EMDR for Trauma: Eye Movement Desensitization and Reprocessing
In EMDR for Trauma: Eye Movement Desensitization and Reprocessing, Dr. Francine Shapiro demonstrates her approach to working with clients still experiencing the effects of past traumatic experiences. EMDR is an integrative psychotherapy designated by the American Psychiatric Association as highly effective and empirically supported. The approach is based on an information-processing model of pathology, directly addressing the stored memories of events that cause clinical complaints, the present situations that are disturbing, and experiences necessary for appropriate future functioning. In this session, Dr. Shapiro works with a 42-year-old retired police officer who is having panic attacks. She uses EMDR to help the client process the images, emotions, feelings, and thoughts associated with his job-related trauma.
This video features a client portrayed by an actor on the basis of actual case material.
Matt entered treatment 6 months after he had retired from the police force, when his wife insisted that he obtain a job and seek psychological help or she was going to leave him. He told her he would get a job first and if that didn't help, he would seek treatment. He started work as a security guard, but 2 weeks later he felt as if his world were falling apart. He was having difficulty managing a job that under other circumstances he would see as a "no brainer." He had difficulty sleeping, had nightmares when he did sleep, and was subject to frequent panic attacks at work. At the end of those 2 weeks he was convinced that he needed help.
Matt's retirement from the police force's homicide division occurred after 24 years of dedicated, outstanding service. He had worked long hours throughout his career and took great pride in the cases that he had solved; however, he also felt relentless guilt for those cases to which he was assigned that went unsolved. Although he had always promised his wife he would retire after 20 years, it took the line-of-duty death of his partner to precipitate his leaving the force.
A third-generation Lithuanian, and the oldest of five children, Matt grew up with a father who was a police officer and a mother who worked at home raising the children. According to Matt, there "was never enough money," as his father had a penchant for drinking and gambling (e.g., playing the numbers), but he was a happy drunk and generous whenever his number paid off. Matt's father had not wanted Matt to become a police officer because of the danger and the relatively low pay. When Matt graduated from high school, they struck a bargain that Matt would go to college for 2 years. If, after that, he wanted to join the police force, his father promised to support the decision. However, his father died of a sudden heart attack the summer after Matt graduated from high school. Matt decided to join the police force immediately, at age 18.
Matt married his wife, Lucy, 2 years after joining the force, and 2 years later they had the first of their two daughters. Matt started as a patrolman, like his father. He was nervous on entering the force and was grateful when he was assigned a partner, John, several years his senior, who took him under his wing, taught him what was important on the job and what was not, and socialized with him after hours. Matt idealized John for their first 2 years as partners; John's only fault seemed to be his prejudice against Hispanics, who formed a large proportion of the population on their beat.
One night Matt and John responded to a breaking-and-entering call from a house in a wealthy neighborhood. They apprehended a young Hispanic male scaling the fence around the swimming pool, his pockets filled with jewelry. John pinned down the suspect, then handcuffed him and led him to the fence. Matt went to radio for help. Before Matt got to the patrol car, he heard a gunshot. He hesitated for a moment before turning back, and when he heard a second shot he radioed quickly and ran back. The prisoner lay face down, 50 feet from the swimming pool, with a bullet in his back.
Matt's first feeling was relief that it was the prisoner, not his partner, who was dead. But his second thought was a more suspicious one: His last memory was of John handcuffing the prisoner; how did the prisoner end up dead? Matt turned to John, who looked oddly unemotional given what had just occurred. "What the hell happened?" asked Matt.
"I was handcuffing him to the fence," John said, "and the son of a bitch broke free and ran. I shouted for him to stop but he didn't so I shot a warning. He kept running, so I fired at him. I didn't mean to kill him, man, only to stop him. Jesus, I'm going to catch hell for this one."
