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Unread July 12th, 2004, 04:35 AM
Gil Levin Gil Levin is offline
Publisher, Behavior OnLine
Join Date: Jun 2004
Posts: 8
Default 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.

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