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Nurses Association
Journal of the American Psychiatric
http://jap.sagepub.com/content/4/5/140
The online version of this article can be found at:

DOI: 10.1177/107839039800400502
1998 4: 140 Journal of the American Psychiatric Nurses Association
Joan Barron, Mark A. Curtis and Ruth Dailey Grainger
Eye Movement Desensitization and Reprocessing

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140
Original
Articles
Eye
Movement Desensitization
and
Reprocessing
Joan
Barron, RN, CS, MN,
Mark A.
Curtis, RN, CS, MS,
and Ruth
Dailey Grainger, ARNP, CS,
PhD
Joan
Barron is a
psychiatric
clinical
specialist
at Veterans
Affairs
Medical Center in
Dayton,
Ohio.
Mark A. Curtis is a
psychiatric
clinical nurse
specialist
at
South Suburban Mental Health Associates in
Bellbrook,
Ohio.
Ruth
Dailey Grainger
is clinical director at
Therapy
Research
Institute, Inc.,
in
Miami,
Florida.
Reprint requests: Joan Barron, RN, CS, MN, Psychiatric
Clinical
Specialist,
Treterans
Affairs
Medical
Center
4100
West Third
St., Dayton,
OH 45428.
Eye
movement desensitization and
reprocessing (EMDR)
is a
therapeutic
method that
was
developed
in the late 1980s
by Shapiro.
EMDR is based on
specific
and
repetitive
rapid eye
movements similar to those
experienced naturally
in
rapid eye
movement
sleep.
When the client holds in
cognition
the visual
images, negative statements,
and dis-
tressing feelings
associated with trauma
memory
and
engages
in EMDR at the same
time,
a desensitization
spontaneously occurs,
with intensive
information reprocessing
leading
to resolution.
(J
Am
Psychiatr
Nurses Assoc
[1998]. 4, 140-144)
Western
medicine has a
long history
of revolu-
WW
tionary
discoveries
leading
to
improved
health
care and
quality
of life.
Recently,
the most revolution-
ary finding
within the field of mental health has been
the advent of the selective serotonin
reuptake
inhibitors for the treatment of
patients
with
depression
and the new
antipsychotics
for the treatment of
patients
with
schizophrenia.
Therapeutic nonpharmacological techniques
have
undergone
a
variety
of
changes
such as movement
from
psychoanalysis
to more
brief,
focused
psy-
chotherapy.
Most
recently
the advent of
eye
move-
ment desensitization and
reprocessing
(EMDR) as a
new
psychotherapeutic modality
has been viewed as
exciting, promising,
and
revolutionary.
Developed
in 1987
by Shapiro,
EMDR was noted to
have a dramatic effect in the treatment of
patients
with
posttraumatic
stress disorder
(Shapiro,
1989a).
Al-
though
exact mechanisms of action are
currently
under
study,
clinical
application
of EMDR has demon-
strated a
high
level of success with
abating symptoms
and
improving coping ability.
One tentative EMDR
hypothesis suggests
that a traumatic incident
upsets
the biochemical balance of the
information-processing
system
in the brain. This imbalance
prevents
the infor-
mation from
proceeding
to an
adaptive resolution,
and
the
perceptions
of the trauma incident are locked into
the nervous
system.
As
early
as
1927,
Pavlov
proposed
that when a trau-
matic incident
occurs,
the
excitatory/inhibitory
bal-
ance,
which is
necessary
for information
processing
to
occur,
is disturbed.
Currently,
it is believed this
traumatization causes an overexcitation of a
specific
locus of the
brain,
and an actual neural
pathologic
condition occurs. Chemical
&dquo;memory
tracts&dquo; of the
trauma are formed in the limbic
system.
The
strength
of traumatic memories
may
relate to the
degree
to
which certain
neuromodulatory systems
are activated
by
the traumatic
experience. Experimental
and clini-
cal
investigations
have demonstrated that
memory
processes
are
susceptible
to
modulating
influences
after the information has been
acquired (McGaugh,
1990). Activation of the locus
ceruleus-norepineph-
rine
system
that
projects
to the
amygdala
in the lim-
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141
During
the interview the client-
therapist relationship
is
assessed for trust and
safety.
bic (emotional) system by frightening
and traumatic
experiences may
facilitate the
encoding
of memories
associated with the
experiences.
It is
possible
that
reproducing
a
neurobiological
state similar to the one
that existed at the time of the
memory encoding
can

elicit the traumatic
memory (Fogel, Schiffer,
&
Rao,
1996).
