Basic Training Curriculum

1Revised 04.09.2012

1 Basic Training Curriculum 2 3OBJECTIVE: The purpose of the EMDRIA Basic Training Curriculum is to assist providers in 4meeting the minimum standards for EMDRIA Approved Basic Training in EMDR. The goal is 5to create a complete integrated training program that provides the clinician with the knowledge 6and skills to utilize EMDR, a comprehensive understanding of case conceptualization and 7treatment planning, and the ability to integrate EMDR into their clinical practice. At a minimum, 8the Basic Training Curriculum requires instruction in the current explanatory model, 9methodology, and underlying mechanisms of EMDR through lecture, practice, and integrated 10consultation. It is recommended that the syllabus present the strengths and weaknesses of 11Shapiro’s EMDR model including up to date research. 12 13While the EMDRIA Approved Basic Training Curriculum outlines the minimum requirements 14which need to be met, the developer of a specific curriculum can enhance or expand any portion 15as they see fit. 16REQUIREMENTS: 17 I. Three sections with a minimum time and content requirement 18 A. Instructional 19 B. Supervised Practicum 20 C. Consultation 21 II. Faculty: EMDRIA Approved Consultants, as specified. Consultants in Training can also 22 be used under supervision of an EMDRIA Approved Consultant. 23 III.Required Text: Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, 24 Basic Principles, Protocols and Procedures. (2nd ed.). New York: The Guilford Press. 25 IV. Syllabus must be consistent with the above listed text and EMDRIA’s definition of 26 EMDR. 27 V. Supplemental material: 28 A. EMDRIA definition of EMDR (this should be provided in hard copy format). 29 B. Current list of EMDR-related research citations on EMDRIA website. 30 C. Contact information for all EMDRIA Approved Consultants on EMDRIA website. 31 VI. Trainees are required to complete the entire program to receive a certificate of 32 completion. Approval of partial programs will not be granted. Providers are expected to 33 assist trainees through that process. 34 35SECTION ONE: INSTRUCTIONAL 36The goal of the Instructional Section of the training is to provide information and understanding 37in each of the following areas. Although EMDRIA is not regulating the amount of time spent on 38any one portion, it is expected that the majority of time will be spent teaching the Method section 39as well as case conceptualization and treatment planning. The curriculum developer may 40determine the order in which the material is presented. 41Minimum Required Time: 20 hours 42 43 I. History and Overview 44 The goal of this section is to review the historical evolution of EMDR from its inception 45 through validation by randomized controlled studies. This includes, but is not limited to: 46

2Basic Course 1 3Revised 04.09.2012

47 A. Origin: 48 1. Shapiro’s chance observations which led to empirical observations and the 49 development of EMDR methodology. 50 2. The publication of Shapiro (1989) pilot study through the validation of EMDR’s 51 effectiveness through controlled studies. 52 3. Current inclusion in Treatment Guidelines 53 B. Switch from EMD to EMDR: Understanding the significance of the shift in name 54 and model from EMD to EMDR, both in terms of revised theoretical model and 55 procedure. 56 1. Switch from Desensitization model to Adaptive Information Processing (AIP) 57 model 58 2. The effect of EMDR is not desensitization in and of itself, but includes the 59 multifaceted impact of reprocessing all aspects of negative, maladaptive 60 information to adaptive, healthy, useful resolution (e.g., change of belief, 61 elicitation of insight, increase in positive affects, change in physical sensation, 62 and behavior). 63 C. Current EMDR-related Research: The Provider must include information about the 64 representative studies to give the trainees a general grasp of the EMDR literature. 65 1. A current annotated bibliography of EMDR-related theory and research 66 supporting your program’s content that you deem foundational to your students’ 67 understanding of EMDR’s efficacy , model, mechanism, and method should be 68 included in the handouts. This list need not be exhaustive. It should be reviewed 69 no less than yearly, and updated when needed. 70 2. Resource sites where this material can be located and updated on the internet 71 should be provided – with website addresses verified and updated no less than 72 yearly. 73 D. 74 II. Distinguish Model, Methodology, and Mechanism 75 This section of the curriculum explains these three aspects of EMDR and distinguishes 76 among them. The Adaptive Information Processing model (AIP) is the underlying 77 explanatory model of EMDR. It is important that trainers have a full understanding of 78 this model as outlined in Shapiro (2001). The AIP model provides the theoretical 79 foundation of EMDR. The methodology section includes the eight-phase treatment 80 procedures of the basic EMDR protocol, plus safeguards, ethics, and validated 81 modifications for specific clinical situations. The mechanism section includes current 82 hypotheses regarding how or why EMDR works on the neurobiological level, plus 83 current research exploring mechanisms of action. Although hypotheses regarding the 84 mechanism of action are speculative at present, an introduction of these hypotheses is 85 important. With a clear understanding of the AIP model, the specific aspects of the 86 method, and current thinking regarding mechanism, the participants should be well 87 informed regarding the study and practice of EMDR. 88 89 A. Model – Adaptive Information Processing (AIP): 90 Shapiro adapted and applied the Adaptive Information Processing (AIP) model as the 91 underlying explanatory model of EMDR. EMDR is based, therefore, on a distinct 92 information processing model which incorporates specific principles and treatment

