What is EMDR? Part 2

Do you want to learn about psychological growth without sorting through the jargon? You're in the right place. This is the Relational Psych podcast. I'm your host licensed therapist, Tyson Conner. On this show, we learn about the processes and theories behind personal growth and experience a little bit of it ourselves. Join me twice a month for candid conversations about therapy and psychological concepts with real mental health professionals using understandable language and simple experiments that you can try yourself. Keep in mind this podcast does not constitute therapeutic advice, but we might help you find some. And today, we are continuing our conversation of What is EMDR with Dr. Olivia Painter. Dr. Painter is a postdoctoral resident here at Relational Psych, one of my coworkers, and also an adjunct professor at Azusa Pacific where she teaches...

Multiple different classes for undergraduate psychology.

Great. So if you're thinking - if you're a high school seniors are looking for a place to go to school. Consider Azusa Pacific.

Yeah. Or a non traditional student too.

Oh, yeah, that's true! Or, you know, just looking for something to do in all your free time, that I'm sure you've got. Today, we are continuing our conversation answering the question What is EMDR? Last time we covered very broadly, what EMDR is, and how it works. And we started talking through the eight phases of EMDR. And we made it through the first four. So we're going to pick up with-- if you haven't listened to that episode, Listener, stop. Go listen to that first. We explained a lot of the basics in there that you'll want to know for this episode. We won't be re-explaining things if they come up the second time, most likely. So please do listen to that first. Otherwise, this whole conversation won't make sense. And because EMDR is a trauma focused treatment, our conversation today will include some discussions about trauma. We won't go into nitty gritty details, we won't be graphic about it. But if you are sensitive to traumas, some of the sorts of traumas we've talked about in the last episode- might continue using today - are car accidents, family related trauma, medical trauma, religious trauma. So be aware that this conversation will be talking about those things. So if you're especially sensitive to any of those, be kind to yourself, whether you choose to listen to this episode or not. Okay, before we dive back into Phase Five, of EMDR. Any preliminary thoughts or comments, Dr. Painter?

No, I think you about covered it all.

Awesome. Well, let's pick up with Phase Five, what's Phase Five?

So Phase Five is our installation phase. And so this comes after phase four, which is our desensitization phase. So at this point with your therapist, you've worked on clearing out some of the distress associated with the trauma that you experienced. And what we're now trying to reinstall is the positive cognition that we earlier identified at the beginning, or in phase two. So at this point, what you're doing is you'd still be partaking in the bilateral stimulation or the buzzers, butterfly taps. In this point, you are repeating positive cognition to yourself - the belief that you'd like to have about yourself now.

Okay. So during the previous phases, you use the bilateral stimulation to access the trauma in ways that would be less overwhelming. And now in this phase, you're using that same stimulation to like, Inception-style place in different narratives and thoughts about about the trauma?

Right. So the only difference -- the movement is similar that you're using, but it's at a slower rate. So you're reinstalling a positive memory to take place of that negative memory that you had just cleared out.

Interesting. What why a slower rate?

It has to deal with the eye movement and just how we process.

Interesting, like, accessing the trauma, the movement and the process is just a little quicker, but working in and installing something new, the process and the movement is a little bit slower.

Right. So if we're working on something that's more distressing or a negative cognition, we'd be going at a quicker rate. But when we reinstall something that's positive, it takes time for our mind and body to digest that new information, and so we're eliciting that.

What next?

Then we go into the body scan, which is our Phase 6. So once the positive memory is reinstalled, your therapist will check in, based off a set of rating scores to see where you'd rate that. And then to check in with your body to see if there's any type of experience, whether it's positive sensation, a neutral sensation, or sensation of distress. And depending on the response of the patient or the client, the therapist would then utilize the bilateral stimulation again, to either clear out the negative distress or to reinstall the positive experience that the client is feeling.

Interesting. So that sounds kind of like it's the once over before you like, tie it off.

Yes. So because trauma can be held in the body, that's what we're trying to pay attention to. Is there anything else that needs to be cleared out before we move on to the next memory? The next event?

Gotcha. So it's if- to use the analogy of like going on a trip - it's kind of like when you're on your way home from the hotel room, you probably pack everything up, load up in the car, and then maybe walk through the hotel room one more time before turning in your keys.

