The 9th International ESTD Congress Poland 10-12.10.2024 From diagnosis to...Read More
Research and EMDR: new perspectives
“EMDR is one of the psychotherapies that not only treat but also heal. Francine Shapiro passed away leaving us a gift for humanity. It is now up to us to be worthy of it.” This is how Prof. Cyril Tarquinio set the scene at the 10th Metz Academic Meeting (MAM) in Metz, France, at which clinicians, doctoral students, and scholars meet to share and confront their thinking about EMDR therapy practice and research. Research has demonstrated the effectiveness of EMDR therapy in the treatment of posttraumatic stress disorder in a wide range of contexts and populations. Case studies and series, clinical reports, and a number of comparative research studies have described how EMDR therapy may be implemented successfully in the treatment of several other forms of psychopathology and mental health issues. Yet, many questions remain following Francine Shapiro’s passing. What do we know about EMDR therapy today, how does it work, how and when should it be applied, and to whom, and what is its future? For two days, clinicians, doctoral students, and researchers proposed their humble and partial answers to these questions. Twelve presentations were structured around three axes of reflection that were constantly intertwined: a Clinical axis, a Neurological axis, and an Epistemological axis.
The MAM is above all a seminar composed of clinicians. What could be more natural, than to give the floor first and foremost to clinical practice in the field, just as EMDR therapy emerged from a clinical experience? The MAM invites us to open the doors of institutions and private practices to meet psychotherapists at the core of their practice. This is an opportunity to hear the expertise of different consultants as well as the innovations of some psychotherapists. Eva Zimmermann, from Switzerland, reminded us that the desensitization phase of the standard EMDR protocol (phase 4) presents several clinical choice points to the therapist. It appears to be a relatively simple phase for the therapist who stays out of the way to accompany the desensitisation and reprocessing process. Despite this stance, the therapist must nevertheless remain active and present while the patient goes through different stages, which are more or less emotionally intense. By maintaining this course and by their clinical choices, the clinician facilitates change, by continuously adjusting to the complexity of the emerging material, to the affective intensity, or to the issues that are specific to this phase of the treatment: dissociative phenomena, jumps between different traumatic targets, or even looping that requires cognitive interweaves (statements or questions aimed at eliciting adaptive information that may then link with the dysfunctionally stored, trauma-related memories). Changes in the client may manifest through the client’s insights, a distancing of the negative material, a reprocessing at the emotional or sensory level, or more subtly at the imaginary level or even without externally visible signs. Olivier Piedfort-Marin, also from Switzerland, argued that the theory of structural dissociation of the personality (TSDP) (Van der Hart, Nijenhuis, & Steele, 2006) may shed light on the processes at stake in EMDR therapy. TSDP is sometimes the object of a simplified and reductive understanding, summarised in the concepts of the Apparently Normal Part of the personality (ANP) and the Emotional Part of the personality (EP), to the detriment of an understanding of the mechanisms at play in trauma-related dissociation. Piedfort-Marin reminded the audience of the following: Contrary to the phenomenon of dissociation, the objective of psychotherapeutic treatment is the synthesis of the patient’s lived experience, both in its different components (central synthesis) and over time (extended synthesis). Synthesis cannot be achieved without the realisation of the experience, which is itself distinguished in two stages: personification and presentification. Personification is the ability of the individual to feel that they have lived through a (traumatising) event, to take personal ownership of the lived experience. Presentification is the ability of an individual to integrate that the (traumatising) event has taken place in the past and is over, that they can act fully in the present moment and project themselves in the future. Piedfort-Marin proposed a new understanding of EMDR therapy’s Adaptive Information Processing (AIP) model in the light of TSDP. In phase 4 in particular, the client’s associations during the different sets of bilateral stimulation (BLS), involving emotions, cognitions, sensations, and behaviours, enable a central synthesis. The three-pronged focus (past, present, future) subsequently promotes an extended synthesis. Using