93 procedures. The AIP model guides history taking, case conceptualization, treatment 94 planning, intervention, and predicts treatment outcome. (See Appendix A for 95 information about antecedent information processing models.) 96 97 98 1. Basic hypotheses concepts of AIP: 99 a. The neurobiological information processing system is intrinsic, physical, and 100 adaptive 101 b. This system is geared to integrate internal and external experiences 102 c. Memories are stored in associative memory networks and are the basis of 103 perception, attitude and behavior. 104 d. Experiences are translated into physically stored memories 105 e. Stored memory experiences are contributors to pathology and to health 106 f. Trauma causes a disruption of normal adaptive information processing which 107 results in unprocessed information being dysfunctionally held in memory 108 networks. 109 g. Trauma can include DSM IV Criterion A events and/or the experience of 110 neglect or abuse that undermines an individual’s sense of self worth, safety, 111 ability to assume appropriate responsibility for self or other, or limits one’s 112 sense of control or choices 113 h. New experiences link into previously stored memories which are the basis of 114 interpretations, feelings, and behaviors 115 i. If experiences are accompanied by high levels of disturbance, they may be 116 stored in the implicit/nondeclarative memory system. These memory 117 networks contain the perspectives, affects, and sensations of the disturbing 118 event and are stored in a way that does not allow them to connect with 119 adaptive information networks 120 j. When similar experiences occur (internally or externally), they link into the 121 unprocessed memory networks and the negative perspective, affect, and/or 122 sensations arise 123 k. This expanding network reinforces the previous experiences 124 l. Adaptive (positive) information, resources, and memories are also stored in 125 memory networks 126 m. Direct processing of the unprocessed information facilitates linkage to the 127 adaptive memory networks and a transformation of all aspects of the memory. 128 n. Nonadaptive perceptions, affects, and sensations are discarded 129 o. As processing occurs, there is a posited shift from implicit/nondeclarative 130 memory to explicit/declarative memory and from episodic to semantic 131 memory systems (Stickgold, 2002) 132 p. Processing of the memory causes an adaptive shift in all components of the 133 memory, including sense of time and age, symptoms, reactive behaviors, and 134 sense of self 135 136 2. Clinical Implications: The AIP guides case conceptualization, treatment 137 planning, intervention, and predicts treatment outcome 138 a. Clinical complaints that are not organically based or are caused by insufficient 139 information are viewed as stemming from maladaptively stored and

140 unprocessed information which has been unable to link with more adaptive 141 information. 142 b. Earlier memories which are maladaptively stored increase vulnerability to 143 pathology including anxiety, depression, PTSD, and physical symptoms of 144 stress and may interfere with healthy development of an individual’s sense of 145 self worth, safety, ability to assume appropriate responsibility for self or other, 146 or limits one’s sense of control or choices 147 c. The information processing system and stored associative memories are a 148 primary focus of treatment 149 d. Procedures are geared to access and process dysfunctional memories and 150 incorporate adaptive information 151 e. The intrinsic information processing system and the client’s own associative 152 memory networks are the most effective and efficient means to achieve 153 optimal clinical effects 154 f. Targeted memories must be accessed as currently stored so the appropriate 155 associative connections are made throughout the relevant networks 156 g. Unimpeded processing allows the full range of associations to be made 157 throughout the targeted memory and the larger integrated networks 158 i. Interventions to assist blocked processing should mimic spontaneous 159 processing 160 ii. All interventions are viewed as distortions and potentially close some 161 associated pathways 162 iii. Following any intervention, the target needs to be reaccessed and fully 163 processed in undistorted form 164 h. Processing shifts all elements of a memory to shift to adaptive resolution 165 166 3. Differentiate from other models: Highlight how pathology and treatment are 167 viewed differently from other orientations (see Appendix B). 168 169 4. Applications: It is well documented that trauma can contribute to a wide range 170 of presenting problems, not just PTSD. The curriculum provides an 171 understanding of the wide range of applications for EMDR, when the overall 172 clinical picture (i.e., presenting problems, symptoms, and character structure and 173 life stressors) is framed within the AIP model. This section also provides another 174 opportunity for teaching how the AIP model guides case conceptualization, 175 treatment planning and overall clinical practice. 176 a. Scientifically-validated applications 177 b. Non-validated applications still needing research 178 179 B. Methodology – The curriculum explains and teaches the method of EMDR. 180 Although the Basic EMDR protocol is taught, other such issues surrounding the 181 practice and professionalism of EMDR are to be included in the curriculum. 182 183 1. 8-Phases: EMDRIA requires that the latest edition of the Shapiro text be adhered 184 to when teaching Phases 3-6. The Shapiro text and the EMDRIA Definition of 185 EMDR guide the teaching for Phases 1, 2, 7, & 8. EMDRIA also requires that 186 participants must have exposure to all 8 phases through lecture, demonstration,