Yeah, that's a great analogy.

Gotcha. Cool. And then do you just repeat that? What happens next, what's the next stage?

So after you do the body scan, what you want to get to is the positive or neutral sensation experience in your body. At that point, once that's achieved, and your therapist asks again, for your rating scores, and you're at the point where you're able to move on to Phase 7, that's the closure phase. So depending on if a memory or an event was cleared out fully in session or not, the closure statement is a little bit different. But essentially, what you're doing is wrapping it up for the client before they leave the room. So if you didn't clear out all of the distress, and you still needed to work on it in next session, you would do like a transition technique. To help the client close out that session, there's a couple different options to choose from, but usually some type of guided imagery technique is utilized. Otherwise, if you did clear out all the distress and everything feels either neutral or positive within your body, your therapist would just remind you to note any new instances that came up for you. In the next week, whether it was distress or not, any parallels, new information, any dreams you might have, anything that can be brought back to therapy and processed again with your therapist. And then once that statement is completed, depending on time, of course and the end of the session, and you would go into the final stage, which is Phase 8, which is the reevaluation of the treatment effect. And so we call this like "future work." So any type of distress that any anxiety or fear that might pop up, if you were to encounter this situation, again, in the future.

Gotcha. So when you're working with someone and working through multiple different specific incidences of trauma, I imagine you don't do Phase 1 multiple times. Phase 1 happens once at the beginning. But which of these phases do you repeat as you're working your way through that timeline from most to least distressing.

So anytime that you're reprocessing the memory, so around Stage 3, once we have identified each of our clusters, in Stage 2, you'd work through each cluster with your client. And so that's going to include the reprocessing the desensitization, the installation, the body scan, the closure.

And since the listeners will have heard descriptions of some of those phases in the last episode, I think maybe we'll include just like a list or a link to a list of the eight phases in the show notes. So you can go in and review that and hopefully I will have remembered to put them in the previous episode as well because that's very helpful. Okay, so let's just talk about like, what a session would look like. I show up and I say, 'Dr. Painter, I would like me some EMDR. Can you give me some of that some of that stuff because I hear it's helpful.' What happens?

So typically with a client or a patient, I'd ask them what brings them in. Asking how they heard about EMDR, I think is always important, seeing what information they already know. From that, I typically like to show my clients a visual - I'm a visual learner so it's helpful to show a video, so they can kind of get a graphic idea of what bilateral stimulation looks like. People aren't often talking about bilateral stimulation in everyday conversation. So that's helpful to see. And then from there, we would do what we call history taking. And so this is going to include that trauma timeline that we would do in Phase 1 that we touched on last session, we would also include the clustering at that point too, once all of the trauma memories are identified.

Would you get through all of that in the first session? Is that common to be able to do a whole timeline and clustering?

For some clients, not often. Usually, that can take about three or four sessions? It depends on what the client is coming in for and what their trauma history is, and what they still consider to be distressing. So when you're creating the trauma timeline, it's what's distressing for me now as an adult, or as a child, currently. And we're rating each of those memories based off of how I feel now, when I recall that memory.

Right. Okay, cool.

And then from that, we would do the dissociation index together to talk about and discuss therapist and client, how to manage dissociation, if that were to come up in session, as well as outside of session, so we can be knowledgeable together of the frequency, or the rate that that happens for the individual. And then we do what's called our safe calm place protocol.

Right, which was the experiment that people could have done in last episode.

Yeah. So that's kind of that first process before you go into the following phases that you would do for then each memory going forward.

Gotcha. Okay, so that that's the list of stuff you do to get started. And that's the stuff that you only do once, and then the rest of the phases kind of repeat as needed.

Yep. So when you would do the reprocessing, this is where things can look a little bit different, that bilateral stimulation is when you follow your therapist's fingers back and forth, left and right. There's also buzzers that can be used, which you'd hold in your hand, so for some clients, that's really helpful. Especially if the trauma impacts the individual's body, or they have more of a psychosomatic experience of trauma, that can be really helpful. Or butterfly taps, or knee taps, where the client would be tapping themselves. As you, the therapist, would guide them through the process.