clinical vignettes, Piedfort-Marin suggested that the therapist’s interventions, such as cognitive interweaves, follow the same process of synthesis, first suggesting personification and then presentification, depending on where the client is at. As Eva Zimmermann had already illustrated, the role of the therapist in phase 4, which appears so “simple and minimalist, even withdrawn”, then appears essential. Clinical discussions were pursued regarding applications in specific clinical contexts. Cyril Tarquinio, from France, shed light on the application of EMDR therapy in oncology. Cancer involves the conceptualisation of a specific psychopathology, it implies more than the cumulation of reactive symptoms or disorders. Recent work shows associations between depressive mood and adverse childhood events (ACEs) and the evolution of cancer. Furthermore, cancer is a word synonymous with “death” in the collective imagination. It is a succession of emotional shocks (diagnosis, treatment, relapse, upheavals in daily life and in the lives of loved ones, etc.) which not only generates psychotraumatological symptoms, but also feelings of vulnerability, despair, loss of control and autonomy. Life as a whole is then reshuffled, the cards are redistributed and priorities redefined. Because it is an illness that is rarely defined in time, it upsets the client on at least three levels in terms of temporality, identity, and changes in values. EMDR therapy appears relevant in the approach it proposes: it not only reduces reactive symptoms (depressive, anxious, post-traumatic) but can repair fractures in terms of identity and temporality. The EMDR therapist can thus work on optimistic projections, remobilise the individual in their daily life and give hope of a way out of the unbearable powerlessness imposed by cancer. Moreover, the idea is to help the client grow from this ordeal (post-traumatic growth), which allows them to access a new understanding of their world and of themselves, in an ultimately spiritual and deeply resilient dynamic. For her part, Dolores Mosquera, from Spain, described the application of EMDR therapy to the treatment of women who have experienced domestic violence. Domestic violence causes many upheavals, not only because of the disturbing emotions that are experienced, but also and in particular, because of the internalisation of inappropriate response models. In other words, the domestic violence survivor then more or less consciously repeats a dysfunctional behaviour that has been learned. To this may be added certain cultural beliefs that are unfortunately still very much in vogue (“It is better for children to grow up in a family with a father and a mother, even if ‘things happen’ sometimes” or “If a man controls you, it is because he loves you”). The consequences for the woman experiencing domestic violence are numerous, among them: blocking of emotions (fear, shame, guilt, and sorrow for the partner), ambivalence or difficulties to protect oneself and to set boundaries. These emotional blocks lead to inappropriate responses that need to be identified in therapy. Identifying these difficulties in the client allows the therapist to define strategies for client’s stabilisation, the extent of her resources, but above all to assess whether sufficient adaptive information is available. When there are many distortions, the processing of the trauma often remains blocked (due to the impossibility of connecting to adaptive information that is missing). As these clients have difficulties in feeling safe and ensuring their own safety, a strong therapeutic alliance will be absolutely necessary. The EMDR treatment plan will also depend on the client’s degree of awareness, which is a key element of the treatment, and whether she is ready to leave her partner, something that is eminently difficult due to the ambivalence and idealisation of women towards their partners.
Mosquera suggested the following steps:
1. Explore the risk factors and try to increase the client’s safety and protection as much as possible. Develop her social network and the ability to access it.
2. If the victim has to make important decisions, help her to assess the pros and cons of the situation, including the level of risk posed by each decision.
3. Assess responsiveness to problems, conflicts, and unexpected events. Address as necessary.
4. General psycho-education on gender-based violence.
5. Psycho-education on the difficulties presented by the client, including the link between her life history and the maladaptive learning of her current violent situation.
6. Self-care, improved functioning in daily life for the client and her children, if applicable.
7. Work on boundaries (emotional, physical, and psychological).
8. Work on emotions and defences (including self-regulation, to avoid relapses caused by emotional dependency and idealisation).
