Can you define some guidelines for clinicians in recommending EMDR? – EMDR Discussion – Interview with Dr. Andrew M. Leeds Ph.D.

Well there are a lot of factors that go into that Steve. It’s actually a very sophisticated and complex issue and hard to discuss in a matter of minutes. In general terms I would say there is going to be a spectrum of cases. There are going to be some people where, for a variety of reasons that I’ll touch on briefly. You’ll probably need to wait a little while, at least for the standard protocol. With others you tend to begin and will need to begin sooner. So what are some of the factors? Well certainly first, if they’re in heavy detox.

Andrew M. Leeds, Ph.D. – Clinical Psychologist

That’s not the time to increase their level of distress even in the short term. So people have to be medically stable first of all and not going through intense cravings. Secondly you have a lot of general readiness criteria that are used when you consider using EMDR. Have you screened for a disassociative order. If you have some type of a disassociative you are going to need to modify the way you’re approaching with EMDR. There’s work that’s being done in Europe examining this question, some pilot studies have been done with some slightly modified EMDR protocols.

In early phase recovery from severe alcohol abuse showing that EMDR can be used in early phase residential treatment programs to decrease relapse rates. So again it’s going to depend how soon is the client ready for that and clinicians need a lot of experience to make that determination. So, clinicians early trained in EMDR will need to consult with approved consultants to help sort that out, but a lot of people will be ready early on. You have to have a standard protocol for treating PTSD and in some cases that’s going to be appropriate. Other people aren’t being troubled so much by their PTSD symptoms.

They are really being troubled more with severe urges to use and there are modified EMDR protocols to target the urge to use itself that are showing promise in early trials. Those modified approaches can be useful in early phase recovery where people are struggling with the urge to use. Maybe we’re not going. to be treating their trauma. We’ll be treating their compulsions, we’ll be treating their urges. That’s also true for other addictive compulsive behaviors like compulsive gambling, compulsive spending which are sometimes co-occurring with substance abuse disorders.

The same is also true with eating disorders where you often find eating disorders co-occurring with substance abuse disorders. So when EMDR becomes appropriate and which EMDR protocol becomes appropriate is a complex question. There are a number of protocols to be considered and a lot of research that’s going to need to be done to demonstrate which protocol is going to be used at which time.

Why is EMDR an important protocol in treating addicts? – EMDR Discussion – Interview with Dr. Andrew M. Leeds Ph.D.

Well I think this is a really important question and first I want to say that it’s really a privilege to be associated with the ONE80CENTER. I worked with you Steve and with Bernie even before you founded the ONE80CENTER and I’ve consulted on some of your other cases before. It isn’t just a feeling or a clinical observation that trauma is commonly involved with substance abuse problems. The SAMHSA, The Substance Abuse and Mental Health Services Administration research shows that the vast majority of people with alcohol and other substance abuse problems have co-occurring disorders.

Andrew M. Leeds, Ph.D. – Clinical Psychologist

Most commonly trauma related disorders. Trauma typically leads to symptoms of post traumatic stress disorder, but it can also cause other anxiety disorders and other depressive disorders. The vast majority of people with these co-occurring disorders don not receive treatment for both their substance abuse problem and their other co-occurring conditions which is why most treatment programs have high relapse rates. If you don’t treat the co-occurring condition then the person is going to continue to have a need to medicate.

If their prescription medications don’t meet their needs adequately they are going to begin to self medicate again. So, relapse rates are very high if you can’t resolve this. PTSD in particular has an episodic cycle. People alternate between phases of intrusion and phases of numbing. So people can have a quiescent phase where their intrusions are somewhat hidden and then as they get triggered their intrusions begin to get reactivated and then have urges to relapse again. It isn’t just a chemical process of detoxification.

It’s the condition association between a long established history of self medication in response to the cyclic turn of the trauma material. The trauma material as Bessel Van Der Kolk has pointed out is not that often in the form of disturbing images or nightmares in the kind of overt signs of PTSD that many clinicians may be looking for. The most common forms of the reoccurrence of trauma symptoms are body sensations and emotional states, that are the re experiencing of aspects of traumatic experiences.

So clinicians who don’t have a strong background in psychotraumatology won’t recognize that the cues that are triggering relapse are associated with traumatic experiences. They wouldn’t have gone looking for the trauma history. They would be thinking that’s too disruptive to the client who is in a recovery program to uncover that material and they won’t even think about treating it. As a result these co-occurring conditions largely go untreated and so what you are doing here at the ONE80CENTER, I think is really pioneering work.

