| Francine
Shapiro, Ph.D., B.C.E.T.S. is the originator
of Eye Movement Desensitization and Reprocessing
(EMDR). Dr. Shapiro is a Senior Research Fellow
at the Mental Research Institute in Palo Alto,
California. She has trained over 30,000 clinicians
internationally. EMDR has been used to treat
thousands of trauma survivors worldwide including
individuals who have survived rape, sexual molestation,
Vietnam combat and natural disasters. Dr. Shapiro
is a member of the Editorial Advisory Board
for Journal of Traumatology and a member of
the "Cadre of Experts" of the American
Psychological Association & Canadian Psychological
Association Joint Initiative on Ethnopolitical
Warfare. She has also served in the Editorial
Advisory Groups for Treating Abuse Today and
the Journal of Traumatic Stress. She has been
invited to lecture around the world and was
the recipient of the 1993 Distinguished Scientific
Achievement in Psychology Award presented by
the California Psychological Association. Her
articles have appeared in numerous journals
and she is the author of several publications
including Eye Movement Desensitization and Reprocessing:
Basic Principles, Protocols and Procedures (Guilford
Press,1995), EMDR: The Breakthrough Therapy
for Overcoming Anxiety, Stress and Trauma (with
Margot Silk Forrest, BasicBooks, 1997) and the
forthcoming EMDR and the Paradigm Prism (American
Psychological Association Press). Dr. Shapiro
is currently serving on the Board of Scientific
& Professional Advisors of The American
Academy of Experts in Traumatic Stress.
JSV: I know that you
maintain numerous roles as a psychologist, lecturer,
researcher and consultant. Can you tell me about
your current positions?
FS: I am a senior research
fellow at the Mental Research Institute in Palo
Alto. In addition, I am Executive Director of
the EMDR Institute and President of the EMDR
Humanitarian Assistance Programs. The Humanitarian
Assistance Program is a global network of clinicians
who have dedicated themselves to alleviating
suffering by breaking the cycle of violence
worldwide. We do pro-bono training and direct
intervention when called upon. And I am also
a consultant on a number of grants including
some by NIMH evaluating EMDR in a variety of
forums. JSV: What made you focus on
traumatic stress as a specialty? FS:
It was actually an accident! When I first began
developing EMDR and noticed it effects I wanted
to test whether it could have positive results
within a clinical population. I then reviewed
the symptoms that it had worked well with. It
seemed like old memories were affected most
easily. I then asked the question "what
clinical populations had the most difficulties
with old memories?" It appeared that rape
victims, molestation victims, combat veterans,
especially struggled with memories (of their
trauma) and posttraumatic stress disorder (PTSD).
Thus, I came about it sideways. When we observed
the effects of EMDR in that population, it became
something that I dedicated my life to. JSV:
As the originator and developer of Eye Movement
Desensitization and Reprocessing (EMDR), can
you provide an overview of how it is used. Also,
please describe the way in which this therapeutic
intervention evolved? FS: Well, it started out,
actually as a technique for alleviating anxiety.
At least that's the way that I thought about
it because I came from a primarily behavioral
background. But as we explored it and refined
it over time, it became clear that desensitization
of anxiety was only a by-product of what was
going on. What we were really looking at was
"reprocessing" which actually means
an active learning process. Thus, the individual
might be disturbed by a particular event, and
we viewed it as being stored in the brain in
a form similar to how the perceptions were initially
encoded. The natural information processing
that was necessary to take it to resolution
appeared to have been "knocked off- line"
because of the disturbance. So when we use EMDR,
we access the earlier events that are problematic
and we stimulate the processing system. We make
sure that the information continues moving toward
adaptive resolution. What is useful is learned,
stored with appropriate affect and able to guide
the person appropriately in the future. What
is useless, the negative self-talk, painful
emotions, physical arousal, are simply discarded.
It's a natural outcome of the dynamic learning.
The individual not only desensitizes anxiety,
but goes through any number of emotions such
as guilt, anger, sadness and rage that typical
psychotherapy is unable to touch (e.g., exposure
therapies are not usually helpful for guilt
issues or anger issues). EMDR promotes learning
- very rapid learning. The person not only moves
to a level of appropriate emotion, but takes
on the appropriate level of insight and understanding
of what had occurred to them. The individual
can then make the associations that are necessary
to resolve the issues. What you're really looking
at is individual growth. It's not solely about
taking away pathology or taking away overt symptoms,
but also self-enhancement. It is important to
consider that many disorders that bring a person
into a psychologist's office are the product
of earlier experiences. It doesn't have to be
the large "T" Trauma of a rape or
a combat experience but can be the small "t"
trauma of childhood humiliations or abandonment.