9. Work on trauma.Mosquera then proposed to organise to target memories in a chronological order, or if they are too numerous and similar (as is often the case), to work on them in clusters as follows:
1. Memories of situations of immediate risk for the woman and her loved ones;
2. Targets related to memories of powerlessness, physical violence, and abuse;
3. Intrusive thoughts, cognitions or memories;
4. Negative early childhood experiences related to the problem presented in each case.
In order to circumvent the ambivalence and idealisation that clients may present and which impede the successful application of the standard EMDR, Mosquera suggested that specific interventions be executed first by desensitising the experienced positive affects that are dysfunctionally stored, similarly to what may be done in addiction therapy. After that, realisation is possible and classical EMDR treatment may prove effective. If the MAM is a French and predominantly francophone seminar (although, this year, three of the twelve presentations were made in English), it also invites us to look at the practice of therapists around the world. Let’s cross the Mediterranean and go to Turkey. Berfin Bozkurt-Bayhan presented the volunteer work performed within the scope of EMDR-HAP (Humanitarian Assistance Programme) after the biggest mining disaster in Turkey, in which 301 miners lost their lives in 2014. She introduced the EMDR Group Protocol (EMDR-GP) that was applied to children who lost their fathers and to mothers who lost their husbands (Korkmazlar, et al., 2020; Bozkurt-Bayhan, et al., 2022). EMDR-GP, administered 18 months after the disaster, is a group protocol which can be applied to participants aged older than 6 years and includes 8 phases of the standard EMDR protocol. One of the details that makes this voluntary study interesting is that the field study was not carried out for research purposes at first, but it was carried out on a volunteer basis. Therefore, a research design was created after the group intervention. It can be said that the strength of this study was the case presentation and the evaluation of the drawings of safe place, desensitization phase, and resource installation. According to the results of this voluntary study, it was shown that SUD (Subjective Units of Disturbance) levels decreased significantly during the intervention, and trauma-focused scale scores decreased significantly one year after the intervention for both children and mothers. It can be said that working with trauma is a difficult process, especially when working in the field. In the presentation, Bozkurt-Bayhan touched on the subtleties of intervening in the trauma field. The importance of exchanging information with a local professional, preparing a manual that allows for a structured intervention program before going into the field, and going to the field as a team within the framework of an association or institution was emphasized. In addition, attention was drawn to the evaluation of the emotional state of the therapists, the planning of individual EMDR sessions if necessary, and the organisation of daily consultations during the field study. As working in the trauma field is a challenging process, it was recommended that the working time in the field be 4-5 days. Finally, it was emphasized that it was important to present a report to the next team when finally leaving the field.Opening up to the world is also an opportunity for clinicians to be inspired by other practices and to to share their experience with others. This is the case of Joanic Masson, from France, who presented how he combines EMDR psychotherapy with acupressure from Traditional Chinese Medicine (TCM), a medicine practice that is over 5000 years old. Rather than performing SBL in the traditional way, Masson stimulates different acupressure points chosen according to the disorders presented by the patient. For example, point 40 Stomach (Feng Long), which is located on the outside of the thigh, can be used to facilitate the regulation of sadness and the release of the throat, in accordance with Chinese nomenclature, which maps the body not only by organs and bones as does Western medicine, but to which it adds, among other things, the meridians, which are the privileged channels through which energy (Qi) flows. Each meridian is associated with pairs of organs that have energetic, emotional, psychological, physiological functions, etc. However, Masson’s presentation went further than the presentation of a clinical practice. He proposed to compare the EMDR psychotherapy model as we conceptualise it today with the TCM model. Firstly, because EMDR considers the need to integrate all aspects of experience in treatment, since emotions cannot be dissociated from the body, which is a fundamental postulate of TCM. Secondly, because the EMDR therapist in phase 4 is in a state that can be called “focused mindfulness” where they observe by being fully present to and mindful of the client (as brilliantly explained by Eva Zimmermann and Olivier Piedfort-Marin) and to themselves, and let the process happen. This implies that the process is self-organised spontaneously, perhaps sometimes unconsciously, in a way that is similar to that found in a hypnotic state – in short something akin to letting go. This “letting go” is in fact another fundamental concept of TCM, taken from Taoism: non-action (Wu Wei). In a few words, non-action is in no way inaction, but rather the ability to detach oneself from doing, from control, in order to let go. Paradoxically, it is thus an eminently active posture, but one that allows the body to do what it needs to do to regain its balance. This understanding by Joanic Masson allows us a beautiful transition. The challenge for EMDR today is not only to evolve in its clinical practice, but also in a new epistemological perspective.
