What happens in an EMDR Therapy session?

Eye Movement desensitisation and reprocessing (EMDR) is a unique type of psychotherapy that reduces the symptoms of trauma, PTSD, anxiety and depression by using the brains natural capacity to heal itself.  It it known for its use of eye movements as a key feature in the therapy, but this isn’t just what EMDR is about.  So, what happens in an EMDR therapy session?

EMDR – An 8 Phase treatment model

Before we jump into healing the unprocessed memories that are causing your present symptoms, we need to do some ground work first.  As such, EMDR is broken up into 8 different phases that enable us to address your problem by targeting the right memories that are leading to your problem.

Despite EMDR being adapted when it is applied to different problem types and client populations, you will often hear the phrase, “there is only one protocol.”  And, here it is:

The 8 phases of EMDR Therapy

Phase one:  History taking and case conceptualisation/target planning

Phase two:  Preparation

Phase three:  Assessment

Phase four:  Desensitisation

Phase five: Installation

Phase six: Body Scan

Phase seven:  Closure

Phase eight:  Re-evaluation

So, to answer the question of what happens in an EMDR session, we will look at each of these 8 phases in turn.

EMDR Therapy Phase One:  History taking and case conceptualisation

In this phase, we are interested in clarifying how the problem that you are presenting with in therapy is related to previous events in your life.  We will conduct a clinical assessment around your particular problem, identifying the triggers, the emotional elements, negative thoughts and intrusive memories or flashbacks, and how it leads to changes in your behaviour. We will also explore how you want to change as a consequence of your EMDR treatment.  In this sense, EMDR is what we call a “three-pronged” therapy.  We are seeking to alleviate distress in the present, improve functioning in the future, by targeting unprocessed memories of past events.

Whether you are wanting EMDR to help with symptoms of PTSD, trauma, social anxiety, depression, or any other type of problem, we will also include the use of psychometric psychological measures so that you can evaluate the success of your treatment.

In terms of case conceptualisation, we want to be very targeted with regards to the memories that have led to your current problem.  So, when we are doing history taking, we will be exploring how earlier experiences led to changes in themes of choice, responsibility, self-defectiveness and safety.  We will do this via discussion of events that you feel are relevant, but we will also use tools like the “affect bridge” or “floatback”, in which we rely upon the minds natural ability to take us to the origins of the problem.

EMDR Therapy Phase two: Preparation

This phase of EMDR treatment looks at developing the internal and external resources needed to successfully process difficult memories in a safe way, to reduce symptoms and increase functioning.  Depending upon what the client needs to increase preparedness, we will use the preparation phase to develop whatever we need to to enhance stability and the effectiveness of treatment.  Examples of interventions used in the preparation phase include:

• Psychoeducation about EMDR, adaptive information processing, about the client’s symptoms and what to expect from treatment.
• Emotional regulation strategies such as the “safe place”, diaphragmatic breathing, guided imagery, or the “light stream technique.”
• Behavioural activation in which we activate the client, in a safe and appropriate way, to re-engage with avoided activities.
• Social resource planning.  Identifying, if possible, a network of people who the client identifies as being safe, supportive and available for the client to contact when needed.

As with all of the EMDR phases, preparation is not a one-off, one and done phase.  We will revisit it across therapy to ensure that you feel supported and resourced, even when dealing with tricky and unpleasant memories.

EMDR Therapy Phase Three:  Assessment

In the assessment phase of EMDR, we are talking about how we specifically “light up” the relevant memory network for processing.  In trauma focused work, we understand that traumatic memories are held in the brain-body not just as images or thoughts about what happened, but are also emotional and somatic (in the body) too.

This means that we want to light up the whole memory network by activating all components of the trauma memory.  We do this by asking you to think about the event and ask you the following questions…

• What image comes to mind when you think about the event?
• What negative thoughts about yourself come to mind when you think about it?
• What positive or more helpful belief would you like to believe instead?
• On a 1 to 7 scale, with 7 being the most believable, how much do you believe this positive belief when you think about the event right now?
• Holding the image and the negative belief together, what emotion do you feel right now?
• On a 0 to 10 scale, how intense is that emotion for you?
• Where in the body do you feel it?

You can see how each component of the memory is being activated ready for targeted processing.  The positive belief relates to the identification of a more adaptive, helpful belief that we can move towards when the trauma has been fully addressed.

Now, we are ready to do some direct work on the trauma memory itself.

EMDR Therapy Phase Four: Desensitisation

Now that we have lit up our trauma memory, we use bilateral stimulation to reduce the intensity of distress associated with it.  The bilateral stimulation method that EMDR was initially developed with was, of course, eye movements.  However, we can also use sounds directed to each ear, handtapping, buzzers, or the butterfly technique.  I’ll cover each of these techniques in other articles, but the main idea is that we are using these methods of bilateral stimulation to stimulate the left and right hemispheres of the brain while we process the trauma memory.

