Eye Movement Desensitization and Reprocessing (EMDR) Therapy
What Is EMDR?
Eye Movement Desensitization and Reprocessing (EMDR) is a therapy method developed in the late 1908s to treat trauma and PTSD by minimizing the effect of traumatic memories. Emotional distress that many people experience is usually a result of disturbing life experiences. The primary goal of EMDR therapy is to treat and alleviate underlying trauma to assist with the overall addiction recovery process. Extensive research has determined that EMDR is highly effective in treating clients with PTSD as well as those with one or more of the following symptoms:
- Repression of Traumatic Events
- Flashbacks of Traumatic Events
- Nightmares and/or Disturbing Dreams
Physical Reactions to Stress
When a person is subjected to stressful and traumatic situations, the body is designed to react by either fighting or fleeing.
Physical reactions include:
- Pupil Dilation
- Tense Muscles
- Slowed Digestion
Within seconds, the body is poised and ready for some sort of reaction. The physical reactions listed above, and all associated work, occurs in the person’s subconscious mind. A person has no control over these reflexes. These reactions cannot be turned on or off with conscious thought. While this response to stress can be helpful, it can be so powerful that some people find that they cannot stop feelings of nervousness and stress after the traumatic event has passed. People that experience this are commonly diagnosed with Post-Traumatic Stress Disorder (PTSD). Research suggests that therapies such as EMDR which combine talk therapy with eye movement help to restore a person’s ability to relax and feel normal again, minimizing the effects of past traumatic events.
Living With PTSD
When people hear about PTSD, they often visualize a veteran who has been through the fog of war. However, there are many traumatic events that take place every day very far from a war zone that can cause PTSD. In fact, PTSD is a mental illness that can develop in response to many different types of traumatic events. These events can include:
- Rape/Sexual Abuse
- Mental/Physical Torture
- Witnessing Death or Murder
- Mugging or Physical Assault
- Plane Cashes or Automobile Accidents
- Earthquakes or Other Natural Disasters
- Trauma to Loved Ones
The National Alliance on Mental Illness (NAMI) suggests that people who have PTSD feel alert and agitated all the time, even when in a place the affected person previously considered to be safe.
Symptoms of PTSD
Symptoms of intrusive memories may include:
- Recurrent, unwanted distressing memories of the traumatic event
- Reliving the traumatic event as if it were happening again (flashbacks)
- Upsetting dreams or nightmares about the traumatic event
- Severe emotional distress or physical reactions to something that reminds you of the traumatic event
Symptoms of avoidance may include:
- Trying to avoid thinking or talking about the traumatic event
- Avoiding places, activities or people that remind you of the traumatic event
Negative changes in thinking and mood
Symptoms of negative changes in thinking and mood may include:
- Negative thoughts about yourself, other people or the world
- Hopelessness about the future
- Memory problems, including not remembering important aspects of the traumatic event
- Difficulty maintaining close relationships
- Feeling detached from family and friends
- Lack of interest in activities you once enjoyed
- Difficulty experiencing positive emotions
- Feeling emotionally numb
Changes in physical and emotional reactions
Symptoms of changes in physical and emotional reactions (also called arousal symptoms) may include:
- Being easily startled or frightened
- Always being on guard for danger
- Self-destructive behavior, such as drinking too much or driving too fast
- Trouble sleeping
- Trouble concentrating
- Irritability, angry outbursts or aggressive behavior
- Overwhelming guilt or shame
How EMDR Therapy Started
Dr. Francine Shapiro discovered EMDR Therapy in 1987 while she was walking in a park. She noticed that she had visualized upsetting thoughts and feelings, but they quickly subsided. She questioned why the thoughts quickly left her mind and decided to investigate the answer to her mystery. Dr. Shapiro began to experiment on a way to minimize traumatic thoughts and memories when they occur in the brain. She observed that when she moved her eyes back and forth rapidly while these traumatic thoughts were in her mind, the thoughts would begin to subside. She developed a protocol that is now known a Eye Movement Desensitization and Reprocessing Therapy, or EMDR for short. With this new protocol developed, Dr. Shapiro began to work with people suffering from Post-Traumatic Stress Disorder. After multiple therapy sessions, people with PTSD reported that their symptoms had decreased. Since the development of standard EMDR protocols, this therapy has become one of the most researched psychotherapeutic treatments for trauma.