187 and practice. It is imperative that trainees understand how case formulation and 188 treatment planning are incorporated into each of the 8 phases. 189 190 191 a. History Taking, Case Conceptualization & Treatment Planning (Phase 192 1): The curriculum provides instruction on what information is gathered from 193 the client and how this information is used. That information with the 194 evaluation of current level of functioning, character structure, and treatment 195 goals are used to assess appropriate client selection, client readiness, target 196 selection based on the three-pronged protocol and treatment planning. 197 198 i. Focus on areas of history taking unique to EMDR practice/processing 199 ii. Offer variety of ways to take a history of traumatic events, abuse, neglect, 200 or thematic negative cognitions 201 iii. Offer an understanding of the impact of trauma and neglect on healthy 202 development and assessment of potential developmental holes or 203 maladaptively stored information that underlies current problems or 204 symptoms 205 iv. Introduce three-pronged approach and methods to identify appropriate 206 targets as treatment planning methodology 207 v. Explain the treatment planning aspect of the selection and ordering of 208 memories to be processed 209 vi. Introduce appropriate techniques used to identify earliest associated 210 memories 211 vii. Introduce case conceptualization issues, such as degree of stabilization, 212 affect intolerance, assessment of adequacy of skills and resources, 213 duration of issues/dysfunction 214 viii. Client selection criteria and indications of client readiness. 215 ix. Client’s ability to sustain Dual Attention 216 x. Explore issues that might impede or interfere with processing and 217 readiness, such as: 218 a) Secondary gain issues 219 b) Present-day stressors (personal, work-related, medical) 220 c) Timing issues (e.g.,. unavailability of clinician) 221 d) Medical concerns 222 e) Legal issues, (e.g. impending testimony) 223 224 b. Client Preparation (Phase 2): The goal of this section of the curriculum is 225 to assure that the client is informed about EMDR, prepared for EMDR 226 processing, and to help the client establish the necessary ability to maintain a 227 Duel Awareness during processing and the ability to manage affective 228 reactions between sessions. These activities include but are not limited to: 229 i. Education about EMDR and its effects 230 ii. Assess/develop therapeutic rapport 231 iii. Address client’s concerns 232 iv. Explain the details of the EMDR procedure

233 a) Seating arrangement 234 b) BLS (e.g., different types, testing speed & distance) 235 c) Accurate observation and reporting 236 d) Setting expectations and utilization of the “Stop” signal 237 v. Client Safety and Stability: 238 a) Assess/develop client’s stabilization skills 239 b) Knowledge of commonly used procedures to enhance safety and self- 240 control for issues related to safety and stability. 241 c) Appropriate use of Safe Place, containment skills and Resource 242 Development 243 vi. Review client selection criteria and precautions 244 245 c. Assessment (Phase 3): All aspects of the assessment of targets are taught. 246 The curriculum explains and teaches the function and importance of each 247 component of the assessment, and how to obtain them, (e.g., distinguish 248 between appropriate and inappropriate cognitions), and the rationale for the 249 order of the assessment. 250 i. Image 251 ii. Negative Cognition (NC) 252 iii. Positive Cognition (PC) 253 iv. Validity of Cognition (VOC) 254 v. Emotions 255 vi. Subjective Units of Disturbance Scale (SUDS) 256 vii. Sensations 257 258 d. Desensitization (Phase 4): In this section, the curriculum provides 259 instruction on all aspects and expectations of what and how the reprocessing 260 occurs and evolves. 261 i. Explain channels of processing 262 ii. Explain the application of all forms of bls, provided (offered) in discrete 263 intervals, and circumstances when alternatives to eye movement may be 264 necessary 265 iii. Note types of processing to expect (e.g., visual, emotional, sensations) 266 iv. Emphasize the importance of therapist maintaining empathic 267 connectedness while allowing the client to process without unnecessary 268 therapist intrusion 269 v. Emphasize the importance of following the client’s processing in 270 determining the length of BLS sets. 271 vi. Reinforce the three-pronged approach 272 vii. Note themes and plateaus or difficulties in processing such as self worth, 273 appropriate responsibility for self and other, safety, and choices 274 viii. Explain working with abreactions 275 ix. Note how to work with the emergence of new memories that 276 spontaneously occur during processing which may need additional 277 targeting 278 x. Identify the selection of appropriate clinical interventions for ineffective