Gotcha.

So that's what reprocessing looks like. Typically, a session can be 45 to 50 minutes, some clinicians prefer to go longer. I've heard of some people going up to around the two hour mark, depending on the work that they do. I think that is just individual preference.

And that that happens in a lot of different modalities. I've noticed, like the 45 to 50 minutes kind of seems to be pretty standard for a lot of psychotherapy. There are some people who do shorter sessions, kind of famously who are outside of EMDR. But it sounds like it's also decently common for people to offer longer sessions. But as you mentioned in the last episode, as well, sometimes if you're doing a reprocessing session, and someone just gets too flooded too soon, too overwhelmed, right? Then you can you can stop whenever you need to stop.

Exactly, yeah, you have the authority to stop at any point. And then from there, you'd work through the phases. And then at the end of each session, I think it's important for the clinician to check in about self care, with the client. What are you going to do for yourself, that you can take care of your body and your mind today? As well as what do you look forward to the coming weekend.

Right. Because as with any sort of trauma oriented treatment, it's going to be distressing, you're going to experience distress in your body and in your mind, and having a plan for what to do about that-- you know, you don't want to stir up someone's emotions and just throw it back into the world with no sense of how to land.

We want to care for ourselves too.

Absolutely. Cool. So, what might make somebody a good fit for EMDR? If someone's listening to this, a listener, and it's like, 'oh, this sounds really interesting. I might be into that.' What are some some indications that EMDR might be a helpful modality for somebody.

So typically what's most common, people come in for PTSD? Or CPTSD - Complex?

Ooh, yes. Let's talk about that. Let's slow down about that a little bit. I did this a lot last episode, and I haven't done that much this episode I've been noticing. Largely because we're just saying stuff we explained last time. But PTSD, most people are familiar with that acronym, post traumatic stress disorder. Breaking it down even slower post traumatic means after the trauma, stress disorder, meaning after you've had a trauma, you are stressed out, and it causes trouble. That's what PTSD means. When we think about PTSD, in like, pop culture, we generally tend to think about things like combat veterans, or people who've experienced violent assaults, that sort of thing. And PTSD can be caused by those things, and can also be caused by really any incident that's traumatic. And trauma is an experience that your mind doesn't know how to make sense of. So it kind of gets stuck in the brain and causes trouble. CPTSD is a bit of a more recent category, I suppose, just like in the past, what five years really, it's taken off? When we're recording this in 2022, so you know, do the math Listener. And the C in CPTSD stands for complex. Basically, what it came from was trauma treatment -- people.. traum- traumatologist! People who study trauma and treat trauma, were noticing that the theory of trauma that we had, we talked about this a little bit last episode too - the theory of the trauma that we had was very distinct. There was one trauma, and that's what you worked through. And sometimes that happens, sometimes there is an accident, an event a terrorfull - uh - a terror, terror-full thing, ha, that you need to work through, and then you work through it, it's over. And then sometimes you have these prolonged, complicated cycles of events and sequences of events. Maybe you didn't have a violent person in your home who did violent things to you one time then it stopped. Maybe you had an emotionally violent person in your home who said very hurtful and cruel things to you. And then eventually, it stopped after decades, right? The first immediate incidences of big trauma, probably get diagnosed with PTSD, you would process those immediate big incidents. For the subtler, more long form, more complex things, you get diagnosed with that complex PTSD. And my understanding is that complex PTSD often has very powerful interpersonal elements to it. CPSTD is usually associated when the trauma is related to intimate relationships, partners, parents, children, those sorts of things.

Yeah, and I think the difference between PTSD and CPTSD as we're looking at an acute event, versus like an event, like you said, that happens repeatedly over time,

Right, like PTSD is about a thing that happened. And CPTSD is about a way things were.

Yeah, exactly.

Cool. Alright, anyway. So if you have either of those things, then hey, EMDR might be good for you.

We also see people come in a lot for panic, or anxiety. That is also common. There are therapists who also specialize in -- so not only do they specialize in EMDR, but in-specialize in EMDR. So you can get your specialization, for example, in substance use for EMDR. There's like specific protocol for it. Or EMDR for depression, or -- there's different kinds of subsets for working with children, specifically.