Benefits of EMDR in Addiction Treatment
EMDR therapy is frequently used in conjunction with Cognitive Behavioral Therapy (CBT) techniques in a drug and alcohol treatment program. Depending on the client’s individualized treatment plan, EMDR therapy may be used in both individual and group settings. EMDR in an addiction treatment environment allows a therapist to resolve trauma, which has been identified through clinical research to address the root causes and contributing factors of an individual’s addiction who has suffered traumatic life events.
EMDR provides benefits for patients in drug and alcohol rehabilitation programs. These benefits include:
- Alleviating psychological symptoms of trauma and PTSD
- Alleviating physical symptoms of trauma and PTSD
- Reducing stress from disturbing memories
- Improving the self-esteem for the patient
- Resolving present and future trauma triggers
Concurrent treatment of PTSD and substance use disorder has been found to be more effective than treatment focusing on one disorder alone. Since 1994, the use of EMDR therapy for treating addictions as part of an overall treatment plan has been discussed and experimented with by many therapists. Existing research offers many insights as to how EMDR therapy can be implemented into a comprehensive addiction treatment plan for clients suffering from addiction as a result of past trauma. Upon reviewing the data collected on treatment completion, it has been concluded that integrating EMDR therapy into an addiction treatment program can improve graduation rates and decrease the number of relapses. EMDR therapy can lead to significant changes in PTSD symptoms by targeting traumatic memories with the standard protocol. By reducing the impact these past traumatic events have on the patient, the patient is in a better mental state to accept the other therapies which increases the likelihood they will be in a better mental state to manage their long-term sobriety.
Stages of EMDR Treatment
Throughout the eight phases of EMDR treatment, the client works with their therapist to resolve traumatic experiences through a learning state that allows the memory of traumatic experiences to be stored with appropriate emotions in the brain. The negative symptoms of these traumatic memories will dissipate as those experiences are resolved. This allows the client to be left with healthy emotions, understanding of past trauma, and have new perspectives of those experiences.
EMDR treatment incorporates the following eight stages of treatment:
- Client History & Treatment Planning –The therapist collects a detailed history of the client in an effort to develop an appropriate treatment plan.
- Preparation– During the preparation stage, the therapist defines the goals and expectations for treatment. Next, the therapist helps the client develop techniques for self-control which they can use during EMDR sessions. The therapist will discuss the client’s past trauma and how it relates to their substance abuse disorder to establish an understanding of the treatment process that is to be performed during their addiction rehabilitation treatment.
- Assessment– The therapist and client identify a past traumatic memory that will be the focus of the session. The client chooses a scene that best represents that memory and makes a statement that expresses a negative self-belief associated with the event. The therapist then asks the client to make a positive statement that contradicts the negative belief.
- Desensitization– The therapist guides the client through a series of eye movements while they focus on their selected scene. During this time, the therapist encourages the client to be open to the unfolding thoughts. After each series of eye movements, the therapist instructs the client to stop focusing on the scene they were previously focused on.
- Installation– During the installation phase, the goal is to increase the strength of the positive belief the client has associated with the scene. By pairing the positive belief with the previous negative belief, it is believed the negative associations with the scene are reduced.
- Body Scan– The therapist asks the client to visualize the same scene again, but this time, take notice of any tension that remains when the scene is visualized. Tension can manifest physically as well as mentally. If there is tension, the therapist will help the client target each of these sensations for reprocessing to reduce and eliminate any remaining negative physical or mental stressors associated with the visualized scene.
- Closure– The client uses their self-control techniques they learned during the second phase and uses them to restore an internal state of balance. The client is asked to journal any disturbances they experience in between sessions.
- Reevaluation– Over time the client will be reevaluated to ensure the therapy has a lasting effect. During these sessions, the therapist revaluates the client’s progress to ensure it has been maintained and identifies any new target areas that require treatment.
