EMDR for Birth Trauma related PTSD
This is the last in a series of articles looking at how Post Traumatic Stress Disorder can emerge from experiencing a traumatic childbirth. Here we are going to look at a fantastic, relatively new approach to treating PTSD symptoms. This approach has been shown in clinical trials to be such an effective treatment treatment for PTSD that it is recommended by the UK clinical guidance body NICE as a first line psychological treatment for trauma.
This treatment is what we call, “Eye Movement Desensitisation and Reprocessing” or, if you’re not feeling especially wordy, “EMDR” for short.
I’m going to take you through what EMDR is, why it works and what to expect if you receive this treatment from a qualified therapist. As always, the content on this site is intended for information purposes, and you should seek an appropriately qualified therapist (not someone who says they do therapy “like EMDR”) to take you through this process.
Missed anything so far?
Click on the links to the right to access the other pages in this series of Birth trauma related Post-Natal PTSD articles.
What is EMDR?
Emdr is a type of trauma focused therapy which aims to alleviate emotional distress through activating the brain’s natural capacity to heal itself.
It is based upon a concept called “Adaptive information processing” or AIP for short.
Our body always aims to arrive at a state of balance, or homeostasis. For instance, if we have been exercising and we get out of breath, then eventually our body will take steps to correct this back to the normal balanced state. Likewise, if our balance is upset through us becoming unwell, then the body will seek to restore balance by releasing antibodies to kill the infection. Our body is working hard to maintain balance all of the time.
This is what our brain does too. Adaptive information processing means that our brain seeks to process new information in a way that it can be accommodated, with minimal distress, into our already existing beliefs, ideas and self concept. This is how our memories are created.
We experience something new. The brain processes it in relation to existing memories. Balance is restored.
This is even happening to you now. All day. Everyday. Even while you sleep.
That is, until we experience an event which is significant enough to require a lot more resource to achieve balance.
A traumatic event is like this. We experience an event which is so out of the ordinary that it carries with it aspects of intense emotion, graphic visual imagery, vivid, pained sounds and overwhelming sensations. To process such a traumatic event requires the brain to spend more resources on processing the memory, to achieve balance.
However, because the memory of the event is so emotionally intense, trauma sufferers will often try not to think of the event, they will avoid reminders of it and experience nightmares which means that it is difficult to process the event in their sleep. The Adaptive Information Process is disrupted, meaning that the brain cannot return to the balanced state.
How does EMDR work?
EMDR aims to help the brain achieve balance again. One of the distinctive ways in which it does this is through “Bilateral Stimulation”.
Bilateral stimulation refers to a set of techniques that the therapist will use to stimulate the left and right sides of the brain and will be applied whilst you focus upon aspects of the memory of the traumatic event.
Bilateral stimulation can be done in the following ways:
- Eye movements – The therapist will ask you to follow a stimulus with your eyes. This stimulus could be their hands, a light or stick.
- Sounds – Using clicks or tones alternately at either ear.
- Sensations – The therapist may tap the backs of your hands or ask you to hold a pair of buzzers to stimulate sensations alternately.
There are a few theories as to why bilateral stimulation is a beneficial aspect of trauma processing. The one that I tend to prefer is that we are stimulating the processes that occur whilst we are asleep. REM sleep is the stage of sleeping in which we dream. Dreaming is believed to be the process in which our minds make sense of the experiences of the day and process them into long term memory stores. When we experience a traumatic event, because of the additional emotional content of a trauma, rather than just having dreams, we have nightmares. These wake us up and as such, the brain is unable to do its job during sleeptime hours.
REM stands for “Rapid Eye Movement”. If you have ever watched someone while they sleep during the REM stage, you will have seen that their eyes are moving rapidly from side to side – Just like what we do within EMDR.
EMDR helps us to process trauma by simulating “REM sleep in the daytime” using Bilateral stimulation.
How to do EMDR
Although there are more recent variations to EMDR, the original way it was devised by Francine Shapiro, incorporates 8 phases of treatment. I’m going to take you through the standard 8 phases of the original EMDR protocol here but it is important to remember that EMDR, like other modes of psychotherapy, can at times be adapted to meet the needs of the client or patient. As such, there is no 100% right way to do EMDR.
EMDR Phase 1: History taking and Treatment Planning
In this phase your therapist will help you to think about how your current difficulties are related to your traumatic experience(s) and how, once they are processed, you would like to be able to move forward in the future.
It is common for your therapist to be very thorough in getting a detailed history of experiences which may have contributed to the current PTSD presentation. The main aim of this phase is for you and your therapist to decide together which memory to process first.
EMDR Phase 2: Preparation
In phase 2, your therapist will be working with you to develop knowledge and skills which will help you manage your overall levels of distress whilst you are processing the trauma memory and in between sessions.
The therapist will first give you an understanding of how EMDR works, using the adaptive information processing model described above, and they will also tell you about the trauma response, PTSD and the fight or flight response.