279 or blocked processing which include but are not limited to: change of 280 BLS, return to target, maximize or minimize assessment components 281 xi. Explain Cognitive Interweave 282 xii. Identify methods to link to early events that are blocked or not conscious, 283 such as the use of the Affect Bridge, Float Back or Touchstone events 284 xiii. Explain timing of re-accessing and reassessing the target 285 xiv. Explain therapist characteristics or responses that may interfere 286 with adequate processing 287 xv. Explain client perceptions of therapist characteristics or responses that 288 may interfere with adequate processing 289 e. Installation (Phase 5): The curriculum instructs when, how and why the 290 Installation phase is completed. 291 f. Body Scan (Phase 6): The curriculum instructs when and how to conduct the 292 Body Scan, as well as the importance of the information gained during the 293 Body Scan. 294 g. Closure (Phase 7): The curriculum instructs the purpose of closure for both a 295 single therapy session as well as closure to the processing of a given EMDR 296 target. Rationale and methods to ensure client stability in the event of 297 incomplete processing of a specific target must be emphasized. 298 h. Reevaluation (Phase 8): The curriculum instructs on the rationale of 299 “checking your work” of the previous session. It provides information on the 300 status of a fully processed memory, or reengaging the target for continued 301 processing, and re-evaluation all targets at the conclusion of therapy. 302 303 2. Advanced Methodology: Procedural modifications are shown to produce better 304 outcomes in specific situations. The curriculum must include the rationale for any 305 modifications of the EMDR basic protocol. This also provides another 306 opportunity to discuss case conceptualization and treatment planning from the 307 framework of the AIP. (Please Note: Details on procedural modifications which 308 are adequately researched and substantiated by EMDRIA will be incorporated 309 into the curriculum as they are made available. Upon approval, updated 310 information will be forwarded to providers.) 311 a. Special Protocols 312 i. Recent events 313 ii. Anxiety and Phobia 314 iii. Illness and somatic disorders 315 iv. Grief 316 v. Self-use 317 b. The curriculum introduces working with specific populations and encourages 318 additional training for those who work in these areas 319 i. Children 320 ii. Couples 321 iii. Addictions 322 iv. Sexual Abuse Victims 323 v. Complex PTSD or DESNOS 324 vi. Dissociative clients

325 vii. Military 326 327 3. Professional, legal, ethical issues: This curriculum provides an opportunity to 328 remind trainees of the general principles and issues necessary for excellence in 329 practice. It can also provide information about EMDRIA, the need for ongoing 330 continuing education and other professional or practical issues (e.g., insurance 331 reimbursement). 332 a. Scope of practice: Within their competency level (i.e., education, training, 333 and professional experience) and licensure status 334 b. Standards of practice of your professional discipline 335 c. Issues of informed consent 336 337 C. Mechanism of Action underlying EMDR (See Appendix C for more Information) 338 1. Orienting Response: The orienting response is a natural response of interest and 339 attention that is elicited when attention is drawn to a new stimulus. 340 a. Cognitive/Information Processing 341 b. Behavioral 342 c. Neurobiological 343 2. Neurobiology information about trauma/psychotherapy: Given the infancy of 344 the field of neurobiology, the physiological foundations of all psychotherapies, 345 including EMDR are currently unknown, and therefore, all neurobiological 346 models of psychotherapy are speculative. Current neurobiology research 347 involving EMDR must be reviewed. 348 3. The curriculum must provide the most current information in these or any 349 emerging explanatory models. 350 351 352SECTION TWO: SUPERVISED PRACTICUM 353The goal of Supervised Practicum is to facilitate the demonstration and practice of the EMDR 354methodology as outlined above in the Shapiro text, and the EMDRIA Definition of EMDR. 355Time Requirement: 20 Hours 356The supervised practicum should be appropriately scheduled to allow adequate teaching time for 357the full explanation of the component to be demonstrated and practiced. 358Faculty Requirement: Practicum faculty may be an EMDRIA Approved Consultant or 359Consultant in Training under the supervision of an Approved Consultant. The ratio of faculty to 360trainees should not exceed 1:10 to allow for direct behavioral observation of each trainee. 361 362 I. Practice Exercises 363 A. To achieve the goals of the Supervised Practicum, practice may be done in dyads or 364 triads. 365 1. The role of the clinician is required. 366 2. The role of clinical recipient is required. 367 3. The role of “observer” is preferred but not mandatory. EMDRIA recognizes that 368 it is not always possible to fill the role of Observer during the supervised 369 practicum. 370 B. It is imperative that trainees receive direct behavioral observation and feedback.