Childhood Experiences, PTSD, and Addiction
Early life experiences are an important risk factor in addiction. The Adverse Childhood Experiences (ACEs) study showed that the number of adverse childhood experiences was highly associated with the incidence of addictive behaviors in adults. Traumatic experiences in childhood are also associated with presence of multiple chronic diseases in a patient, which may not include the typical symptoms seen in posttraumatic stress disorder (PTSD). Although these adverse childhood experiences are an important risk factor in the development of an addiction, they may also go unreported when screening for PTSD.
Once vulnerable individuals are introduced to a substance, other factors add to the transition from recreational use to addiction. Addictive behavior is characterized by compulsive engagement in reinforcing stimuli. This reinforcement can either be positive emotions and physical sensations, or from peer group approval. It is assumed that the first increase in problematic behavior is driven by positive reinforcement. As the addiction worsens, negative reinforcement reflecting relief or avoidance of burdensome responsibilities becomes more and more important to the addicted person. Negative reinforcement may also reflect an early motive for ongoing use in first-time users with psychiatric problems such as people with a depressed mood, anxiety, or posttraumatic intrusions.
EMDR can help relieve strong memories that are activated when an addicted person is anticipating or experiencing drug effects, withdrawal symptoms, cravings, or relapse. These memories are part of what has been called “the addiction memory”. These memories are activated not only by using drugs or alcohol, but also by the anticipation or visualization of using the drugs or alcohol. Whenever a memory of substance abuse is triggered, it may induce positive feelings, a negative feeling, or a craving. Individuals may also be triggered by thinking about an addiction-related situation or idealized future incident. If the user’s memories are emotionally charged, they are thought to be capable of motivating and influencing behavior.
Challenges in Addiction Treatment
Many people that need help do not have the resources to afford the help they need. Many people who do have the resources drop out of treatment without completing the program. Substance abuse disorder is seen as a chronic condition characterized by periodic relapses, so treatment often requires multiple interventions and ongoing monitoring. Studies show that more than 85% of patients relapse within the first year of completing a drug and alcohol treatment program. Those who remain in treatment generally find a way to abstain from substances and live a more balanced sober lifestyle. A sober lifestyle is associated with decreased criminal activity, and improvements in occupational, social, and psychological functioning.
Pharmacotherapy efforts aimed at reducing cravings, blocking the effect of opioids, or inducing adverse sensations after alcohol consumption have shown to increase treatment success. However, pharmacotherapy has been shown to present issues limiting its efficacy, such as unsafe use or misuse. Many patients also stop taking or refuse medication because of side effects, limited effectiveness, or their views on medication use. Finally, for most addictions, there are no effective pharmacotherapeutic options.
Cognitive-Behavioral Treatment (CBT) is a common treatment method used in addiction treatment.
Cognitive-Behavioral Treatment commonly includes:
- Providing the client incentives to remain abstinent
- Changing the client’s attitudes and behavior towards substance abuse
- Enhance coping skills to manage stress and prevent cravings
- Typical interventions for addiction aimed to enhance self-control
While Cognitive-Behavioral Treatment is an effective tool used when dealing with substance abuse disorder, it can be further enhanced when paired with EMDR therapy. The effectiveness of CBT is partially limited when we look at both treatment retention and relapse rates for people with traumatic incidents in their past. Eye Movement Desensitization and Reprocessing (EMDR) therapy fits these requirements. EMDR therapy is a well-known therapy for the treatment of PTSD so it can be applied in addiction disorders to treat symptoms resulting from adverse, traumatic life experiences. In addition, adapted EMDR therapy protocols that focus on the addiction itself have shown promise as well, especially in alcohol use disorder.
EMDR Addiction-Specific Protocols
EMDR addiction-specific protocols are based in the same model as standard-protocol EMDR therapy. The authors of these protocols put forward as a basis of argument that whether an addiction is chemical or behavioral, the symptoms can be reduced by the use of EMDR and other ongoing treatment.
The DeTUR Protocol
The DeTUR protocol is different from the standard EMDR protocol. It focuses on the client’s present conditions that cause uncomfortable feelings leading to cravings to abuse drugs or alcohol. Once the client’s triggers for using are no longer activated, past issues are addressed. The protocol uses the level of urge (LOU) as the unit of measurement that guides the therapy. Clients are empowered by accessing and installing positive resource goals, reducing triggers to use, and developing greater resistance to relapse.