What we look for in the use of EMDR is where
the clients are stuck - what earlier experiences
are contributing to their problem, and what
positive elements need to be incorporated for
them. EMDR can also catalyze enhancement of
positive affects, positive beliefs, and positive
behaviors. So we actually look at the full spectrum
of the clinical picture.
JSV: I have read that
EMDR has had more published case reports and
controlled research to support its use than
any other method used to treat trauma. If this
is the case, then why do you suppose there has
been such controversy among trauma researchers
and clinicians about using EMDR?
FS: I think it developed after
a 1989 publication. When I published the first
controlled study in 1989, I was reporting positive
effects with the application of only one session.
Yet PTSD had been looked at as extremely resistant
to any treatment. There were no controlled studies
at the time that I submitted mine for publication.
When it was published, it came out with two
other studies on various other methods which
showed very moderate or minor results, with
12 - 15 sessions of treatment. So it just didn't
seem possible that EMDR could achieve what we
were indicating that it could do. So a split
between "science" and "practice"
evolved, because clinicians learned it and used
it and became very enthusiastically vocal about
it, while the science had not yet caught up.
The controversy arose between the enthusiasm
of the clinicians and the lack of other research
about it. However, over the past 10 years, there
have been more controlled studies supporting
EMDR than any other method of intervention for
trauma. The standard of EMDR PTSD treatment
is that 84-90% no longer have civilian PTSD
in the equivalent of three 90 minute sessions
(e.g., Marcus et al., 1997; Rothbaum, 1997;
Scheck et al., 1998; Wilson et al., 1995,1997).
So I think that, if there is any present controversy,
it's simply because of the ignorance regarding
the research that exists-as well as a great
deal of misinformation regarding the treatment
itself.
JSV: What educational
background and training does one need to utilize
EMDR? What are the consequences of inadequate
training?
FS: Well, we only train licensed
clinicians or students who are supervised by
licensed clinicians. It is not a simple technique.
It is a complex integrative method or approach
to psychotherapy that attends to the entire
clinical picture. If someone inadequately trained
provides treatment, the client may be brought
to access earlier memories that are disturbing,
and be re-traumatized by them. Training, whether
it is done through the universities or through
private workshops, always involves practice
sessions where the individual is closely supervised.
Clinicians should make sure that any training
they attend is authorized by the EMDR International
Association. It is an independent, non-profit,
professional association that sets standards
for EMDR training and practice.
JSV: Have you observed
the by-product of inadequate preparation?
FS: Yes. Originally, I had
people sign agreements not to train until they
were, themselves, approved as trainers. That's
because after I had taught two workshops in
California, I began to hear of clients who claimed
to be hurt by the procedure. We tracked down
the practitioners and discovered that people
who had taken the training were now teaching
their own version of it to massage therapists
and hypnotherapists! The method was not being
used in accordance with the appropriate clinical
precautions and procedures. For instance, a
clinician was working with partners of abuse
victims and he was recommending to the husbands
of sexual assault victims that their wives get
EMDR treatment. A couple of the men said "I'll
never let my wife go anywhere near that (EMDR)
- she had the worst week of her life - she nearly
ended up in the hospital." As it turned
out, some hypnotherapists had simply accessed
the earlier memory, tried to process it through,
but didn't know what to do in order to bring
it to resolution because they hadn't been trained
appropriately. Some of the problem involves
misinformation about EMDR that leads people
to think that is all about "waving your
hand in front of a person's face," when
it is very much not that. EMDR is an integrated
approach that incorporates aspects of all of
the major psychotherapies in a unique combination.
And, in addition, it has an aspect of stimulation
which can be either eye movements or hand taps
or auditory tones. But the use of that stimulation
is part of an integrated method. It is not a
stand-alone technique. The problem is, because
of all the media hype and misinformation, that
people think all you need to do is just have
a person follow your fingers with their eyes
and that's supposed to take it to completion,
but it certainly is not the case. And unfortunately,
many so-called "eye movement techniques"
have been launched which are trying to capitalize
on EMDR's popularity. Just because someone puts
the words "eye movement" in the name,
doesn't make it EMDR. Unless clinicians check
with the EMDR International Association to make
sure the training is authorized, they may be
seriously misled.
JSV: A while back I
had spoken with Jeff Mitchell and George Everly
about the reactions of emergency care workers,
police officers and firefighters who are first
"on the scene" of an accident or crime.
