The Covid-19 pandemic has made life unpredictable, and accordingly, mental health concerns have grown exponentially. In fact, 13% of the population of 5 Western countries reported trauma linked with the pandemic.
Trauma is one of the primary symptoms of post-traumatic stress disorder (PTSD), which develops upon experiencing a subjectively traumatic event. Through Covid -19 related phenomena such as quarantine, supply shortages, and death, many people have felt exactly this.
Eye Movement Desensitization and Reprocessing (EMDR) is a widely used intervention for PTSD and during the pandemic, as many services and therapies have been, this treatment has been delivered online as remote EMDR (eEMDR).
As a researcher who’s keen on studying different psychotherapeutic approaches, the uniqueness of EMDR caught my eye. As part of my postgraduate degree in Clinical Psychology, I have been introduced to several psychotherapeutic approaches, most of which revolve around themes like feelings, thoughts, childhood, etc. EMDR on the other hand, is based on the concepts of recollection and desensitisation, which are discussed below. While a relatively new approach, it is gaining popularity rapidly, and with this blog, I want to explore what PTSD is and how EMDR can improve one’s experience with the same. Moving on, the differences between the standard EMDR therapy and its online variant are discussed, alongside the strengths and weaknesses of eEMDR.
Symptoms of PTSD include intrusive memories of the traumatic event, hypervigilance, sleep disturbances, emotional withdrawal, irritability, and lowered concentration. Thoughts of the traumatic event happen in the form of recurring nightmares, flashbacks, and dreams, and must last for at least a month for diagnosis. These unprocessed memories elicit other distressing thoughts, emotions, somatic (bodily) sensations, and beliefs that occurred on originally experiencing the traumatic event.
Recognized as an effective treatment for PTSD by the World Health Organization and the National Institute for Health and Clinical Excellence, EMDR is aimed at altering the way the traumatic event memory is retained in the brain, in order to change the feelings, thoughts, and sensations these memories elicit. Standard (in person, and on-site) EMDR is typically a 6–12 week long intervention, with one or two 60–90 minutes sessions per week, divided into eight phases. eEMDR (online) follows a similar pattern, with the exception of a different way of delivering “bilateral stimulation”, and there being a heavier emphasis on “grounding techniques”.
Let’s take a closer look at these eight phases and how each compare between in-person and online EMDR.
Phase 1: Client History
This is when history-taking, diagnosis, the establishment of treatment goals, and the development of the therapeutic alliance take place.
History-taking in standard EMDR is done using observation and direct questioning; in the remote variant, questionnaires are administered online. Extending into phase 2, a successful therapeutic alliance is when the therapist is able to adapt themselves to the client’s needs and understand the client’s tolerance when re-experiencing their traumatic event. In the process, a case conceptualization (the clinicians detailed and combined understanding of the patient’s biological, psychological, and social contexts) that is Adaptive Information Processing (AIP) informed, is created. The AIP model suggests that memories of recurrent or typical events are stored adaptively, and those of traumatic events are stored maladaptively, and recommends that PTSD is caused by dysfunctional storage of memories that haven’t been fully processed.
Overall, the main aim of Phase 1 is to understand the client’s memory network of their experiences underlying their current difficulties.
Phase 2: Preparation
The goals here include strengthening the therapeutic alliance and introducing and preparing the client for the unique power and speed of EMDR. The process of EMDR is introduced while grounding techniques, which help clients understand that their memory and reality are not the same, are being taught. This is done by reorienting oneself to the present by stimulating ones senses (vision, hearing, smell, touch, and taste). One of several grounding exercises is “butterfly hug”. This technique is elaborated in Phase 4.
Phase 3: Assessment
During this phase, clients work to identify which moment of the traumatic event is most distressing for them. Once identified by the client, the distress caused by it is rated on a Subjective Units of Disturbance Likert scale, varying between “no disturbance” and “worst possible disturbance”.
Phase 4: Desensitization
This phase marks the beginning of ‘reprocessing’, where clients recall the traumatic event memory to a degree that they are comfortable with and which causes the least possible level of disturbance.