Interesting.

There's training and work you can do to in those interest areas.

Have you done any thing like that?

I have some experience doing group therapy EMDR. So that's, that's unique.

How do you do -- Like, what's different when you're with a group versus when you're with an individual person?

Obviously, confidentiality is important in a group setting. And so instead of doing it verbally, the processes are still the same. The phases are still the same. You'd have, though, the clients draw pictures instead. And then you're making sure as the clinician: are those images changing? Opposed to, are those words or memories changing? So that way you can do it with a group of people, they don't have to share their experience with the other members if they don't want to. So they're monitoring it more for themselves, but you're still guiding them through the process.

Fascinating. Wow. Cool.

That's an option too. And then yeah, so I think with that, any type of trauma is usually what people assume EMDR is associated with, but really EMDR can cover a lot of different things. You're not a good fit, though, if you have high rates of suicidal ideation, currently, when you're partaking in this work.

So is that because EMDR stirs up so many of those sort of old, panicked feelings? That if you have high rates of suicidal ideation going into it and might make it worse?

Yeah, we want to make sure that you have coping skills, because distress is going to come up. But we want to make sure that we can cope with that distress. We also want to be mindful of high dissociation, which is why we do that index, initially, similar to like, the suicidal ideation - just to make sure that the client is able to be present in the work that they're doing. Otherwise, it wouldn't be beneficial for them. Also, any type of TBI might rule someone out for doing EMDR.

And just to clarify, because I'm realizing I don't think we defined dissociation last time. So let's define both of those categories, dissociation and TBI. So let's start with dissociation. That's pretty important. Dissociation is when something really overwhelming happens to a person, and they kind of mentally 'check out.' There are bunches of different ways of doing it, there's a bunch of different ways that it shows up. The sort of 'classic' version is if you can imagine like, a scene from a movie after there's been like a major catastrophe of some sort of building that caught on fire. And you have some people who were inside the building, and they're sitting in the back of the ambulance, and they're wrapped in the blanket with that blank stare, just staring off into nothingness, right? That's a form of dissociation, where people just sort of blank out. Really high levels of dissociation can sometimes come with, like, losing track of memories, like not realizing what's going on, and not coding memories, losing time. Sometimes people dissociate by daydreaming, or like going into another world in their head. Sometimes people dissociate in ways where they like, will actually go through the motions of their daily life, but then they won't remember any of it because neurologically their brain's just like disconnecting from the rest of what's happening. And because EMDR is about reconnecting to traumas, if you have high rates of dissociation, you're encouraged to maybe find ways to stay close to your experience so that when the trauma experiences come back up, you're not just like, 'pew,' out of there.

Yes.

Did I miss anything?

That was great! I think when I talk with my patients, a lot of it is like the difference between derealization and depersonalization. So thinking about like, okay, derealization is, 'I don't feel like I'm in reality,' which I think fits with several of your examples. And then versus depersonalization. Which is like, 'I don't feel like I'm present in my body right now.' So, which matches some of those other experiences. And so oftentimes, people can find themselves fitting in one of those camps, or sometimes even both.

Yeah, yeah. And then TBI. TBI stands for traumatic brain injury. We hear about TBIs a lot when we're talking about football players, right? Or people who have been in car accidents or people who've been in combat. TBI is really common in those situations. And like a concussion is also a form of a TBI. A TBI is anytime your brain gets jostled and has an injury to it. When the brain has an injury to it, your neurons adapt, but it also means that they behave differently and sometimes unpredictably. And since EMDR, is a modality that's so neurologically oriented and tries to use predictable neurological patterns, if something has happened to your brain, where your neurological patterns might be less predictable. It might be risky to use this approach.

Yeah, exactly.

If someone has had a concussion when they were playing basketball in like, high school or something, is that something that you talk about? Or would you say don't do it? Or...

I think it just depends on the individual. So, absolutely, I asked about it. For sure. It's like noted, usually in their intake paperwork. And then if I see something that's highlighted there, I'd follow up with the client, depending on if they received care after it or not, you know, might change the situation: if they were sent to the hospital, or they kind of just regained consciousness on the fields and are fine... I think it just depends on the individual.