371 C. Whenever appropriate, trainees practice with real life experiences. 372 D. Ample practice is recommended before introducing/teaching the Cognitive 373 Interweave. 374 E. Practice should be included for each phase of the procedure as outlined in the 375 Instructional Section. Special attention should be given to the following: 376 1. Phase One: History taking 377 a. Case conceptualization 378 i. Appropriate techniques are used to identify the earlier associated targets 379 ii. Target identification is associated with primary presenting complaints 380 b. Treatment planning 381 i. Selection and ordering of targets to be processed 382 ii. Three pronged approach 383 4. Phase Four: Desensitization 384 a. Application of all forms of bls, provided (offered) in discrete intervals, and 385 circumstances when alternatives to eye movements may be necessary. 386 b. Types of reprocessing to expect (e.g., visual, emotional, sensations) 387 c. Importance of allowing the client to process without unnecessary therapist 388 intrusion. 389 d. Note the emergence of new memories that spontaneously occur during 390 processing that may need additional targeting 391 e. Timing of re-accessing and re-assessing the target 392 f. Working with abreactions 393 g. Selection of appropriate clinical interventions for ineffective or blocked 394 processing which include, but are not limited to: 395 i. Change of BLS, return to target, maximize or minimize assessment 396 components 397 ii. Cognitive Interweave 398 iii. Affect Bridge or Float Back technique to identify earlier disturbing 399 memories that need to become the focus of processing 400 iv. Re-accessing the target and reprocessing in undistorted form. 401 h. Each trainee practices the basic elements of EMDR treatment planning using 402 the three-pronged approach with a single issue or event by demonstrating the 403 selection and reprocessing of: 404 i. One or more earlier and related disturbing memory 405 ii. One or more current stimuli 406 iii. One or more future situations. 407 k. Additional areas that may be explored when they arise: 408 i. Therapist characteristics or responses that may interfere with adequate 409 processing 410 ii. Client perceptions of therapist characteristics or responses that may 411 interfere with adequate processing 412 413SECTION THREE: CONSULTATION 414Consultation is a new required content area which has already been added into Basic Training by 415some Training Providers. By including consultation, trainees will be able to safely and 416effectively integrate the use of EMDR into their clinical setting. Consultation provides an

417opportunity for the integration of the theory of EMDR along with the development of EMDR 418skills. During consultation trainees receive individualized feedback and instruction in the areas 419of case conceptualization, client readiness, target selection, treatment planning, specific 420application of skills, and the integration of EMDR into clinical practice. Ethical and professional 421guidelines already call for clinicians to obtain consultation when incorporating new methods into 422their clinical practice. Requiring Providers to include consultation as a component of Basic 423Training will raise the professional stature of EMDR training and assure consistent adherence to 424this guideline. A variety of mechanisms can be employed by different Providers to include 425consultation. Consultation increases the use of EMDR by those who have received training, 426reduces the formation of bad habits and the risks of problematic use of EMDR. It also allows the 427clinician to develop and integrate EMDR skills creatively into their other skills in a way that 428enhances clinical efficiency and effectiveness in helping a wider range of clients meet their goals 429for change. If a behavioral sample of a trainee’s work with actual clients is required by the 430Provider, consultation provides an excellent forum in which that activity can take place. 431 432**Since consultation is a new requirement, EMDRIA would appreciate feedback regarding your 433experiences while implementing this section of the Basic Curriculum.** 434Time Requirement: 10 hours of consultation are required and are provided in developmental 435increments to extend over the course of the training. 436Faculty Requirement: EMDRIA Approved Consultant, or Consultant in Training under the 437supervision of an Approved Consultant. 438 439 I. Consultation addresses, but is not limited to, the following content: 440 A. Use of EMDR within a structured treatment plan 441 B. Application of the standard EMDR procedural steps 442 C. Case conceptualization and target selection 443 D. Client readiness including inclusion, exclusion and cautionary criteria for EMDR 444 reprocessing 445 E. Client safety and effective outcomes using the standard EMDR procedural steps 446 F. Integration of EMDR into their existing clinical setting or in an alternate clinical 447 setting 448 G. Specific application of skills 449 H. Consultation is about real cases and not experiences that occur in practicum 450 II. Consultation provides opportunity for the faculty to assess the strengths and weaknesses 451 of each trainee’s overall understanding and knowledge of EMDR and the practice of 452 EMDR skills and the opportunity to tailor further learning experiences to address deficits. 453 III.Consultations sessions are appropriately scheduled to allow adequate time for teaching, 454 practicum and clinical use of EMDR, to maximize the discussion of case 455 conceptualization, client readiness, target selection, treatment planning, specific 456 application of skills, and the integration of EMDR into clinical practice. 457 IV. Consultation may be integrated into an extended training format or consultation may be 458 provided by local Approved Consultants and reports of completion sent to the Provider. 459 In the latter case, the Approved Consultant must furnish the Provider with written 460 documentation that the Consultation requirement has been met (i.e., feedback may be in 461 the form of a simple feedback form which is completed and submitted to Provider). 462 V. Acceptable Consultation Formats