It is
possible
that
repetitive eye
movements such as
those found in
rapid eye
movement (REM)
sleep
are the
bodys
automatic
information-catalyzing process,
which
serves to restore balance and allow the traumatic over-
load to be resolved. The trauma
pathology may
be said
to &dquo;freeze&dquo; the information in its
original anxiety-pro-
ducing form, complete
with the
original image, negative
self-assessment,
and
negative
affect.
Shapiro
(1989a)
theorizes that the
eye
movements or other forms of
alternating
stimulation to the
hemispheres
of the brain
allow
long-delayed learning
to take
place. &dquo;Undigested&dquo;
or &dquo;unmetabolized&dquo; memories form blocks in the chem-
istry
of the
brain,
tied in their own isolated neural net-
works to the rest of the brain.
Correcting
these
blocks,
EMDR resolves or unfreezes this information. These
results are
usually lasting
over time
(Shapiro,
1989a). A
number of researchers have
postulated
that the REM
state serves to
process
information
including emotional,
stress-related,
and survival material
(Neilsen, 1991;
Wilson, Becker,
&
Tinker, 1995). In
addition,
deliberate
instigation
of
eye
movements
may
stimulate the corre-
sponding
cortical
functions, leading
in turn to new
&dquo;memory
tracts&dquo; and thus to the
healing cognitive process.
The
EMDR/REM
hypothesis
contin-
I
ues to be researched and is not
necessarily
correlated to the
observed treatment effects at this
time.
EYE MOVEMENT DESENSITIZATION AND
REPROCESSING MODEL
Shapiro
describes
eight phases
of the EMDR model.
Phase One: Client
History
During
the interview the
client-therapist relationship
is
assessed for trust and
safety.
The clients level of emo-
tional
disturbance, presenting pathologic condition,
and belief
systems
are
explored. Adequate healthy
support systems
are reviewed. General
physical
health
and
neurological
status is obtained. The
potential
for
secondary gain
is also assessed.
Targets
for EMDR are
investigated.
Phase Two: Client
Preparation
Thorough explanation
of EMDR
theory
is essential.
The client understands that he or she has the control
to
stop
the session at
any
time.
Eye
movements are
tested for comfort with
preference
of direction. A safe
place
is established
through
relaxation and visualiza-
tion that
may
be used as an emotional catharsis when
processing
trauma.
Phase Three: Client Assessment
The client is asked to
identify
a
target issue,
which is
a
disturbing image, thought,
or sensation identified
with a traumatic
memory.
Linked to the
target
memo-
ry,
the client associates a
negative cognition
that
expresses
the belief about himself or herself now. The
client relates a
positive cognition
of what the client
would
prefer
to believe about himself or herself now
and rates how true this belief is on a
Validity
of
Cognition
scale of 1 to
7,
where 1 is
completely
false
and 7 is
completely
true
(Shapiro,
1989a).
Current
emotions are identified. A second
scale, Subjective
Units of
Disturbance,
rates from 0 to 10 how disturb-
ing
the
memory
feels to the client
now,
where 0 is
neutral and 10 is the
highest possible
disturbance
(Shapiro,
1989a).
Phase Four: Desensitization
The client
brings up
the
negative memory, negative
cognition,
and current emotions and follows the clin-
icians
fingers
with- his or her
- eyes
as
they
are moved back
and forth. Movements
may
be
horizontal, vertical,
or
diagonal
to clients
preference.
Of note is
that side-to-side
auditory
or tac-
_ tile stimuli
may
also be used if
a visual
pathologic
condition
does not allow for
eye
movement. A
therapist
work-
ing
with an individual with a visual
impairment
such
as macular
degeneration may
use a side-to-side hand
tap
to stimulate the EMDR
response.
Reassessment of
the
Subjective
Units of Disturbance scale occurs at
this
phase.
Phase Five: Installation of the Positive
Cognition
The clients
original positive cognition
is reassessed
for
validity
and with the
eye
movement
technique
is
instilled. The
Validity
of
Cognition
scale is used to
assess
change
in the belief.
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142
Phase Six:
Body
Scan
The client recalls the
original memory
with the
posi-
tive
cognition
and scans the
body
for
any unpleasant
sensation. These sensations are
targeted
with addi-
tional sets of
eye
movements.