What are your observations of the responses
of these individuals to such events as motor
vehicle accidents, bombings or other catastrophic
experiences? FS: I think part of the
problem is that the "front-line" providers
tend to compartmentalize and often pride themselves
on their stoicism. However, sometimes the load
just gets so heavy that the compartments start
leaking, and they start breaking down. This
was observed with the Oklahoma City bombing.
People who had been doing that type of work
for years were devastated because, for the first
time, they were seeing these little baby body
bags being taken out. Many of the responders
erroneously believed that they had not "done
enough." Others saw their own children's
faces transposed on top of the victims. These
types of experiences can be devastating because
the images, at a certain point, end up remaining
with these folks. As caretakers who feel they
have failed, the pain can be overwhelming. Accumulated
inappropriate feelings of guilt take their toll.
I think that as a society, we have to start
really taking care of our front-line providers.
I know that after the Oklahoma City bombing,
for instance, many of the teams that originated
in California simply resigned upon their return.
They just couldn't take it any more. I think
that there needs to be more done in terms of
care for these professionals. Their experiences
are equivalent to going out and fighting a Vietnam
war day after day after day and we're just not
giving them enough care and protection.
JSV: Unfortunately,
many are fighting a "personal" war
as a consequence of their effort to help others.
Although you alluded to this earlier, I believe
that an assumption of EMDR is that the alteration
in the memories of traumatic events is facilitated
by repeated eye movements. What do you suspect
is the mechanism responsible for the improvements
that are reported with clients successfully
treated with EMDR?
FS: Again, the thing to emphasize
is that the eye movements are only one component
of this intervention that brings together aspects
of psychodynamic therapy, cognitive therapy,
behavioral, experiential and body-oriented therapy.
All of these are part of EMDR's approach and
each of these aspects have a contribution. As
far as the stimulation itself (which can be
eye movements, handtaps, or audiotones), the
use of it began with my observation of the effects
of eye movement on disturbing thoughts. It turns
out it wasn't the first time that observation
had been made. There were a series of experiments
by Antrobus in the 1950's that also found that
eye movements were associated with a shift in
cognitive content. However, the question "Why?"
is still unanswerable. Recently, there was a
study done in England which tested the hypothesis
that the stimulation was disrupting the visio-spatial
template. In that experiment, they found that
eye movements were most effective, but hand
taps were also effective. The thing to keep
in mind is that we're at a point right now that
is similar to the historic use of antibiotics.
People first started using antibiotics and found
that they could see it work but couldn't figure
out why. There simply is not enough knowledge
in the field of biology in order to determine
its mechanism. So, some of the work that had
been conducted by Andrade indicates that it
could be a disruption of the visio-spatial template.
Other individuals have talked about the "orienting
mechanism" - that is a conditioning process
that brings a sense of comfort in the present
while being able to observe the material from
the past. Some work by van der Kolk is showing
differences in brain structures that are lit
up before and after EMDR treatment. So it's
a very exciting time. There are different investigations
going on, but it is still very much a "black
box." And really, it's impossible to describe
any form of psychotherapy on that type of neurological
level, but we'll see what opens up in the next
ten years.
JSV: I am very interested
in the research on the association between traumatic
events and the hippocampus. It certainly is
exciting yet so many unknown variables remain.
FS: Yes, and the thing to keep
in mind is that there is a long way to go before
we have any definitive answers. For instance,
there has been talk over the last few years
that you get hippocampal shrinkage with prolonged
traumatic stress. That was causing a number
of people to turn around and tell chronic combat
veterans that there was nothing that they could
do for them because the damage was permanent.
But further research has indicated that the
hippocampal shrinkage was not necessarily permanent.
What dies off, in fact, may be dendrites, not
the axons. Moreover, we are now learning that
brain cells are able to be generated. I think
that over these next few years, we'll have a
better understanding of neurobiological processes.
I think we also have to be very careful not
to make pre-judgements, especially ones that
seem to tell people that they're "never"
going to be any better. Some directors of V.A.
PTSD units have brought back vets they previously
failed with and have successfully treated them
with EMDR. If, instead, they had been influenced
by the preliminary biological data, those vets
would still be suffering.
JSV: Traumatic stressors
are quite diverse and go well beyond the devastating
effects of large-scale disasters and catastrophes.
The American Academy is, in fact, especially
interested in looking at day-to-day traumatic
experiences such as chronic illness and domestic
violence. Can EMDR be used effectively to treat
such survivors who need to manage a cascade
of overwhelming emotions on a regular basis?
FS: Well, the goal is not so
much to have to manage overwhelming emotions,
but to get rid of them. That is the goal of
EMDR treatment. As I said previously, by accessing
earlier memories and allowing them to be processed,
learning is able to take place. The old information
is learned and essentially stored with the appropriate
emotion. This guides the person in the future.