Yeah, that makes sense. Cool.

And then also, any type of current substance use, we want to be conscious of too. So because that's something that can also impact our brain neurologically, similar to like the TBI, the work that might be done in EMDR might interrupt some of those processes.

How does that intersect with people who are doing EMDR concurrent with taking psychotropic medications? Is that that ever an issue? And, Listener, psychotropic medications just means meds for your brain. Does that ever cause trouble?

You know, that's a really good question. I think it depends probably on what the medication is, as well as what the individual struggles with. And what their dosage is too, you know, I think there's a lot of different influences. I don't know specifically the research on that, that'd be something I would need to look more into, like, what would be dangerous versus what wouldn't be. But I mean, if you're taking like an antidepressant or anti-anxiety medication, you can still do EMDR.

Gotcha. And what if you're having a little bit of marijuana everyday before bed?

Yeah, so I think that's something I always ask clients about is like, well, what is your rate of use? And why are we using it? In the way that our dreams can change because of EMDR, we might experience different type of hallucinations, or have maybe more psychotic experiences if we're using a substance that maybe we haven't had before.

Interesting. Good to know. So it's not like it's a'don't do EMDR at all, if you regularly use recreational substances,' but have that conversation with your provider, so that you're aware of the risks.

Right. And if you are someone who's using substances regularly, maybe consider seeing someone who specializes in EMDR and has specialized training in substance use.

Gotcha. Cool. Awesome. Well, with all this in mind, let's say, again, that hypothetical listener is like,'Yeah, this is my jam. I am a good fit. These are why I'm a good fit. I don't fall into all the bad fit options.' How do we find an EMDR therapist? I mean, I got one sitting right across from me.

Haha yeah, come see me! You want to make sure you see someone who's certified EMDR, that's really important. You know, unfortunately, I've heard from other clients they thought the person was certified. Make sure when you're the client, you're asking to see that - there should be a certificate, essentially, kind of like a diploma, any type of degree the therapist would attain. Maybe it's hanging on their wall, or maybe they have it in their desk, but they should have that.

So if I'm looking for an EMDR therapist, is it, like, what do I ask? Like, if I say to someone, 'are you trained in EMDR?' They could say yes, if they took a 30 minute online slideshow training about EMDR. But if I say, 'Are you certified in EMDR, that means something different?'

Right. And there's four levels of certification that a therapist can receive. You need just Phase 1 to be able to practice with clients. So you don't have to necessarily ask what certification you are, unless maybe you're curious. But you do want to make sure that they're certified, that they didn't just watch a YouTube video and are doing this.

Yeah. So if you're uncertain and want to make sure that you're seeing someone who's been trained enough, then you can ask, 'Are you certified?' And then they'll say yes. And if you're still uncertain, you can say, 'What level are you?' And then they'll say, one most likely, or something higher. And if they say, you know, like, a zodiac sign in response to something - Gemini - that person's not doing EMDR.

And EMDRIA, the website we talked about last session, would be the one who's kind of the national certification. So most people go through an EMDria.org. If you want to look it up.

If we pulled that up, are you -- do have like a provider search and you're listed on there?

Yeah, the thing is, is some people get training-- so like I got trained at Texas Tech University, because that's where I was doing my hours at by someone who was a level three and a level four trained person. So they came to the institution and trained me. So on my certification, it has like the university emblem and information. So like, the certifications might look different across the board. But that is the National Board of EMDR.

And everyone who's certified in EMDR, in the US will have a listing profile, like their name on that website?

The only exception that might be is if you're not a licensed therapist yet. Because you can be a Phase 1 trained certified EMDR therapist without being licensed. Once you are a licensed therapist, then you move up to level two. So that might be the only thing if like you're an MFT, or master's level, or even postdoc may not be listed.

Yeah. And, Listener, there is another episode that you could find of this podcast where we talk about different levels of licensure. But basically, what we're saying is that there are some people who might be trained in EMDR, who aren't listed on that website, because they haven't gone through their trial periods, basically. They're fully trained, they're fully functional and highly competent and capable therapists. But there's a certain amount of time that you need to be a competent, capable therapist in the eyes of the state, before you're considered fully licensed. So sometimes people are in that in-between spot.