They will then give you practical coping strategies to enable you to deal with your symptoms both in and out of session. These may be in the form of physiological control techniques such as diaphragmatic breathing or progressive muscle relaxation, sensory grounding techniques and imaginal techniques such as the “safe place”, the “container exercise” or the “lightstream technique”. These are all really effective techniques that your therapist will help you to learn for yourself.
The therapist may also introduce you to the “butterfly hug” or “butterfly technique”. This is a simple technique, that you can use together with the other imaginal techniques to do your own bilateral stimulation.
EMDR Phase 3: Assessment
Assessment in EMDR means something a little bit different to assessment in other types of treatment.
In EMDR the assessment phase is when we are assessing, or activating, all of the individual elements of the chosen target memory. In the assessment phase, your therapist will guide you to access all of the visual, verbal, emotional and physical aspects of the trauma memory by using a structured set of questions designed to “light up” the memory structure.
First the therapist will ask you what Image represents the worst part of the event. There may be several images that come to mind when you think of the trauma event but your therapist will guide you to think about the image that brings about the highest tolerable level of emotion.
Next, the therapist will ask you for a “Negative cognition”, by using the phrase, “when you think about this event, what words describe how you feel about yourself right now?” This questions sometimes needs a little bit of clarification. If we think about what is occurring in PTSD and Trauma, a memory of an experience from our past, when activated, gives us a sense of current threat. This suggests that the re-experiencing of the traumatic memory carries with it a thought which triggers the threat emotion in the here and now. So, example negative cognitions might be, “I’m in danger” or “I’m powerless”. As you can see, these example thoughts are self-referential – They relate to how you think about yourself, right now.
Now because we are working from the premise of the “adaptive information processing” protocol, we are expecting that our EMDR work will enable the brain to link up the distressing trauma memory with more helpful, adaptive, memories. We need to think about an alternative, positive cognition. To access this, the next part of the assessment phase asks you, “what you would like to believe about yourself when you have this memory?” This lights up an adaptive, positive belief alongside the current negative one.
Now, at first it is unlikely that someone with PTSD will believe very strongly in the positive cognition, but we would expect this to change as successful processing occurs. To assess the starting point of the belief in the positive cognition, we will ask for the client’s VoC – This stands for “Validity of Cognition”. The Voc is a very simple scale for us to use to rate how much belief the client has in the positive cognition. The scale goes from 1 (I don’t believe the thought is true at all) to 7 (I completely believe the thought to be true).
So, so far we have an image, a negative cognition, a positive cognition and a validity of cognition. Next we want to understand how thinking about the trauma event actually makes the PTSD sufferer feel. We ask simply, “when you have the image in your mind, and you think of the negative thought, e.g., ‘I’m not safe’, what emotion do you feel?”
Emotions can best be described in terms of one word answers. “Sad”, “Angry” and “Scared” are all examples of emotions.
The therapist will then ask you for a rating of how intense this emotion is for you. To do this we use a scale which we call “SUDS” – This stands for, “Subjective unit of distress”. The SUDS scale is incredibly simple to use in that it is basically a 0 to 10 rating of intensity – 0 is the absence of distress, and 10 is the highest it could possibly be.
Finally, we must activate the physiological aspects of the memory. As you can see, EMDR understands trauma memories in much broader terms than just words and pictures, and sees trauma as being manifested in the body as a whole. As such, we pay special attention in EMDR to what we feel in our body when we experience in trauma related distress, where we feel it and how it feels. Your therapist will guide you to think about where in your body you experience the distress at its most intense.
So in the Assessment phase we now have all the parts of the memory activated.
The stages we work through in the assessment phase represent the “hierarchical structure” of the brain. We have the images and words represented on the outer cortical areas, the emotional aspects located in the hippocampus and amygdalae (the emotional centres of the brain) and finally the physical aspects of the memory located in the limbic system of the brain.
When these parts of the memory structure are “lit up” and available to work with, then desensitisation can begin.
Phase 4: Desensitisation
Desensitisation is the stage that a lot of people think of when they think of EMDR – Lots of handwaving from the therapist and eye movements from the client!
During this stage, the therapist will provide the agreed upon form of “bilateral stimulation” – Typically this will be in the form of their hand moving from side to side in front of you, with the instruction being for you to follow their hand with your eyes. Bilateral stimulation can also be done with sensations, e.g., tapping the backs of your hands or with sounds – e.g., alternate clicks at either ear.
The therapist will do a “set” of bilateral stimulation, whilst they ask you to notice whatever comes up into awareness. The therapist will instruct you to experience “whatever comes up” in a way that you can observe it, without necessarily getting caught up in it. I personally ask my clients to imagine that they are on a train, looking out of the window. The scenery that is going past is the thoughts, feelings and sensations that relate to the memory – we can watch whatever comes past, but we don’t necessarily have to become caught up in it. It is now just memory.