By definition, epistemology is the study of scientific knowledge. EMDR is today a true epistemological object, because it has been a revolution in the field of psychotherapy and psychopathology. This is the context in which Cyril Tarquinio set the MAM’s first presentation of MAM, in which he addressed the clinical, theoretical, and moral considerations since the death of Francine Shapiro. EMDR therapy today is no longer limited to PTSD, it raises many questions about what psychotherapy is and how to understand the processes involved. Firstly, because EMDR is still poorly understood. It is mainly explained through the AIP model, which is more of a working hypothesis for the clinician, although very relevant and useful, rather than a scientifically valid model. The only other models that allow us to understand the processes at play are in neurology, which is both necessary and regrettable, because they limit the exercise of therapy to the use of bilateral stimulations or the exact application of the standard EMDR protocol, which seems to be far removed from the complexities of clinical practice. We lack a psychological theory. At present, only the theory of structural dissociation of the personality, as proposed by Piedfort-Marin in his presentation, could address this lack. Today, we should no longer think of science as being off the ground with rigorous methodological designs that are too refined and far from the complexity of clinical realities. Science without conscience is but the ruin of the soul, said Rabelais. The challenge today is to grasp all the numerous parameters that intervene in parallel and are in perpetual motion, and that we still have difficulty identifying in order to truly grasp what is at stake during EMDR practice. It is in this perspective that a research project, presented by Juliette Machado, from France, was born in the hope of being part of this dynamic, the DETECT-EMDR project (“The therapist’s dimension in the effectiveness of EMDR treatment of simple trauma: the forgotten dimension?”) It was a question of starting from this epistemological postulate but also from a clinical observation, that few therapists strictly apply the standard EMDR protocol in their daily practice. However, it is clear that they obtain results, even though academic research shows that it is the strict application that 22ESTD Newsletter Volume 11 Number 3, December 2021 is the key! It follows that we might as well seize this paradox. The challenge was to consider the practice of EMDR as a professional situation and to study it as such, with methodologies borrowed from study of clinical practice. Indeed, it is well known in the field of professional psychology that workers never limit themselves to their job description, they take more or less freedom to be as close as possible to what they need to do. The same applies to therapists who adjust and adapt to the complexity of their clients, which can lead them to stray far from the guidelines set out by Francine Shapiro. By filming all the sessions, these two conditions were compared: a group of therapists who were asked to treat their patients strictly according to the standard protocol (strict group), and another group whose only instruction was to treat their patients “as they usually do” (free group). Among the different analyses carried out, let us retain the most original one: subjecting the therapist to the self-confrontation device, a device borrowed from the observational analysis of work activity. The therapist is invited to watch the video of their practice and comment on what they see themselves doing. Accompanied by the researcher, the aim is to make the therapist’s practice more aware in order to approach what we call the “difficult to say” (“at that moment I made this choice for my patient, but I don’t know why I did it, I sensed it that way”). Preliminary results were presented and already point to interesting observations: all therapists globally apply the protocol, including those who are free not to do so, although the latter have a more flexible practice, especially for phase 3. However, the protocol is always present as a red wire and the global steps are respected. It is in the application within the phases that differences are observed. Moreover, the way in which the protocol is experienced seems to differ from one group to another. The emotional commitment of the therapist is different according to the place they give to the technique in their work, but this observation seems to depend on the confidence that the therapist has in themselves, but also on the psychopathological complexity of the client and the type of target to treat. However, the protocol is very clear, and