Joseph S. Volpe, Ph.D., B.C.E.T.S., F.A.A.E.T.S.
Director, Professional Development Editor, Trauma Response®
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.
Published by the American Academy of Experts in Traumatic Stress - 2020