Phase Seven: Closure and
Debriefing
An
explanation
is
given
to the client that
processing
of
information
may
continue between sessions. A
journal
to
log
associated memories or
feelings
or new memo-
ries or
feelings
as
they
occur is recommended. A back-
up safety plan,
such as
contacting
the EMDR
therapist
or other identified
support system,
should also be dis-
cussed and in
place
should the client
rapidly
decom-
pensate.
Phase
Eight:
Reevaluation
At this
phase questions
to be considered include: Has
the
target
issue been resolved? Has associated materi-
al been activated that must be addressed? Have all
necessary targets
been
reprocessed
to allow the client
to feel at
peace
with the
past, empowered
in the
pre-
sent,
and able to make choices for the future? And
have desired behavioral
changes
occurred?
USE IN PRACTICE
EMDR was seen as
highly
controversial when it was
first
introduced,
and
many clinicians, particularly
those
deeply
involved with their own
preferred
treatment
modalities,
were
initially skeptical.
As research has
repeatedly
demonstrated the
efficacy
of
EMDR,
it has
gained
more
acceptance
in clinical areas
(Jensen, 1994;
Shapiro 1989b; Wilson, Becker,
&
Tinker, 1995, 1996).
There has been an increased interest
by third-party
payers
and
managed
care
organizations
in
using
EMDR-trained
therapists
to
accomplish goals
faster and
with less
costly longer-term psychotherapy. Many
employee
assistance
programs
are
using
EMDR for
workplace violence, accidents,
and critical incidents.
The Federal Bureau of
Investigation
has endorsed
EMDR
along
with critical incident stress
debriefing
for
individuals
showing symptoms
after a trauma
(Solomon, 1994).
Initial clinical
application
of EMDR was
generally
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143
Memories of childhood or related
traumas
emerge.
limited to
posttraumatic
stress disorder. As EMDR has
evolved,
clinicians are
using
this method with a vari-
ety
of
symptom presentations. Many
clients with
early
trauma histories have
difficulty progressing
in
therapy.
This
may
be
partly
due to
early
memories that influ-
Many
clients with
early
trauma
histories have
difficulty progressing
in
therapy.
ence
perception
and a lack of
coping
skills for the
client to
effectively
deal with current traumatic or cri-
sis situations. These
perceptions
and ineffective
cop-
ing
skills then
may
be the
primary
basis for
present
emotional difficulties. These clients often do well with
EMDR.
Many nurse-psychotherapists
have been
trained in
EMDR,
and some are
conducting
research
into its
efficacy
with
psychological
and also
physio-
logical
conditions
(Grainger, Levin,
&
Allen-Byrd,
1994).
The use of EMDR
requires
a
high
level of
compe-
tence
by
an advanced
practice
licensed
professional,
because EMDR is an
adjunct
to
psychotherapy.
EMDR
requires
clinical
judgment regarding
its
appropriate
use. EMDR has the
potential
of
creating powerful
reac-
tions,
and sometimes abreactions and a
thinning
of the
amnesic barrier
may
occur. It is not uncommon for the
client to recall details of the
target
trauma of which
he or she had been
previously
unaware on a con-
scious level. The clinician
should assess
ego strength
and must be able to
arrange
hospitalization
before
using
EMDR in clients who would
be in
jeopardy
with
outpa-
tient treatment alone. It is
important
that the nurse
using
EMDR receive
proper training
and
supervision
in its use.
Referrals

A wide
variety
of clients are
appropriate
for EMDR
such as those with
posttraumatic
stress
disorder,
anxi-
ety, phobias, depression,
or
any
neurotic
symptomatic
response. Currently,
EMDR network
study groups
and
special
interest
groups
have
developed protocols
for
using
EMDR in such varied areas as dissociative iden-
tity
disorder and dissociative
spectrum disorders,
enhancing
human
performance, preventing
substance
abuse
relapse,
and
dealing
with
symptoms
of
physical
illnesses
including lupus
and cancer. Research with
EMDR is
ongoing
with survivors of natural and man-
made
disasters, smoking cessation,
and
drug
addic-
tion.
If a nurse has a client he or she thinks
might
bene-
fit from
EMDR,
a discussion with a clinician trained in
EMDR will
help
make this decision before
making
a
formal referral. The names of local EMDR-trained clini-
cians and information
regarding
EMDR
training
can be
obtained
by contacting
the EMDR
Network, Inc.,
at
(408) 372-3900.
