can be understood and conceptualized in that framework. If one is a human being, there is the ability to apprehend the ineffable and the possible. The goal is to develop the tools of science to understand the governing principles of mind, body, and nature--from the subatomic to the universal. While an ape might not believe in holy water, neither would it believe in--nor have been able to conceptualize--the atom. And without the capacity for symbolic thought and conceptualization beyond the realm of what is known, all progress ceases.

BOL EDITOR: You have said that EMDR is a method that enables "reprocessing dysfunctionally stored experiences". That phrase implies that most experiences, including those that carry high affective are stored in a "functional" way and therefore do no harm to the person.

How much can you say or speculate about such functional storage? How it occurs and where? And what are the conditions that lead to "dysfunctional storage? In other words, what usually "goes right" and what goes wrong in the case of trauma?

FRANCINE SHAPIRO: The clinical observations of EMDR treatment effects seem to dovetail with conjectures by van der Kolk and others regarding memory storage. That is, when a memory of a past event is functionally stored it is in declarative or narrative memory. If it is dysfunctionally stored it is in motoric memory and retains the physical sensations and high level of affect that was there at the time of the event. With EMDR, we see clients start at a high level of affect and physical sensations and after treatment that is no longer there, and learning has taken place.

Traumatic events can cause dysfunctional storage. However, I think trauma can be defined in a number of ways. We can say the *big T* trauma that a clinician needs to designate a diagnoses of PTSD (like a rape, kidnapping, combat) , or *small t* traumas which are the ubiquitous experiences which have a negative impact upon the self and psyche. If you bring up a memory of a childhood humiliation you may find that the emotions and physical reactions are still there.

If so, I would consider them dysfunctionally stored in unprocessed form. That is the perceptions are unchanged since the time of the event and learning has not taken place. The unprocessed experience may be contributing to problems in the present that are related--such as difficulty with groups, relationships, learning, authority, etc.

I think affect and evolution theorists could contribute here regarding why certain experiences are ingrained and unchanged. It may be due to certain developomental windows. It may be due to the interaction of types of neurotransmitters and high arousal. We are biologically determined to respond in certain ways when danger and survival fears surface. It may be that experiences such as being humiliated in childhood are the evolutionary equivalent of being cut out of the herd. At any rate, if you bring those earlier experiences to mind and you get no negative physical reaction, but adaptive/adult related thoughts spontaneously emerge, then I would say the information is appropriately processed.

Why one experience is processed and not another, or why one person processes it and not another, may be due to earlier nurturance history that made the experience more tolerable, sufficient counterexamples, or biological determinants, or perhaps being comforted/calmed soon after the distress. Many maladaptive behaviors, negative beliefs, and attitudes that people carry around seem to be caused by these types of dysfunctionally stored events with affects that are easily triggered in the present. They do not have to be *big T* traumas to cause them, and the associations revealed during processing are fascinating to watch.

smoothies4all September 6th, 2010 04:35 PM

Re: A Dialogue with Francine Shapiro
I've always thought of this technique being very effective, especially when dealing with trauma. Does anyone know where I could find a directory of practitioners in different areas of the country? Thanks in advance.

Sandra Paulsen November 10th, 2010 11:21 AM

Re: A Dialogue with Francine Shapiro lists all members of that organization, also those who have met criteria for the status of EMDR practitioner, also those who have met criteria for EMDR consultant.

if you go to you will find names posted by the EMDR Institute including EMDR facilitators.

the more qualifications the better, generally

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