I think you’re one of a handful of programs around the country that’s even thinking about attempting to use a comprehensive approach. And I know you do more than just conventional recovery work and EMDR here. You use lens neural feedback and other innovative approaches to try to get at the source of what’s going on behind the urge to use. EMDR is an essential part of a comprehensive treatment program for substance abuse programs. If you don’t treat the trauma people will relapse. That’s been demonstrated over and over again.

I think they’re kind of a common myth that you have to wait until people have been stable in recovery for years before you think about treating the co-occurring conditions. That was a model that was promoted in the 1980s. Researchers now have demonstrated that that doesn’t work. If you don’t begin to treat the co-occurring conditions immediately people will fail. They’ll go through a rehab program and then they’ll relapse again. So it’s essential. In EMDR compared with other approaches for treating the co-occurring PTSD or similar traumatic or depressive symptoms that patients may have, has a lot going for it.

As I think the first choice in ways of treating co-occurring disorders compared with prolonged exposure and cognitive processing therapy. The main thing it has going for it is it’s efficiency. The research studies show again and again that the modal response is faster to EMDR that prolonged exposure and cognitive processing. PE and cognitive processing do catch up with enough sessions but for people who respond well to EMDR, they respond faster and they get symptom relief faster.

So I think when you’re in a residential treatment or an aftercare program offering EMDR it’s a much more attractive modality to be considering because it’s going to produce faster symptom relief. When patients who have relapsed again and again start to experience substantial symptom relief of long existing symptoms in a few EMDR sessions they become believers. They go, I want more EMDR. Forget about that other stuff.

Can you tell us why EMDR works? – EMDR Discussion – Interview with Dr. Andrew M. Leeds Ph.D.

Well, we aren’t sure exactly how EMDR works and there are several leading models to explain the well established effectiveness of EMDR. So the first thing to make clear is that EMDR is a well established approach to psychotherapy and has shown to be effective for post traumatic stress disorder acute stress disorder and for specific phobias and there is quite a bit of emerging evidence for other conditions as well. The two primary models that are given the widest attention for how EMDR works, the first is the REM orienting response hypothesis and the second is the working memory hypothesis.

Andrew M. Leeds, Ph.D. – Clinical Psychologist

The REM, rapid eye movement or orienting response hypothesis, assumes that the system in the brain for orienting response is behind the effectiveness of EMDR. The REM hypothesis which explains how memory is reorganized during REM sleep. These two actually fit together. So as most mental health professionals are aware all mammals have REM sleep and deep sleep phases and in the REM phase of sleep memory is pruned. Parts of the memory are thrown away without this we would be left with a flood of images and feelings and physiological responses to mildly and severely distressing life experiences.

During REM sleep memory is digested and the unimportant aspects of memory are discarded taking away the emotional vividness, taking away the sensory vividness of memories and leaving us with a gist of these life experiences. The most important parts and the parts we can learn from. Something similar seems to happen during EMDR during the eye movements with EMDR. The unimportant parts of memory. The vividness of the feelings, the vividness of the sensory impressions become weakened and fade. In a way very similar to what happens during REM sleep.

Partially this may be caused by what’s called the orienting response developed by Sokolov a contemporary of Pavlov, who described a multi-phase process for how mammals respond to novel stimuli in the environment. When there’s a novel stimulus in the environment say a noise in the bush and there’s a deer out grazing. Acting under instinctual behavior it hears this noise and it orients towards it. It turns it’s head, it’s ears swivel, it’s eyes scan the environment, it’s nostrils sniff the air, trying to determine whether it’s a threat or not.

One of three things happen at that point. The first is that with orientation there is a spike of arousal and during this appraisal phase that comes right afterwards the animal checks a database stored in the amygdule the flight/fight site of the brain for all previous threat cues and it compares the incoming sensory inputs against what’s stored in the emotional part of the brain. If it’s a predator emerging from the bushes the deer sees it and in 1/25 of a second it’s fleeing. If it’s a big male deer with antlers and the doe was in rut she smells the air and goes prancing of toward the male, something good.