for both groups, how it interferes with the therapeutic relationship. The more the therapist describes themselves as close to their technique, the less they feel connected to their client, and vice versa. More detailed analyses are needed, but these observations invite us to open up the field of research in a different way and to grasp certain dimensions that are sometimes put aside. For example, it is the sensory that takes precedence when approaching this “difficult to say”. Therapists feel a connection, without being able to explain why. The implications for research but also for the training of future therapists are promising. Where it will be possible to map, as far as possible, the therapist’s representational universe as a key element in the effectiveness of EMDR.Jenny Ann Rydberg, from France, pursued this epistemological questioning when describing the course of her doctoral thesis, which asks: “What would EMDR therapy be without its jargon?” Rydberg illustrated the evolution of a doctoral candidate’s thinking while working on their thesis, from initial hypotheses to ever-changing nuances built on the evolution both of one’s own thinking and relevant publications in the field (scientific publishing is not put on hold to give us the time and opportunity to demonstrate and publish our original ideas!). The presentation addressed the question of EMDR therapy’s status as an integrative psychotherapy as well as the relevance of the ever-increasing number of EMDR special protocols, claiming to address the specific needs of different populations, outcome goals, and contexts. Rydberg then moved on to the most recent relevant developments in the field that attempt to address the issue of the future of EMDR therapy, including presentations by Michael Hase and Peter Liebermann at the EMDR Europe conference in June 2021, and the November 2021 article by the Council of Scholars’ (Future of EMDR Therapy Project) “What is EMDR?” article published in the Journal of EMDR Practice and Research. These most recent developments seem to show that EMDR therapy is destined to be regarded as an integrative psychotherapy approach; formulated in a manner based on terminological, conceptual, theoretical, and epistemological clarifications; situated within a broad field of psychotherapies with common ancestors; where EMDR therapy consists of the characteristic and idiosyncratic assembly of certain elements common to several psychotherapies, with guidelines for adaptations under the form of standard variations. It remains for the field to define the boundaries of what constitutes EMDR, perhaps in the form of concentric circles.In another register, but one that has proved to be more topical than ever, Alix Lavandier, also from France, continued this epistemological reasoning by addressing EMDR therapy in an integrative protocol, the TIM-E protocol, using virtual reality in particular. In the Cronos CPTSD project (the TIM-E protocol: Understanding and functioning of a new integrative protocol for adults suffering from Complex Post Traumatic Stress Disorder), the idea is to start from a clinical observation, the difficulty of dealing with CPTSD, and to propose to understand the functioning of the TIM-E protocol, which has provided encouraging initial results on the symptoms of this disorder. The TIM-E protocol (Temporalist Investigation Model & Experiencing, Dieu and ARCA, 2016) proposes that people focus on temporality by using time as the main variable. The TIM-E model is inspired by and uses different already-existing models and concepts: the temporal perspective (Zimbardo, 1999), AIP, the social learning model (Bandura, 1980) and the Good Life Model (Ward, 2002). The TIM-E protocol is divided into 9 individual sessions (with virtual reality with a temporal perspective, cognitive distancing exercises, exercises on basic needs), 9 group sessions (development of interpersonal skills, construction of temporal identity, cognitive distancing, work on erroneous cognitions) and EMDR sessions. The methodology of this doctoral research was designed in relation to other research already underway on EMDR therapy and should provide data, particularly on the temporal perspective, the therapeutic alliance, and psychological flexibility in the management of CPTSD using EMDR. The aim is to come as close as possible to what is done in current care practice. The interest of this research is therefore both clinical and scientific: Clinicians are therefore confronted with many difficulties in the treatment of CPTSD and research does not always reflect this clinical complexity. This work is intended to test the effect of the TIM- E protocol and also to understand how it works.