Something about the way John avoided looking at him made Matt feel sick. If the man hadn't been Hispanic, Matt thought, maybe he would still be alive. Matt continued to work with John for the next several weeks but found he could no longer talk or joke with him. He finally asked John to request a change in partners. The fact that John agreed to do this without question seemed to confirm Matt's worst fears about John. Matt never told anyone about the shooting incident, and, when questioned by Internal Affairs, he did not share his suspicions with them, although he later felt guilty for not speaking.
Soon after, Matt decided to do what was needed to become a homicide detective. He wanted "to be part of the solution," he told his wife Lucy, "instead of part of the problem." His devotion to this new aspiration kept him away from home even more, but Lucy was understanding, despite just having had a second child. He was doing it in part, they both thought, so that their financial future would be brighter.
A few years later, Matt was assigned to the homicide division, where he was highly successful. His rate of solving murders was above average, in part due to his working many hours overtime, always going the extra mile to find the perpetrator of what would prove to be many heinous crimes. With two young daughters to care for, Lucy was less understanding of his absences from home. She was, however, proud of his success and the fact that when he was home, he spent as much time as possible with their daughters. Whenever Lucy would complain, Matt would promise that he would retire as soon as he had worked 20 years. When 20 years came and went, and he was still working overtime, their marriage became extremely strained. Both daughters were in college, and Matt used this as a reason for not retiring: Now more than ever, they needed the money.
Lucy suggested that she take a full-time job as manager of the retail store where she had worked part time since their daughters were in high school. That way, Matt could afford to retire. When Matt refused to even consider this, Lucy told him that she would work full time if she wanted to, since he had always done what he wanted.
After an initial tense period, Lucy's new job actually seemed to decrease tension in the house; her self-esteem grew as her success as manager was confirmed. She no longer complained about Matt's long hours on the job.
In his 21st year on the force, Matt was assigned a new partner, Sam, who was younger than Matt but who had been a successful homicide detective on the East Coast; his specialty had been organized crime. Matt had never met such a bright, effective, but friendly detective. Sam encouraged Matt to work fewer hours on the job, suggesting that if he learned to work "smarter" he wouldn't have to work longer. Together, their success rate was much higher than either had achieved with previous partners.
In May of Matt's last year on the force, he and Sam were working on a drug-related case, which was not unusual. What was unusual was Sam's intensity about this particular case. Sam seemed to see it as his case alone, and he kept Matt in the dark about certain information, about which Matt would learn a few days later. They argued about this, which was also unusual. One night, Sam, acting alone and without telling Matt, set up a sting operation that went bad. His bludgeoned body was found floating in the river the next day. Matt insisted on seeing Sam's corpse in the morgue. Even after all his years of seeing dead bodies, he left the morgue vomiting.
Thereafter, Matt became extremely depressed and contemplated suicide. Crying in bed, after he thought Lucy had gone to sleep, Matt heard her quietly say, "Matt, don't you think you've had enough, that we've had enough? Isn't it time for us to have a life?" These words seemed a miraculous solution to him, and he heard the option of retirement as if for the first time. His depression lifted; he felt like a new man. Within a month, he had retired with full benefits.
The honeymoon with retirement lasted only 2 weeks, however. Matt then became irritable and morose, and he focused his complaints on the amount of time Lucy worked. Even though she was away only 40 hours a week, it seemed much longer to him, and he began harassing her to quit her job. When she refused, they argued heatedly.
After these arguments, Matt would suddenly feel anxious for Lucy's safety and began insisting that he drive her to and from work. This relieved some anxiety and gave some structure to his day. But soon he began worrying about her safety on the job, and he would check on her multiple times during a day. At first tolerant, Lucy became embarrassed and angry as the frequency of his visits increased. That is when she finally told him that he needed to go to work and seek psychological help or she would move out.
He applied for a job in the K-Mart near his wife's store. She was not happy about his proximity, but at least he was occupied during the day. Matt, however, was surprised that he felt completely inadequate on the job. He couldn't think clearly or apply his police experience to the new situation. The store had a large Hispanic clientele, and he felt very uncomfortable when he suspected one of the Hispanic customers of shoplifting. Images of the long-forgotten Hispanic male his partner had shot came to him unbidden.