But, if it’s just the wind blowing the bushes it’s determined to be neutral, uninteresting and the arousal hoes down. Well this is what happens with eye movements with EMDR. You have an orienting response. There is a brief spike up as the eye movements begin and then as the amygdule looks out through the eyes it’s kind of in this paradoxical situation because the therapist has activated all the trauma cues active in the imaging in the brain and the same part of the brain where you see current imagery.

When you bring up old memories that are traumatic the same parts of the brain are active as during current sensory perception but the amygdule now is looking at the lights or the hand of the therapist going back and forth and sees something boring. It’s not a threat, it’s not exciting either. So arousal goes down. So the orienting response model says the dearousal is a compelled relaxation response. That’s what David Wilson called it. Part of the normal investigatory or orienting response process. That’s when the emotional parts of the brain perceive boring sensory stimuli.

So, what happens during REM is that emotionally intense material moves to the right hemisphere stored in vivid sensory to the left through a process organized primarily by dopamine. These things seem to go together. The orienting response the REM system in the brain being activated, information becomes decreasingly vivid decreasingly intense and moves from the right hemisphere into a narrative form in the left hemisphere. So that’s the first hypothesis. That’s the REM orienting response hypothesis. There’s not a lot of research behind that but there are some studies that support it. For example, The Quechan study Quechan bermyols and stern I believe did a study showing that with eye movements we become more creative.

We find more creative ideas and it had a very novel research protocol for demonstrating that. Showing that we make new associations more easily when we are making eye movements. The hypothesis with the most research support for it is the working memory hypothesis and this is actively being investigated by a group of researchers in the Netherlands and they’ve done a large number of studies that support this. Showing that both eye movements and auditory tones and the kinesthetic simulation that we use are capable of disturbing working memory. There are several parts of working memory but let stay with visual working memory for just a moment. If you see information written down, say a phone number you want to memorize. You temporarily hold that information in your short term working visual facial template of working memory.

If you then move your eyes it will disrupt the image. You wont be able to hold onto it. Working memory hypothesis researchers have demonstrated through their studies that for most disturbing memories the eye movements are dramatically more efficient at disrupting memory than the auditory tones or kinesthetic stimulation because they disrupt the visual spatial template of short term working memory. However, some clients suffering more from difficulties with sounds of disturbing memories and in some cases the auditory tones may be better for some people but certainly we could use them for people who cannot tolerate the eye movements.

So the working memory hypothesis has shown that different forms of distraction work almost as well as the bi-lateral eye movements that we use. Almost any visual distraction will work. The eye movements are just a little bit more efficient than some others so those are the two leading hypotheses. Now, there are others slightly more esoteric having to do with the role of the thalamus in the brain and a 40Hz binding frequency that’s put out by the thalamus under certain conditions and the eye movements seem to enhance the ability of the thalamus. To put out that 40Hz signal. One of the factors that allows consciousness to occur.

That is for a person to be aware of what’s going on in their brain. Different regions of the brain need to be simultaneously in communication with each other. As you know, during states of disassociation different parts of the brain are active but they’re not in communication with each other. So there is a fragmented experience. The 40Hz signal that’s put out by the thalamus helps to coordinate disparate regions of the brain so that they become into a relationship with each other to create a cohesive experience of consciousness. With all the different facets of sensory perception and memory and cognitive capability.

So, the eyes movements that we use in EMDR seem to enhance the ability of the thalamus to coordinate activity from disparate regions of the brain and allow consciousness to come into play. Another factor of what allows EMDR to work is the process of mindfulness. Some people who have studied meditation have joke that EMDR is like mindfulness meditation on steroids and certainly there is evidence from some of the brain studies that have been done that pre-funnel activation. This part of the brain. The pre-funnel orbital cortex where executive function resides is activated more strongly following EMDR sessions.

It brings the pre-funnel system back online. The pre-funnel system is one of the things that allows the brain to regulate the level of activation in the emotional brain. In the mammalian brain in the limbic system. So enhancing mindfulness is one of the factors that EMDR seems to do. Certainly, the metaphors we use when we do EMDR are intended to enhance mindfulness. We use the metaphor of being on a train and just noticing what’s happening. The need not to have to verbalize but to simply notice things silently, during brief intervals of eye movements.

Enhances the clients ability to mindfully attend to their experience without having to engage in narrative, without disrupting a continuous process of just noticing. The eye movements seem to enhance the brains ability to go into that state of mindful noticing without judging. Which is very different than what happens during prolonged exposure. Where people often go into prolonged intense emotional experiences and are sort of stuck there for an hour or longer. During EMDR the experience of intense emotional reprocessing is typically very brief because mindfulness comes to play, the arousal process comes to play, working memory comes into play and things change very quickly. So those are four of the leading hypotheses for how EMDR works. There are probably some others. I’ll just mention a fifth for fun.