As discussed in this video by Andrew Leeds, there are a couple of different explanations as to why the bilateral stimulation supports reducing the intensity of traumatic memories:

In this phase of treatment, you will sit with the memory and, while the bilateral stimulation is taking place, allow the mind to make new connections to enhance the processing of the memory. You may notice new aspects of the memory, changes in emotion or in the body. The therapist will do short sets of bilateral stimulation and stay out of the way as much as possible while this process takes place. The therapist will not interpret or offer new information as we are trusting your minds own natural ability to heal itself to do the work needed.

When there appears to be no significant changes, or when the memory links to content that is neutral or positive on two sweeps of bilateral stimulation, we return to the target memory and again measure the level of distress associated with it on our 0 to 10 scale. We typically find that the distress will have reduced. If it is still above a 1, then we continue with more desensitisation. But if it has reached 0, or 1 if there is an organic reason for it to stay at this level, then we move onto the next phase: installation.

EMDR Therapy Phase Five:  Installation

EMDR relies upon something which is called adaptive information processing.  This means that we are enabling the brain’s ability to process experiences in a way that supports better functioning with minimal distress.  In this installation phase, we are supporting this process by returning to our positive belief and building strength in it in relation to the trauma memory.

The positive belief that we are looking to develop isn’t something that is magical or blindly positive, but is instead something that feels valid to you and supportive in terms of how you relate to the trauma, it’s symptoms and your future functioning.

Here are some example of positive cognitions that we may want to move towards in the installation phase of EMDR:

I am now in control
I’m safe now
I deserve to be happy
I can choose who to trust

When we are comfortable with our chose belief, we return to the desensitised image that represents the event and hold the positive belief alongside it.  I then ask you, “at a gut level, on a 1 to 7 scale, how believable does this belief feel to you right now?”

Depending upon how you rate it, we continue with sets of bilateral stimulation.  This focus upon the new positive belief typically strengthens as new more adaptive information is linked to it.  Clients typically report other memories and perspectives emerging during the installation phase, that support this growing believability.

When you are able to feel the new cognition has a validity of 7 out of 7, and we are happy that it is stable, we then move onto the next phase which is called the “body scan.”

EMDR Therapy phase 6:  Body scan

One of the key features of EMDR, and one that takes it away from being simply a “talking therapy”, is its focus on understanding how traumatic memories are also represented in the body.  We don’t just “remember” the trauma, we literally feel it in the body.  A key text in the trauma literature that talks about this in more detail is Bessel van der Kolk’s book “The body keeps the score.”

What this means in practice is that a trauma memory may not be fully resolved until the body feel it to be.  As such, in phase 6, we focus on the body memory of your trauma event, using bilateral stimulation to ease and change the sensation of trauma in the body.

I will ask clients, “when you think of the incident and hold your positive belief in mind, scan through your body and tell me where you feel anything.”

If any uncomfortable sensations are present then we will use bilateral stimulation until the feeling resolves.  If positive feelings are there, then we will again use bilateral stimulation to strengthen the feelings.

EMDR Therapy Phase 7:  Closure

Closure is an important part of the EMDR protocol in that we want to make sure that you are feeling safe and comfortable after a trauma processing session.  We can do this in many ways.  Sometimes we might use our safe or calm place resource.  Other times we may do some grounding using diaphragmatic breathing or guided imagery.

The closure phase helps clients to know that, even though they may have been working on difficult memories, that they can always return to a resourced state in the here and now.  This supports emotional regulation and confidence in knowing difficult memories can be safely accessed and worked with, without having a negative, long lasting effect.

EMDR Therapy Phase 8: Re-evaluation

The final phase of EMDR therapy treatment is re-evaluation.  This typically takes place at the beginning of each EMDR session and involves an evaluation of how previous trauma processing has been in reducing the distress of the memory and maintaining the positive cognition.

Here, we will decide whether the particular memory is “done” or whether we need to do more work on it.  We will also review how this processing is helping with alleviation of the current symptoms, and if there are other memories that have emerged which may be helpful in assisting recovery.

Summary

Although the above phases are presented in a quite linear fashion, EMDR is delivered more flexibly dependent upon your particular needs and the process of therapy itself.  If an important memory emerges that we feel is more relevant to alleviation of your symptoms, we can return to our case conceptualisation and consider whether this should be our target.  Essentially, we are aiming to do what works based upon our adaptive information processing model, upon which EMDR is founded.

It’s also helpful to remember that to access EMDR training, your therapist will also have to be a qualified mental health practitioner in the first place, and so will have a core understanding of all of the other attributes that make therapy work.  The therapeutic relationship is key in making you feel safe and have confidence in your therapist.

If you have found this article helpful and would like to find out more about EMDR, then please feel free to get in touch at [email protected]

by George Maxwell

EMDR UK accredited EMDR Practitioner, BABCP accredited CBT therapist and supervisor