Negative emotions, physical sensations and painful
beliefs are let go. When you're using EMDR,
you're not only dealing with those earlier memories
and getting them "unstuck" (i.e.,
out of the system so that they're no longer
pushing the negative emotions and negative behaviors),
but you're also continuing the treatment. The
goal is ultimately to take on positive affect
and positive behaviors. The idea is not simply
to return someone to a state where they are
no longer overtly suffering, but to take them
to a higher plateau of functioning. Chronic
illness is debilitating in many ways. EMDR would
be used to deal with physical pain, any underlying
psychological stressors, present sense of self,
maximizing potentials, etc. For victims of domestic
violence, EMDR would be used to address a realistic
appraisal of the present situation, psychological
factors contributing to the problem, increasing
resources and appropriate behaviors, etc.-in
addition to reprocessing the memories of the
violence which might be causing overt PTSD symptoms.
It is extremely important to address the entire
clinical picture and liberate the person into
being able to make the best choices for the
future.
JSV: Essentially, you
mean assist the victim in becoming a survivor
and ultimately, a thriver?
FS: That's it...that's right.
JSV: I know that you
began to address this point earlier, but I was
wondering about which things you believe are
in need of greater investigation at this time
in the area of traumatic stress?
FS: Well, we have to determine
what makes 'normal' processing take place. We
need to know what happens to the brain when
the individual is 'stuck' in their processing
of information (e.g., dysfunctionally stored
memories). Such investigation can facilitate
more robust treatment. Of course, it's very
exciting to determine what is going on internally,
but I'd like to see more of the research geared
toward making the treatments that we are using
more applicable across the board to clients
with a variety of pathologies. It is also essential
that research incorporate appropriate levels
of clinical validity, treatment fidelity, and
a large enough subject pool in order to make
the studies valid. Many studies exist in our
field that completely fail to guide the practicing
clinician because they have no relation to the
real world. A partnership between practicing
clinicians and research academics is essential
if our field is going to progress.
JSV: As you are aware,
The American Academy of Experts in Traumatic
Stress is a multidisciplinary organization with
more than 200 areas of specialization represented.
The Academy recognizes that traumatic events
are an unfortunate part of the human experience
that professionals and workers from many fields
work with on a regular basis. What do you see
as the major advantage of an organization such
as the Academy that is dedicated to increasing
awareness and, ultimately, improving the quality
of intervention with survivors of such events
across such an eclectic group?
FS: I think that such an eclectic
membership is a very great strength. It allows
for the cross-pollination of work and ideas
that have been effective in many of the different
areas and disciplines. Being able to bring together
the "best and the brightest" (as the
Academy does) in order to work on a better understanding
of traumatic stress and, most importantly, how
to advance clinical applications is a strength.
The fostering of educational outreach is also
essential. Educating communities and individuals
after a traumatic incident is essential because
many people are out there suffering with symptoms
and thinking that they're simply "crazy"
or "over-reacting." We know there
is a much higher incidence of chemical and alcohol
abuse in a traumatized population. They are
clearly trying to self-medicate themselves because
they don't know there are fruitful alternatives.
We need to let them know that what they're going
through are normal responses, and they do need
help, and that they can be assisted. If through
representatives of the Academy's diverse populations
we can generate greater educational outreach
and assist with making clinical applications
more robust, then I think this organization
can do a wonderful service to humanity.
JSV: With regard to
the effects of traumatic exposure on children,
what recommendations could you give to support
personnel who regularly respond to and intervene
on behalf of children exposed to traumatic incidents
(e.g., gang and school violence, domestic violence,
shootings)?
FS: I think it's extremely
important to have support groups and methods
like EMDR available to children on a regular
basis. I think that if we look at the level
of violence in the school systems, we should
recognize that we must intervene at an early
stage. We're not only helping to alleviate the
pain of the victim, but we're also potentially
assisting in stopping further violence. It's
important that the children who have not only
been victims, but witnesses of violence be treated.
Support personnel should make sure that the
need for support groups and individual therapy
is emphasized, along with a relationship between
all the care-givers. Kendall Johnson has a wonderful
book called Trauma in the Lives of Children
that can serve as a excellent guide. Intervening
at an early age can increase the individual's
resiliency and remove the toxic effects of violence.
If we don't do that, then we're simply going
to see the violence continue. Those children
who have engaged in violence are ones who are
also hurting. We all know there is a cycle of
violence that needs to be stopped.