The cerebellum is the part of the brain in the back that used to be thought of as predominately involved with sensory motor coordination. It does a lot of other things. One of the other things the cerebellum does is it helps to regulate our emotional life. A healthy cerebellum is able to down regulate activity in the amygdule. People who were raised with emotional neglect and abuse. You will often hear that they will report that when they become agitated they rock because they can’t quite do this internally in the cerebellum.

The two halves of the cerebellum are not properly connected the cerebellar vermis is incompletely developed. In EMDR when you do bi-lateral eye movements you get activity going on both sides of the cerebellum. It enhances activity in the cerebellum and helps the cerebellum to down regulate excessive activation in the amygdule. Left eye movements are therefore more effective because it’s an active muscular movement of the eyes. Where as passive listening to auditory tones in kinesthetic stimulation don’t activate left right cerebellum nearly as strongly.

So those are five of the possible hypothesis for what’s going on. None of them have been demonstrated conclusively , but there’s new research that’s being done where you can do simultaneous EEG and MEG studies during EMDR In the past we weren’t actually able to monitor the brain during eye movements because it produces a lot of artifacts on EEG. But there are new technologies that are going to allow us to monitor the brain in real time during EMDR sessions. Previously we’ve seen changes pre and post.

We’ve seen what could happen with a spect image before EMDR versus a spect image after. We can see how the over activation in the right hemisphere is moderated the under activation of the left hemisphere is brought up as the information moves from the left to the right side. Increase activation of the pre-funnel regions. Decreased excessive activation in the interior singlet, but we’ve never been able to watch the brain in real time during EMDR. That’s just starting to happen. So, I think these next few years we are going to see a lot more brain imaging studies and other types of brain studies that will demonstrate conclusively exactly what’s happening during EMDR. But you know, we don’t know how other therapies work yet either. So, we have some good hypothesis and the research is coming.

Can you discuss EMDR as an orientation as opposed to a technique? – EMDR Discussion – Interview with Dr. Andrew M. Leeds Ph.D.

There are several facets to that, but it’s a really good point Steve. I’m glad you bring that up because a lot of people do think of EMDR as a simple technique. They think you just think of this disturbing memory and that’s all there is and the rest of the time you’re doing regular therapy. Actually EMDR is not a simple technique it is an approach. What makes it an approach is the adaptive information processing model.

Andrew M. Leeds, Ph.D. – Clinical Psychologist

Imaginable exposure also sometimes talks about the need to do cognitive processing because of the limitations of pure exposure therapy. They don’t understand emotional information processing the way we do in the EMDR world, through the lens of adaptive information processing model. The AIP gives us an idea of how memories are organized. It gives us an idea of how people omit adaptive behaviors. It isn’t that people are bad. It isn’t that people want to do bad things. People process reality, they process their experience through the lens of what’s stored in their brain and it’s stored in maladaptive ways and the way that they perceive the world is going to be maladaptive. If you see someone smile at you, you might think that’s a friendly person.

Someone else looks at that person and thinks, what are they trying to get out of me? How are they trying to manipulate me? That suspiciousness, the paranoia, responding to innocuous cues in the environment as if there is a trauma that’s about to happen. Like combat veterans who hear a loud noise and think that they’re under attack. This is what’s stored in the brain. Understanding the way that dysfunctional stored material is organized in the brain is informed by the AIP model. So we need the model to be able to conceptualize what’s happening with our clients and how to develop treatment plans with the simplest cases. With a single incident trauma you don’t need a complicated plan, but those types of cases are relatively rare. Most of the cases that we see are either complex trauma cases or they are cases with co-occurring disorders.

With co-occurring disorders the way you’re going to organize the treatment plan , the sequence of targets you’re going to work with needs to be carefully selected to meet the needs of that person. Without the AIP model I don’t know how people would be able to figure that out. You need to understand the model. So in the beginning when clinicians are first trained in EMDR they often don’t understand the importance of the model and they are approaching EMDR as just a technique, but when they start having some successes and some treatment failures then they come back for more consultation and they begin to appreciate more and more the need to think within the model in order to be successful with a wider range of clients.