Yeah, exactly.

Great. Any other recommendations for how to find an EMDR therapist?

You can look also through Psychology Today. That's a great option. And you can go into your search criteria, and check off the box for EMDR. And it will pull up providers who are certified or listed that that's a specialty of theirs. Also, your insurance provider can provide you a list of who takes your insurance and providers may offer EMDR through that as well.

Yeah, and the one caveat there that I'd give is that both insurance listings and Psychology Today, Good Therapy-- what else is our Therapy Nest? Is that another one -- these sites that list therapist profiles. Those are all self identified. So nearly anyone, any therapists can create a profile and can click whatever specialties they want. So hopefully, people are being honest. And to make sure you're really getting EMDR - going back to the EMDRia.org - search that listing, or when you first contact them, ask them if they're certified? Is there anything that we didn't talk about about EMDR that you want to make sure to share with the people?

I don't think so. I think we hit everything. I think reminding clients like this can be for any age. So you could be two years old and receiving EMDR all the way up to in your 90s. The process might look a little bit different depending on needs and ability status, but it's an option for for all people.

Yeah. One of the things that, I was in a training recently with this guy named Daniel Shaw, who's a fascinating dude. And he writes some cool stuff. And what's interesting about him is that, you know, he's this like, relational psychoanalyst guy. So you know, that's why I'm there. But he's taken a lot of trainings in like EMDR, and TF-CBT, and DBT. And like he's been trained up to, I think he's only level one with EMDR. But like, he doesn't use those modalities, he uses relational psychoanalysis. But one of the things that he said was, what's great about these sorts of trauma oriented modalities is that they assume that the client has this innate, sort of born into them, healing capacity, that like you, Listener, have all the healing you need inside of you. And then the role of the therapist is to help you access it. Instead of the therapist being this person who you know, descends from the heavens and brings you healing from somewhere outside of you. The therapist becomes someone who moves with you, through your own journey inside to find that source of healing and health that's already there. Which I think is really neat.

I love that. Yeah, I think that's important. And I tell that to my clients each time like, 'I'm only guiding you through this process. This is all you. You know know what you know, and you also know what you don't know. Right?' Interesting to explore together.

Cool. Great. Well, thank you for coming on to the podcast again, for dividing it into two episodes, do you have plugs, further learning, or an experiment for the people today?

Something that might be helpful for people they can practice -- Obviously, they can't do eye movement desensitization on themselves. But something that might feel helpful if you are noticing yourself feeling distressed, you can do bilateral stimulation butterfly to yourself or on your knees. And so if you find yourself outside of session, or even just experiencing distress, doing that rapid eye movement kind of stimulation might help you lower your distress too. So that might be something that can be practiced.

So we'll include a link in the in the show notes to directions on how to do butterfly taps. That sounds like a great experiment. And what about further learning? Do you have any recommendations?

Yeah, I think last time we talked about EMDRIA and the different trainings or information that's there. So circling back to that, I think is important. If you're a therapist, and you're listening to this, and you are interested in any of these things, you can also find trainings enslisted if you're wanting to help clients and clients can also use website to find therapist. So, it works both ways.

Yes, absolutely. All right. Great! Thank you.

Yay!

Special thanks to Dr. Olivia Painter, Dr. Painter can be found at Relational Psych. In the shownotes, you will find links to a simple one sheet explanation for the butterfly taps coping skill of bilateral stimulation that they use in EMDR, as well as links to EDMRIA.org for further learning. The Relational Psych Podcast is a production of Relational Psych, a mental health clinic providing depth oriented psychotherapy and psychological testing in person in Seattle and virtually throughout Washington state. If you are interested in psychotherapy or psychological testing for yourself or a family member, links to our contact information are in the show notes. If you're a psychotherapist and would like to be a guest on the show or a listener with a suggestion for someone you'd like us to interview, you can contact me at podcast@relationalpsych.group. The Relational Psych podcast is hosted and produced by me, Tyson Conner, Carly Claney is our executive producer with technical support by Sam Claney and Ally Raye. Our music is by Ben Lewis. We love you, buddy.