He began to have panic attacks, which he thought at first were heart attacks until that was ruled out. His sleep, never normal, became even worse, and he was usually up at 3:00 a.m., awakening from a nightmare in which Sam, looking physically like he did in the morgue, kept trying to say something that Matt could never make out in the dream. Matt was left only with the sense that if he could understand what his partner was saying, Sam would be alive today.
These dreams and day images were so vivid that Matt began to "worry that he was going crazy." His wife, seeing this, reminded him of his promise to get professional help. This time, he admitted that he could not do it by himself any longer. "Call any shrink you want," he said, "I'll go."
Lucy had called the Employee Assistance Program at the police force over a month earlier. They had recommended that Matt see Dr. Francine Shapiro, and Lucy called her immediately. Matt had an appointment within 48 hours.
- What is your impression of Matt?
- How typical or atypical are his life experiences and his current behavior?
- What do you believe are the core issues for Matt?
- What is the utility of these initial formulations?
- Before reading the next section, what topics and issues do you think will be addressed in the initial sessions?
Notes on Previous Sessions
Session 1: This 1 1/2 hour session was devoted to getting a history of the presenting problem and Matt's functioning to determine whether he was suitable for EMDR treatment: Level of disturbance, personal stability, and life constraints were evaluated. When suitability was ascertained, the remainder of the session was devoted to getting a complete clinical picture of his dysfunctional behaviors, symptoms, and characteristics that would need to be addressed in treatment.
Next, the specific targets that needed to be reprocessed were defined: the Hispanic prisoner's death involving his original partner, the mayhem Matt had witnessed in his years as a homicide officer, and the death of his last partner. Time was also spent defining the present triggers that stimulated the dysfunctional behaviors.
Finally, the EMDR process was explained, including its effects, and relaxation techniques for coping with high stress were outlined.
Session 2: A week later, the second session provided an opportunity for Matt to ask questions about the treatment and discuss any symptoms that had occurred since the first meeting. Because Matt had been having intrusive thoughts of Sam's death through the week, and had experienced high anxiety over Lucy's safety, the target Dr. Shapiro selected was Sam's death. Dr. Shapiro asked Matt to select the image that best represented this trauma, which Matt reported as seeing Sam's body in the morgue.
Dr. Shapiro assisted Matt in identifying the negative self-attribution related to this image. This was, simply, that "I'm to blame." Then Dr. Shapiro helped Matt to identify a positive cognition that was more rational, realistic, and empowering. This was, just as simply, "I did the best that I could."
To provide a baseline measurement, Dr. Shapiro asked Matt to report how valid the positive cognition felt on a 7-point Validity of Cognition (VOC) Scale, with 1 = it feels totally false and 7 = it feels totally true. He reported a level of 3 on this scale.
Dr. Shapiro and Matt also discussed the emotions and the physical sensations associated with the traumatic experience. The primary feeling was guilt. Dr. Shapiro asked Matt to rate the intensity of the emotion on a 11-point Subjective Units of Disturbance (SUD) Scale, with 0 = neutral and 10 = the worst it could be, to provide a baseline from which to assess changes during the procedure. Matt rated his guilt as a 9. He also noted that he had feelings of pain and agitation in his stomach and arms.
The actual reprocessing of the trauma began 20 minutes after this assessment. The thread of associations Matt communicated was "I let everyone down." He reported flashes of seeing his wife, his first partner, his father's death. Matt talked about not having given his father what he wanted—his father died before he could make him proud. Matt began crying and feeling the grief he had never let himself feel before. In successive reprocessing sets Matt said sadly, "I tried to be a good cop—I tried to be a good son—I did the best I could." Dr. Shapiro ended the session by using a stress-reduction technique, debriefing Matt on the potential for more processing, and providing instructions for keeping a log.
