Integral EMDR
An exclusive interview with Francine Shapiro, the originator of Eye Movement Desensitisation and Reprocessing, on why it's a protypically integrative approach
By John Soderlund
NT: You've spoken about EMDR as an integrative approach. Could you start by explaining what you mean by that.
It brings together aspects of all of the major orientations. For instance, bringing in the psychodynamic aspect by its concentration on the earlier events that are believed to set the groundwork for major dysfunction. And then, in the three-pronged approach, another group of targets would be the present stimuli, which are more aligned with behavioural theory in order to make sure that those triggers have been processed.
And then it brings in the cognitive approach by inclusion of the negative and positive beliefs, the negative beliefs that are inherent in the dysfunctionally stored events and the positive beliefs that the person would prefer to have. There is the experiential aspect. It is an extremely client-centred approach, where the clinicians are taught to follow the lead of the client rather than to be dictating or moulding the different treatment aspects.
There is the integration of the physiological or body oriented therapies, with the concentration on affect and the physiological concomitant of affect. So, in other words, those are some examples, but it pretty much brings in all the major orientations. As a matter of fact, the next book that I will be bringing out hopefully within a year, is called EMDR and the Paradigm Prism, where luminaries of different orientations such as Paul Wachtel with psychodynamic and Bessel van der Kolk with neurobiological, are viewing EMDR through their own psychological orientations and giving the reasons that they have the effects they do. What you also see with EMDR is that change is monitored on all of the major dimensions. You are looking for insight and for cognitive changes. But you're also looking for changes in affect, in physical response, in behaviours. So all of these things are monitored.
NT: Can you run briefly through the eight phases of EMDR with some reference to where some of the integrative elements are most obvious?
When we're dealing with phase one, which is the clinical history, we're identifying the earlier memories that set the groundwork for the dysfunction, so this would be primarily compatible with the psychodynamic heritage. And then we're bringing in the present events that triggered the dysfunction, which would be more compatible with the behavioural. We're identifying what new behaviours and new skills the person needs in order to orient completely within their social system for the future, so that's bringing in systems theory and the imaginal work would be coming in from the hypnotic field. We're identifying the negative beliefs that the person has, which are in the dysfunctional self-concepts and themes, which is bringing in some of the cognitive work. And then we're basically looking for where is the dysfunction throughout the person comprehensively. It's not simply a function of specific symptoms which we look for, but also the whole development of the individual, which you find more in a developmental psychology or psychodynamic or intrapsychic psychology.
The preparation phase is working strongly within the experiential tradition because you're making the person fully able to deal with the processing that needs to arise. And bringing in different self-control techniques also which come from the cognitive behavioural and hypnotic traditions. These are more on-the-spot shifts of state. It is important to discriminate between changing state and trait. Cognitive behavioural techniques help the person to keep down their stress level in the present. These are important tools, but they are considered a first step in the EMDR treatment. The primary goal is to change the dysfunctional traits of the person, in addition to giving them "state" control.
Then in the assessment phase we're bringing together the various components of the targets. This brings in some of the neurobiological research about the way traumatic memories or certain other dysfunctional memories are stored in fragments. In order to facilitate EMDR processing, we're bringing together the various fragments in terms of the image and the verbalisation and the affect and the physical sensation.
Then in the reprocessing phase, the desensitisation and the installation phases, we're monitoring changes via shifts in insight, which is more psychodynamically oriented; changes in beliefs, which would be the cognitive orientation; changes in affect and physical sensations, which are more the neurobiological indicators. We are also looking for changes in tone and timbre, so that if we're working with a childhood event, the client will often start verbalising with that type of affect predominating. Because in the information processing model that we use, these earlier events, we believe, have been stored with the emotion and physical sensation that were there at the time of the event. In neurobiological terms, they would be stored in implicit rather than explicit memory systems. And so the person might be starting out with the intonation of childhood and part of what we're monitoring is that shift to a more adult tone. Consequently, we're bringing in the aspects of developmental as well as neurobiological domains.
In the physical body scan, done in the next phase, we are looking at body oriented therapies in order to make sure that there is no physical residual response.
And then in the closure phase, we bring in some of the cognitive behavioural and hypnotic traditions again in order to allow the person back into a state of stress control and equilibrium. We're bringing in the use of a journal, which is a behavioural way for monitoring. And the next phase, the re-evaluation, is specifically monitoring the journal and the behavioural outcomes that have occurred. We're looking at the targets that need to be monitored and addressed, which are again going back into the psychodynamic aspects of the earlier event.
NT: There are a couple of explanatory theories about how EMDR works and it seems from the research that the active ingredient has been identified as the eye movement, certainly from the earlier work that was done.
While the eye movement, or other stimulation, is used and has been investigated, it's important not to minimize the complexity of the entire EMDR methodology. The description that I have just been giving you, these procedures that are drawn from the major psychological orientations, these are also active ingredients and the fact that they are combined in this way with EMDR makes a very distinct form of therapy. All of these procedural aspects are part of the active ingredients.
NT: So your position on this is that the active ingredient of eye movement in and of itself is fairly meaningless.
Not meaningless at all. It is simply not sufficient for the comprehensive treatment effects achieved in EMDR. You see, when I brought the approach forth in the late 80's as "EMD," I was concentrating primarily on the eye movements, frankly because I was ignoring all the other aspects that I was doing. It was the water I was swimming in. Now the eye movements certainly seem to have an important effect, but it's the complete package of EMDR and all of these aspects together that give its results. The sensory stimulation (eye movements, taps and tones) have been evaluated in a number of very small studies that are individually incapable of drawing concrete conclusions.
A number of recent meta-anlyses that have evaluated the pooled results indicate that there is a distinct advantage to their use. However, if you were to take out the sensory stimulation at this point, you would still have an effective form of therapy. In addition, by training clinicians to look at the clinical picture in a certain way - through an information processing model - in itself has a lot of benefit. The information processing model is the one that actually honours and draws together the different psychological models in an integrated fashion.