JSV: Although it's
taken some time, we're discovering more and
more about the effects of secondary traumatic
stress on caregivers. What advice do you have
for those who treat trauma survivors? Are there
any suggestions that you could offer to help
buffer caregivers from becoming traumatized
and/or overwhelmed though their efforts to assist
others?
FS: I think that there are
a number of things to consider. First and foremost
is to remember that a common problem is to think
you haven't done enough. It's the downside of
the compassion that brought you into the field.
Caregivers often push themselves to the brink
because they don't put themselves on the priority
list. For that reason, it is important to have
personal support. Have people that you are able
to talk to and that you're able to count on
in order to normalize the reactions that you
may go through. Continue to get your own personal
help if you need to because there is no way
that you can help other people if you're not
taking care of yourself. Sometimes it simply
becomes like Chinese water-torture with one
experience after another building up and it's
very important that clinicians and caregivers,
in general, do not look at themselves as "iron
people" who do not need help. I always
recommend to people trained in EMDR that they
have a group of people that they can speak to
on a regular basis. I suggest that they make
sure that they are taking care of themselves
physically and emotionally. Take all the advice
that they would be giving to their own clients
and make sure that they get their own personal
work at intervals in order to clear out the
residue of what they've been working with over
the years.
JSV: In the years that
you have been involved in treating trauma survivors,
do any specific events stand out in your memories
that you believe have influenced you personally
and professionally?
FS: I think the primary one
was my treatment earlier on of a combat veteran.
During that time, I was first developing EMDR
and I wanted to see whether it would work with
the trauma population. I ended up going to a
V.A. Outreach Center to explore the possibility
and discovered that there were men there my
age who were still suffering from the war, 25
years later. It was a revelation to see the
amount of suffering that was still going on.
And the first combat veteran that I worked with
really exemplified this suffering. He had been
drafted. He said that he went because that was
what he was "supposed to do." He was
"supposed to serve God, supposed to serve
country, and went there in order to save lives."
He reflected on his effort to protect his own
platoon and finding that in order to preserve
life, he had to take it. To take care of his
own men, he had to go against all of his religious
teachings : He had this incredible dilemma as
a 19 year old boy. Twenty-five years later,
he tried to commit suicide because of the pain
of who he might have killed and because of the
guilt associated with the children that he might
have harmed. In the five sessions we worked
together, I saw him put it all to rest. I saw
him come alive. He taught me about the nobility
beneath all of the suffering. But then I looked
around and saw the numbers of people that were
still suffering in that way. I just dedicated
myself (as one of my colleagues, who was a combat
veteran himself, had) to "bringing them
home again." These men have still not been
brought home. We even have World War II vets
who are coming into treatment with retirement
age suddenly triggering PTSD symptoms. The fact
is they are often being told (like many Vietnam
combat vets) that "there is nothing that
we can do for you - you're going to have to
live with it." I think that this is an
absolute, utter shame. It has to stop. The truth
is that articles have been published reporting
complete elimination of symptoms using EMDR
with W.W.II and Korean War vets. And there is
a controlled study with Vietnam combat veterans
(Carlson et al., 1998) which found that after
12 sessions of EMDR, 75% no longer had PTSD.
No one is expendable. We need to work together
in order to figure out how to help all of them.
JSV: As a member of
the Board of Scientific & Professional Advisors
of The American Academy of Experts in Traumatic
Stress, are there any suggestions or concluding
comments that you could offer to our members
with regard to assisting survivors of traumatic
stress?
FS: One of the things that
I mentioned before is that you can't help other
people if you're not taking care of yourself.
I think that regular professional support groups
and personal work are important for anyone in
that position. I also think that it is important
that we not let anyone get lost. It doesn't
matter how long they've been suffering. There's
still hope for them now. Moreover, I believe
that we have to go beyond treating overt symptoms
and help clients leave our office able to lead
healthy lives. This means being able to love
and bond and have joy in their life, not simply
just living without having a flashback or no
longer having intrusive thoughts. And finally,
I'd say it's important to remember that the
work that we're doing has very far-reaching
consequences. It's not just about ending the
pain of the victim, but we're also helping to
stop the man-made violence in the world. I think
that the EMDR Humanitarian Assistance Program
that we have has shown, that as a global network
of clinicians, we can make a difference.
JSV: Francine, you
certainly gave our members something very interesting
to think about. As far as people who are interested
in getting more information, what is your website
address?
FS: The Humanitarian Assistance
Program is in the process of launching its own
website, for now it's available through the
EMDR Institute at www.emdr.com and the EMDR
International Association is www.emdria.org.
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