Session 3: To be viewed.
- Were the initial sessions as you expected?
- As you read this summary of the preceding sessions, were there any areas or topics that you thought should have been covered but were not?
- What other information would you seek to assess the patient?
- Before viewing the tape, what do you think will unfold in the taped session?
- What issues will be discussed?
- What will the relationship between Dr. Shapiro and Matt be like?
Stimulus Questions About the Videotaped Session
In the beginning of the session, Dr. Shapiro asks Matt how his previous week went and attentively follows his lead with occasional questions related to their previous session.
- What are the advantages and disadvantages of beginning a session this way?
- As a therapist, would you have encouraged Matt to continue expressing his concerns about the past week?
- Would you have created more structure or developed an agenda for the session by this point?
About 5 minutes into the session, Matt describes a recurring dream about his deceased police partner, Sam, lying in the morgue trying to speak to him.
- How does Dr. Shapiro respond to Matt's dream and related feelings?
- How might psychotherapists of other theoretical orientations respond to the dream material?
About 6 minutes into the session, Dr. Shapiro elicits Matt's visual images, bodily sensations, and negative cognitions associated with Sam lying in the morgue. She then proceeds with EMDR "processing" of the target image by waving her fingers in front of Matt's visual field.
- How do you anticipate most clients would initially respond to the finger waves?
- If you were the client, how would you react?
- If you were the therapist, what alternative methods might you consider to "process" the target image?
After each eye movement set, Matt expresses the thoughts, images, feelings, or sensations that occur to him during the eye movements. Dr. Shapiro rarely comments directly on the content and instead briefly encourages him to "stay with that" or "just think of that." Psychologists trained in traditional forms of psychotherapy are accustomed to greater verbal participation in response to a client expressing feelings.
- As a therapist, would you be tempted to respond to a client's feelings?
- As a client, would you be comfortable with this minimal amount of therapist speech?
- What are the therapeutic pros and cons of such minimal therapist speech after each set of eye movements?
About 21 minutes into the session, Matt describes a foreboding sense of something negative happening to his wife. He expresses an "intense constriction" in his chest and an anxious feeling. Dr. Shapiro continues the EMDR processing.
- Under which circumstances, if any, would you as an EMDR therapist discontinue the desensitization process in favor of alternative methods of reducing a patient's anxiety?
- What other anxiety-reduction methods might you consider?
Following each set of eye movements, Dr. Shapiro instructs the patient to "blank it out" and to take "a deep breath."
- What therapeutic purposes do these instructions serve?
- How do you, personally, respond to the directive to "blank it out?"
- How might clients variously interpret such a directive?
Dr. Shapiro's closing words of the session are "and I'm here if you need me. Just call."
Her generous offer strikes different viewers in different ways.
- How did you perceive it?
- How did Matt seem to perceive it?
- For which patients might her offer be taken as caring availability and for which patients might it be taken as an indicator that they dependently need the therapist?
In this demonstration session, Dr. Shapiro uses EMDR to target and process Matt's trauma of Sam's death. By the end of the session, Matt reports reduced arousal, decreased guilt, a sense of relaxation, and feeling "a lot more comfortable." He concludes, "Yeah, I did what I could do."
- How do you account for these rapid changes in one session?
- What causal mechanisms or change processes seemed to operate?
- How might a behavior therapist, a psychoanalyst, or an existential therapist explain these changes?
- Did the session progress as you anticipated?
- Was Matt as you expected? Was Dr. Shapiro?
- What are your general reactions to the session?
- What did you feel was effective in the therapy?
- What do you think were the strengths and the weaknesses of this approach?
- If you were not informed that this therapy is "EMDR" what would you have called it?
- Now, after reading about the patient and viewing this session, what are your diagnostic impressions or characterizations of his problem?
- How would you proceed with Matt's therapy?
- What goals would you set?
- How many sessions do you think it would take to achieve these goals?