SUMMARY
EMDR
processes images, memories, associations,
thoughts,
and emotions that often
flip rapidly through
a clients mind like shuffled
playing
cards. Memories
of childhood or related traumas
emerge.
Some
people
cry
out in
rage, grief,
or
fright, reliving
events. After it
is
over,
clients are not
simply
desensitized and less
anxious; they
have learned
something.
Their
thinking
has
changed.
It has been a common
experience
that
no matter how hard
they try
to
recapture
the
previ-
ously strongly
felt emotional
response, they
are
phys-
iologically
unable to. A
&dquo;neurological
event&dquo; has
occurred.
According
to
Shapiro (1995, 1996),
EMDR is a valid
treatment for
treating patients
with
posttraumatic
stress disorder. EMDR
protocols
are also
being
used
for dissociative
identity disorder, phobic disorders,
substance
abuse, body dysmorphic disorder,
and
-
performance
enhancement.
EMDR
incorporates
work
with
disturbing images,
sen-
sations, thoughts,
and emo-
- tions
together
with bilateral
stimulation such as
eye
movements and
alternating
tones or
taps
to shift trau-
matic memories into a
nondisturbing
form. EMDR is
.
not a
simple technique
and cannot be
reliably
or eth-
ically
used
by merely reading
a manual or
seeing
a
demonstration. Formal
training
and
supervised prac-
tice are essential to
develop
the skills needed for safe
and successful
application
of EMDR.
REFERENCES
Fogel, B., Schiffer, R.,
&
Rao,
S. (1996). Neuropsychiatry.
Baltimore:
Williams & Wilkins.
Grainger, R.D., Levin, C., & Allen-Byrd,
L.
(1994, August).
Treatment
project
to evaluate the
efficacy of eye
movement desensitization
and
reprocessing (EMDR) for
survivors
of a
recent natural disas-
at US DEPT OF VETERAN AFFAIRS on March 19, 2014 jap.sagepub.com Downloaded from
144
ter. Presented at the American
Psychological
Association Annual
Convention,
Los
Angeles,
CA.
Jensen, J.A. (1994). An
investigation
of
eye
movement desensitiza-
tion and
reprocessing
(EMD/R) as a treatment for
post
traumat-
ic stress disorder (PTSD) symptoms
of Vietnam combat veterans.
Behavioral
Therapy, 25, 311-326.
McGaugh, J. (1990). Significance
and remembrance: The role of
neuromodulatory systems. Psychological Science, 1(1), 15-25.
Nielsen,
R. (1991). Affect desensitization: A
possible
function of
REMs in both
waking
and
sleeping
states.
Sleep Research, 30,
10.
Pavlov,
I.P. (1927) Conditioned reflexes. New York:
Liveright.
Shapiro,
F. (1989a). Efficacy
of the
eye
movement desensitization
procedure
in the treatment of traumatic memories.
Journal of
Traumatic
Stress, 2, 199-223.
Shapiro,
F. (1989b). Eye
movement desensitization: A new treatment
for
post-traumatic
stress
disorder. Journal of Behavior Therapy &
Experimental Psychiatry, 20,
211-217.
Shapiro,
F. (1995). Eye
movement desensitization &
reprocessing:
Basic
principles, protocols,
and
procedures.
New York: The
Guilford Press.
Shapiro,
F. (1996). Eye
movement desensitization and
reprocessing
(EMDR): Evaluation of controlled PTSD research.
Journal of
Behavior
Therapy & Experimental Psychiatry, 27, 209-218.
Solomon, R.N.,
&
Kaufman,
T.
(1994, March). Eye
movement desen-
sitization and
reprocessing:
An
effective
addition to critical inci-
dent treatment
protocols. Paper presented
at the Fourteenth
Annual
Meeting
of the
Anxiety
Disorders Association of
America,
Santa
Monica,
CA.
Wilson, S.A., Becker, L.A.,
&
Tinker,
R.H. (1995). Eye
movement
desensitization and
reprocessing (EMDR)
treatment for
psycho-
logically
traumatized individuals.
Journal of Consulting
and
Clinical
Psychology, 63, 928-937.
Wilson, S., Becker, L.A.,
& Tinker, R.H. (1997). Fifteen-month fol-
low-up
of
eye
movement desensitization and
reprocessing
(EMDR)
treatment for
posttraumatic
stress disorder and
psycho-
logical
trauma.
Journal of Consulting
and Clinical
Psychology,
65, 1047-1056.
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