Finally, let us finish this overview of the 10th MAM by taking a step back into clinical practice and allowing scholars to meet clinicians. Ad de Jongh, from the Netherlands, took us on a journey between past, present and future. After a brief history of EMDR therapy, he questioned EMDR therapy on several points, in particular: how does EMDR work? How can eye movements allow the emotional discharge of negatively encoded memories? He reminded participants of the teachings of Francine Shapiro. By targeting the memory of the event (thoughts, sounds, images, sensations, emotions, beliefs, in short, everything that was encoded at the time of the event) and by stimulating “the information processing system”, this memory transmutes along the processing system into an adapted memory network. As a result, this memory and the components of the memory change.Research seems to show that performing eye movements, while keeping the targeted memory in mind, works best to degrade the memory in question. The speed of the eye movements is of great importance. The more and faster the movements, the better for the client, but the movements do not have to be horizontal. According to De Jongh, this is a myth in EMDR therapy. Vertical movements would work better, he claimed. Shapiro, by the way, initially mentioned diagonal movements. In the studies presented by De Jongh, there is no difference in effect between horizontal or vertical eye movements. It would follow that it is not so much the bilaterality that is important for the degradation of the traumatic memory, but the fact that the targeted memory is kept in mind and sufficiently activated during the process, otherwise the eye movements would be useless. De Jongh also strongly emphasised that eye movements are not the only effective task. Horizontal or vertical eye movements work, but auditory or drawing tasks also help to reduce the emotional load and thus the complete processing of disturbing memories. Eye movements and all dual attention tasks produce comparable effects. According to De Jongh, all these studies indicate that it is better to use the term “lateral eye movements” and not “bilateral stimulation”. Thus, it is the working memory hypothesis that he favours as the operating model of EMDR. The evocation of a memory brings the memory back into short-term memory, and if a second task is requested during this recall, the emotional charge of the memory will diminish and it can then be reconsolidated in long-term memory in a different way. We must add that the working memory model does not explain everything that is observed in EMDR therapy and that other mechanisms probably also play a role. However, the working memory theory helps to understand why EMDR may not always work, for example where the emotional charge of the memory is too low or the simultaneous task is not sufficient. After Tarquinio’s presentation on the application of EMDR therapy to cancer patients, Sarah Carletto, from Italy, presented clinical and neurobiological evidence of EMDR therapy in cancer patients. In the first part, she discussed the studies on the relationship between cancer and psychological distress. She drew attention to the fact that depression and anxiety are better known in the relationship between psychological distress and cancer, but that there are few studies on psychological interventions for PTSD in medical patients. According to the results of studies conducted with cancer patients, EMDR can be a potentially effective treatment for psychological distress in cancer patients. In the second part of the presentation, Carletto included neurobiological studies showing that the same brain structures play a role in non-oncologic PTSD and psycho-oncologic cases (in particular intrusive symptoms) (Carletto & Pagani, 2016). In the latest study by Carletto et al. (2019), it was shown that there was a significant decrease in depression and PTSD symptoms in cancer patients receiving EMDR therapy. Another important result is that activation was observed in the left angular gyrus and right fusiform gyrus regions in patients who had EMDR therapy when compared with the treatment-as-usual (TAU) according to the EEG results. Therefore, activation of these regions with EMDR therapy facilitates the contextualisation and reprocessing of the traumatic event by providing the activation from the limbic regions involved in emotional states to the cortical regions. All these studies raise new research questions about psychological distress in cancer patients. Finally, the difficulty of identifying the single traumatic stressor, the fact that the situation is an ongoing stressor, intrusive symptoms are future oriented, and the re-experiencing criterion that is associated with the risk of recurrence of the symptoms are important factors for the enrichment of clinical studies on cancer.
“Documenting your outcomes and sharing it is ‘research.’ Research is not just about proving to others. It is a way to guide each one of us to establish the best practices. It is about staying on the right road”. Shapiro.The MAM hopes to contribute to this research, dynamic, engaging in discussions and bringing together neurology, epistemology and clinical practice. We look forward to seeing you in 2022 for MAM#11!
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