463 A. Individual: One-on-one time between participant and consultant. 464 B. Group: Group consultation could involve discussions of issues that have a generic 465 interest, but should not replace the intimate formats that allow for individualized 466 feedback. As a general guideline, groups should allow a ratio of 15 minutes per 467 individual participant. A group of four would meet for no less than one hour; a group 468 of eight would meet for no less than two hours. Participants would receive credit for 469 the total time spent in the group. 470 C. Combinations of Individual and Group: Any combination of Individual 471 Consultation and Group Consultation that meets the time guideline suggested above 472 and provides a total of ten hours of consultation time. 473 474Appendix A 475 I. Antecedent, historical models of emotional information processing: 476 A. Peter J. Lang (1977, 1979, 2000) 477 B. Stanley Rachman (1980) 478 C. Gordon Bower (1981) 479 D. Edna Foa and Michael J. Kozak (1986) 480 481Appendix B 482 I. Differentiate from other models: Highlight how pathology and treatment are viewed 483 differently from other orientations. The trainer should be prepared to highlight and/or to 484 answer questions regarding how EMDR and the Adaptive Information Processing Model 485 contrast and compare with other psychotherapeutic approaches. This might include the 486 view of pathology and health, case conceptualization, and how change occurs. Examples 487 would include: 488 A. Cognitive— 489 1. Irrational thoughts are the basis of pathology 490 2. Cognitions are changed through reframing, self-monitoring, and homework 491 exercises 492 B. Behavioral— 493 1. Cannot see within the “black box” (the brain) 494 2. Learned behavior is changed through conditioning, exposure, modeling, etc. 495 (learning processes) 496 C. “Third wave” of CBT— 497 1. Suffering is inevitable 498 2. Change is through acceptance, commitment, and Mindfulness exercises 499 D. Psychodynamic— 500 1. Explores the impact of Family of Origin, Object relations 501 2. Change is created by insight or “working through” 502 3. Goal is to make the subconscious conscious 503 E. Family Therapy— 504 1. Problems and solutions are interactional 505 2. Exploration and evaluation of family dynamics 506 3. Change through education and role realignment 507 F. Experiential – 508 1. Facilitates client self-healing

509 2. Affect and body are central 510 3. Uses relationship, “two-chair,” “meaning bridge” 511 512Appendix C 513Hypothesized Mechanisms of Action 514A commonly proposed hypothesis is that dual attention stimulation elicits an orienting response. 515The orienting response is a natural response of interest and attention that is elicited when 516attention is drawn to a new stimulus. There are three different models for conceptualizing the 517role of the orienting response in EMDR: cognitive/information processing (Andrade, Kavanagh, 518& Baddeley, 1997; Lipke, 1999), neurobiological (Bergmann, 2000; Servan-Schreiber, 2000; 519Stickgold, 2002) and behavioral (Armstrong & Vaughan, 1996; MacCulloch & Feldman, 1996). 520These models are not exclusive; to some extent, they view the same phenomenon from different 521perspectives. Barrowcliff, MacCulloch, & Gray (2001) posit that the orienting in EMDR is 522actually an “investigatory reflex,” that results in a basic relaxation response, upon determination 523that there is no threat; this relaxation contributes to outcome through a process of reciprocal 524inhibition. Others suggest that the inauguration of an orienting response may disrupt the 525traumatic memory network, interrupting previous associations to negative emotions, and 526allowing for the integration of new information. A study by Kuiken, Bears, Miall & Smith 527(2001-2002) which tested the orienting response theory indicated that the eye movement 528condition was correlated with increased attentional flexibility. It is further possible that the 529orienting response induces neurobiological mechanisms, which facilitate the activation of 530episodic memories and their integration into cortical semantic memory (Stickgold, 2002). This 531theory has recently received experimental support (Christman, Garvey, Propper, & Phaneuf, 5322003). Further research is needed to test these hypotheses.

