| 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.
Return
to The American Academy of Experts in Traumatic
Stress HomepagePlease
visit this page again. More articles will appear
here shortly.
|