The client is expected to focus on the cognitive, somatic, and emotional outcomes of the traumatic event memory while being bilaterally stimulated (being stimulated physically from an external source) during an on-site session. One way this is done is with a “butterfly hug” in its online variant.
“Butterfly hug” is a method in which the client is bilaterally stimulated by orating positive words while the client wraps themselves in a hug by placing their arms on alternate sides of their bodies. It is hypothesized that since the client simultaneously focusses on the traumatic event and utilizes their therapeutic resources with, for example, side to side eye movements, sounds, or taps, the client becomes desensitized to the negative sensations evoked by remembering the traumatic event, thereby making remembering a manageable process.
Phase 5: Installation
During Phase 5, the therapist helps the client establish and strengthen connections between their new, more adaptive thoughts (thoughts via which one is able to ground themselves), and their pre-existing helpful thoughts, via bilateral stimulation — in other words, help them “install” the new positive beliefs to replace the previous negative ones.
While phases 1 to 4 can be conducted in groups, Phase 5 has to be conducted one-on-one since the desired positive and helpful self-beliefs may vary from person to person.
Phase 6: Body Scan
Body scan, which refers to mentally scanning one’s body for any lingering signals, is conducted in Phase 6. The client is assisted by the clinician to find any somatic symptoms, like pain, stiffness, or heavy breathing that arise in their body upon recalling their traumatic event for complete processing. Grounding techniques are especially relevant in Phases 4–6 as the ‘reprocessing’ phases, for self-soothing, and are more relevant to eEMDR due to the absence of the therapist to provide calming tactile stimulation.
Phase 7: Closure
For clients, Phases 4 to 6 in particular can be difficult due to the recalling of the traumatic event, and so in the penultimate step, clients are given the opportunity to indulge in their choice of self-soothing activity and have a chance to share what they have gone through on reprocessing their traumatic experience, to help them calm back down. Clients will not progress to the next stage until they are able to recall the traumatic event and feel completely emotionally and physically neutral about it.
Phase 8: Re-evaluation
In the final and 8th phase, clients who do not present an adequate level of improvement are given individual attention. The nature and severity of their PTSD symptoms are identified and are scanned for comorbid (other simultaneously occuring) mental health issues, using their Phase 2 data.
Evidence that eEMDR therapy is approximately as effective as its standard on-site variant is imperative as it differs from other treatments for PTSD. This online method does not involve exposure to a traumatic event in a verbal manner since the clients do not need to report verbally what they experienced to a therapist. Instead, feelings, thoughts, and sensations that imagining the traumatic events elicit are worked with internally, eliminating the subjectivity of interpretation of the event by the client as, when recalling, clients may unconsciously emphasise certain aspects of the event or may be unable to recall certain others.
Another benefit is that one can undergo therapy from the comfort of their home. In fact, clients who underwent eEMDR expressed over 60% reduction in distress when purposefully remembering their traumatic experience.
However, despite being convenient, and cost-effective in terms of negating travelling to and from appointments, eEMDR has several pitfalls, including the potential for re-traumatization on re-exposure, which is one risk of eEMDR. While this is a possibility even in EMDR, the presence of a therapist acts as a buffer. Clients are also often in environments with distractions which can be an inconvenience as this approach requires focus and concentration. Furthermore, there is a risk of having one’s privacy violated, during eEMDR, due to a lack of encryption of several sites and applications. Moreover, in comparison to other effective interventions, eEMDR is expensive for those seeking therapy for their trauma, as several insurances do not cover it due to its specialization.
Overall, both EMDR and eEMDR are equally effective and is best suited for licensed therapists who have educated clients on the potential positive and negative outcomes of the therapy. It’s my hope that there might be a surge in professionals mastering this technique as research suggests that the treatment has desirable results regardless of the therapist’s experience. In the long run, the accessibility of remote EMDR therapy will play a major role in propagating use among those who need help dealing with PTSD and their trauma.