533There are several research studies (e.g., Andrade et al., 1997; Kavanaugh, Freese, Andrade, & 534May , 2001; van den Hout, Muris, Salemink, & Kindt, 2001) indicating that EMs and other 535stimuli have an effect on perceptions of the targeted memory, decreasing image vividness and 536associated affect. Two possible mechanisms have been proposed to explain how this effect may 537contribute to EMDR treatment. Kavanaugh et al. (2001) hypothesize that this effect occurs when 538EMs disrupt working memory, decreasing vividness, and that this results in decreased 539emotionality. They further suggest that this effect may contribute to treatment as a “response aid 540for imaginal exposure” (p. 278), by titrating exposure for those clients who are distressed by 541memory images and/or affect. Van den Hout et al. (2001) hypothesize that EMs change the 542somatic perceptions accompanying retrieval, leading to decreased affect, and therefore 543decreasing vividness. They propose that this effect “may be to temporarily assist patients in 544recollecting memories that may otherwise appear to be unbearable” (p. 129). This explanation 545has many similarities to reciprocal inhibition.

546Neurobiological aspects of EMDR

547Given the infancy of the field of neurobiology, the physiological foundations of all 548psychotherapies are currently unknown, and therefore, all neurobiological models of 549psychotherapy are speculative. Testing of hypotheses about EMDR’s neurological mechanisms 550awaits the development of advanced brain imaging techniques. Hypotheses concerning EMDR’s 551neurobiological mechanisms are, at this time, purely speculative.

552Rauch, van der Kolk, and colleagues (1996) conducted positron emission studies of patients with 553PTSD in which they were exposed to vivid, detailed narratives which they had written about 554their own traumatic experiences. Patients showed heightened activity only in the right 555hemisphere, in the areas most involved in emotional arousal, and heightened activity on the right 556visual cortex, reflecting the flashbacks reported by these patients. Perhaps most significantly, 557Broca’s area - the part of the left hemisphere responsible for translating personal experiences into 558communicable language -“turned off”. These findings indicate that PTSD symptoms are 559reflected in actual changes in brain activity.

560Case study research by van der Kolk and colleagues (Levin, Lazrove, & van der Kolk, 1999; van 561der Kolk, Burbridge, & Suzuki, 1997; Zoler, 1998) has provided some preliminary evidence that 562changes in brain activation patterns may follow effective treatment. SPECT scans were 563administered pre and post-EMDR for 6 PTSD subjects who each received 3 EMDR sessions. 564The Zoler article has photos of pre and post SPECT scans. Findings indicated metabolic changes 565after EMDR in two specific brain regions. First, there was an increase in bilateral activity of the 566anterior cyngulate. This area moderates the experience of real versus perceived threat, indicating 567that after EMDR, PTSD sufferers may no longer be hypervigilant. Second, there appeared to be 568an increase in pre-frontal lobe metabolism. An increase in frontal lobe functioning may indicate 569improvement in the ability to make sense of incoming sensory stimulation. Levin et al. 570concluded that EMDR appeared to facilitate information processing. Because there was no 571control group, there is no evidence that these effects were unique to EMDR; effective treatment 572of any kind may produce similar results.

573Daniel Amen (2001) has been taking pre and post SPECT scans of his patients. He has used 574EMDR with PTSD patients, and reported a decrease in anterior cingulate, basal ganglia and deep 575limbic activity. The 12th chapter of Shapiro’s (2001) text details some related recent 576neurological research and explains the possible relevance of these findings to EMDR. Also of 577interest is an article by Stickgold (2002), a sleep researcher, who has developed a theory to 578explain the effects of EMDR’s alternating, bilateral stimulation which forces the client to 579constantly shift his or her attention across the midline. He proposed that REM-like 580neurobiological mechanisms are facilitated by this shifting attention, resulting in the activation of 581episodic memories, and their integration into cortical semantic memory. Independent research by 582Christman et.al. (2003) provides some support for this theory. They determined that alternating 583leftward and rightward eye movements produced a beneficial effect for episodic, but not 584semantic, retrieval memory tasks.