Sometimes now thoughts, images, feelings and sensations will arise – sometimes they won’t. There is no right or wrong set of experiences to emerge with EMDR, we are simply creating the conditions for the brain to make new, more helpful, memory connections. Simply notice what comes up.
After each set, your therapist will ask you the question, “what do you get now?” There may be several things that come up, or there may be nothing at all – this is ok. Try to give your therapist a brief idea of what is coming up, so that you can get back to further processing using sets of bilateral stimulation. I usually instruct my clients before we begin to just give me a couple of short sentences about what comes up for them – rather than a full 20 minute narrative! – as this enables us to remain targeted on trauma processing.
After a period of desensitisation, the therapist will ask you for your SUDS rating again. If the SUDS rating is still above 1 or 0, then the therapist will recommend that you continue with the desensitisation phase.
When SUDS are at 0, or at 1 if there is a reasonable justification for it remaining there, and there is evidence that there is no new material being generated by desensitisation, then it is time to move onto Phase 5 – Installation.
Phase 5: Installation
Once you and your therapist are sure that you have desensitised the traumatic memory so that your SUDS are around 0 or 1 intensity, you will move onto the Installation phase. Remember the Positive Cognition and the Validity of Cognition scale from earlier? The Installation phase is the point at which these come into play.
Your therapist will again ask you to recall the image of the traumatic event. They will then ask you if the initial Positive Cognition is still the one that you would like to think when the memory is active, or whether you think another one is more useful.
Once the positive cognition has been decided upon, you will be asked for your Validity of Cognition rating as it applies to the traumatic memory. If you remember, this is a 1 to 7 scale, with 7 being absolute belief in the positive cognition, 1 being the absence of belief in the positive cognition.
As an example, when I have my memory of the traumatic event in my mind, I may have chosen the Positive Cognition, “I’m safe now”, and rated the validity of it at 3 out of 7.
Once you have rated your belief in the Positive Cognition in relation to the traumatic memory, the therapist will ask you to visualise the traumatic event again, and to hold the positive cognition in mind at the same time. The therapist will then continue with bilateral stimulation.
Your therapist will ask you periodically if your strength in the belief has moved upwards or they may ask you just to tell them when you feel that it has strengthened. This procedure will be repeated until the validity of cognition has moved up to 7 whenever the memory is present.
Phase 6: Body Scan
Even though we may think of memories in terms of words and/or pictures, the actual representation of memories is broader than this. Aspects of the trauma memory can be stored as physical sensations in the limbic system area of the brain. The Body Scan phase aims to alleviate this dimension of memory intensity also.
In the body scan, your therapist will ask you to again bring up the incident into memory and to bring up the positive cognition. Whilst holding these in your mind, you will be asked to scan your body mentally and to notice any areas of physical intensity.
The therapist will then again begin bilateral stimulation to allow this area to become desensitised also. Sometimes, if positive sensations are brought up, then the therapist will do sets of bilateral stimulation to strengthen this too.
Phase 7: Closure and Debrief
At the end of the session there are two paths the closure and debrief may take. If the session has ended with a complete reprocessing, in that SUDS are at 0 or 1, and the Validity of Cognition is at 7, then you and your therapist may talk through your experience of processing, and agree for you to keep a log of any new, related memories between sessions.
If the memory hand not been fully processed by the end of the session, then the therapist will follow the “Incomplete Session protocol”. This means that they will support you to use one of the preparation techniques (e.g., the safe place, container exercise or the light stream technique) and to review the coping strategies that you had agreed upon for use between sessions.
You will be again asked to keep a log of any new memories or reflections which emerge between sessions and you will continue with EMDR work at the next session.
Phase 8: Re-evaluation
Finally, we arrive at the re-evaluation phase.
The re-evaluation phase aims to look at whether the processing of the memory has alleviated the problem for you, or whether there is another memory which contributes to the memory which may also be a target for processing too.
Have we achieved our therapeutic aims? If we have, and you are now symptom free, then we may discuss relapse prevention, and consider if there are any techniques from therapy that have been useful which you would want to keep using once therapy ends.
If it emerges from the re-evaluation phase that we still have work to do, then we will consider which memory, or future template, that we want to tackle now to achieve our aims.
Sometimes it is also necessary, in addition to tackling difficult memories, to develop additional skills to achieve the desired treatment outcomes. This is why it is EMDR and CBT can work so well together. Tackle difficult memories using EMDR, tackle cognitive and behavioural challenges using CBT.
George Maxwell is an Accredited Cognitive Behavioural Therapist and director of Access CBT UK.
He specialises in the treatment of Male depression in the post-natal period but also has extensive skills in working with PTSD, Anxiety disorders, OCD and Panic. If you would like to arrange individual therapy with him (either face to face or via Skype), or would like to receive information and updates relating to New Dad Depression then feel free to contact him at firstname.lastname@example.org or follow on twitter @newdad_depressn.