585References 586Amen, D. (2001). Healing the hardware of the soul. New York: Free Press. 587 588Andrade, J., Kavanagh, D., & Baddeley, A. (1997). Eye-movements and visual imagery: A 589working memory approach to the treatment of post-traumatic stress disorder. British Journal of 590Clinical Psychology, 36, 209-223. 591 592Armstrong, M. S., & Vaughan, K. (1996). An orienting response model of eye movement 593desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 27, 21-32. 594

595Barrowcliff, A. L., MacCulloch, M. J., & Gray, N. S. (2001, May). The de-arousal model of eye 596movement desensitization and reprocessing (EMDR), Part III: Psychophysiological and 597psychological concomitants of change in the treatment of posttraumatic stress disorder (PTSD) 598and their relation to the EMDR protocol. Paper presented at the second annual meeting of EMDR 599Europe, London. 600 601Bergmann, U. (2000). Further thoughts on the neurobiology of EMDR: The role of the 602cerebellum in accelerated information processing. Traumatology, 6 (3): 175-200. Also 603Traumatology Vol 6, issue 3, www.fsu.edu/~trauma/for subscribers. 604 605Bower, G. (1981). Mood and Memory. American Psychologist, 36(No. 2), 129-148. 606 607Christman, S. D., Garvey, K. J., Propper, R. E., & Phaneuf, K. A. (2003). Bilateral eye 608movements enhance the retrieval of episodic memories. Neuropsychology. 17, 221-229. 609 610Foa, E. B., & Kozak, M. J. (1986). Emotional Processing of Fear: Exposure to Corrective 611Information. Psychological Bulletin, 99(1), 20-35. 612Kavanaugh, D. J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on 613desensitization to emotive memories. British Journal of Clinical Psychology, 40, 267-280. 614 615Kuiken, D., Bears, M., Miall, D., & Smith, L. (2001-2002). Eye movement desensitization 616reprocessing facilitates attentional orienting. Imagination, Cognition and Personality, 21, (1), 3- 61720. 618 619Lang, P. J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior 620Therapy, 8, 862-886. 621 622Lang, P. J. (1979). A bioinformational theory of emotional imagery. Psychophysiology, 16, 495- 623512. 624 625Lang, P. J., Davis, M., & Ohman, A. (2000). Fear and anxiety: animal models and human 626cognitive psychophysiology. Journal of Affective Disorders, 61(3), 137-159. 627 628Levin, P., Lazrove, S., & van der Kolk, B.A. (1999). What psychological testing and 629neuroimaging tell us about the treatment of posttraumatic stress disorder (PTSD) by eye 630movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 13, 159-172. 631 632Lipke, H. (1999). EMDR and psychotherapy integration. Boca Raton, FL: CRC Press.

634MacCulloch, M. J., & Feldman, P. (1996). Eye movement desensitization treatment utilizes the 635positive visceral element of the investigatory reflex to inhibit the memories of post-traumatic 636stress disorder: A theoretical analysis. British Journal of Psychiatry, 169, 571-579. 637 638Rachman, S. (1980). Emotional processing. Behaviour Research and Therapy, 14, 125-132.

639Rauch, S., van der Kolk, B. A., Fisler, R., Alpert, N. M., Orr, S. P., Savage, C.R., Fischman, A.

640J., Jenike, M. A., & Pitman, R.K. (1996). A symptom provocation study of posttraumatic stress 641disorder using positron emission tomography and script-driven imagery. Archives of General 642Psychiatry, 53, 380-987.

643Servan-Schreiber, D. (2000). Eye movement desensitization and reprocessing: Is psychiatry 644missing the point? Psychiatric Times, 17, 36-40.

645Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of 646traumatic memories. Journal of Traumatic Stress, 2, 199-223.

647Shapiro, F., (2001). Eye movement desensitization and reprocessing: Basic Principles, Protocols 648and Procedures. (2nd Edition) New York: The Guilford Press.

649Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of 650Clinical Psychology, 58, 61-75.

651van den Hout, M., Muris, P., Salemink, E., & Kindt, M. (2001). Autobiographical memories 652become less vivid and emotional after eye movements. British Journal of Clinical Psychology, 65340, 121-130. 654 655van der Kolk, B. A., Burbridge, B. A., Suzuki, J. (1997). The psychobiology of traumatic 656memory: Clinical implications of neuroimaging studies. In R. Yehuda & A. C. McFarland (Eds.), 657Annals of the New York Academy of Sciences (Vol. 821): Psychobiology of Posttraumatic 658Stress Disorder. New York: New York Academy of Sciences.

659Zoler, M. (1998). Eye movement desensitization: Brain imaging shows benefit of PTSD therapy. 660Clinical Psychiatry News, 26, 14.

30Basic Course 15