The Craving Extinguished Protocol (CravEx)
Information about the CravEx protocol was first published in 2009. In this study, a group receiving standard addiction treatment along with EMDR showed a statistically significant reduction in addiction craving 1 month after treatment compared to a group receiving only standard addiction treatment. As with the standard protocol, CravEx addresses the past, present, and future. However, this protocol focuses primarily on addiction memories. Memories of strong drug or alcohol cravings or past relapses are targeted during EMDR therapy sessions.
Feeling-State Addiction Protocol
The Feeling-State Addiction Protocol was first introduced by Robert Miller in 2012. The results of this study show that the part of the protocol that targeted the feeling state was effective in reducing the client’s reactions to the visualized stimuli. Robert Miller’s study also suggests that the feeling states that were targeted may have affected the corresponding behavioral addictions. According to Robert Miller, “the feeling state is conceived as a memory that has been isolated from the overall memory network”. The feeling state connected to addictive behavior consists of any positive feeling that becomes linked with specific behaviors. When the feeling state is triggered, the entire psychophysiological pattern is activated and triggers out-of-control behavior. By targeting the feeling state, the EMDR can connect the isolated memory with the larger memory network and the brain’s more adaptive functioning resulting in changes in behavior.
Effective Studies on EMDR in the Treatment of Drug Addiction
|Study||Addiction||PTSD/Trauma Exposure||EMDR Interventions (Number of Sessions)||Other Interventions||Main Findings||Comments|
|Abel and O’Brien (2010)
Journal of EMDR Practice and Research
|Alcohol||PTSD/single trauma||AF-EMDR (DeTUR and CravEx) and TF-EMDR (3 years, weekly sessions)||AA visits||After 2 years, the patient was still sober and in treatment while PTSD was still in remission.||Typical example of untreated PTSD before referral. Nice demonstration of tailored integrated treatment of AF and TF-EMDR.|
|Brown, Gilman, Goodman, Adler-Tapia, and Freng (2015)
Journal of EMDR Practice and Research
|Various substances||150 patients with trauma history (criterion A) of whom 41% had PTSD||Voluntary TF-EMDR for patients with trauma in history (average 12 sessions, range 4–29)||Structured 12- to 18-month court program for convicts of nonviolent, drug-related crimes plus “seeking safety” groups for those with trauma history.||Patients who chose additional TF-EMDR after seeking safety (n = 65) graduated at a rate of 91%; those who declined (n = 47) graduated at 57%. Recidivism: 12% for patients who chose additional TF-EMDR, 33% for those who declined.||Voluntary T-trauma specific treatment seems to improve court program outcomes, even if symptoms are below PTSD-threshold.|
|Hase, Schallmayer, and Sack (2008)
Journal of EMDR Practice and Research
|Alcohol||Some patients with PTSD||AF-EMDR (CravEx): craving/relapse (2 sessions)||Two-week inpatient treatment as usual (TAU: detoxification, motivational interviewing, AF-group therapy)||At follow-up (1 month), patients allocated to TAU + EMDR had less craving, relapse and depressive symptoms than patients in TAU group.||The only RCT in this field. Very promising results, even after two sessions. However, study dropout was very high.|
|Kullack and Laugharne (2016)
Journal of EMDR Practice and Research
|Alcohol/various substances||PTSD (single trauma in adulthood)||TF-EMDR (±6 sessions)||Patients were referred for PTSD; substance abuse worsened after the traumatic event. No additional treatment for the addiction||At 12-month follow-up, all patients reported a significant decrease in PTSD symptoms as well as in addictive behavior. Three patients no longer met criteria for substance use disorder.||This study describes four cases that support the self-medication hypothesis for the relationship of PTSD and substance use.|
Psychology of Addictive Behaviors
|Various substances||Trauma history, not necessarily PTSD||TF-EMDR (Unknown number of sessions)||Women in long-term addiction, trauma, and mental health treatment on an outpatient basis, integrated with safe and affordable housing||The women were interviewed at least 6 months after EMDR therapy. The participants judged EMDR as important in their addiction treatment||In line with self-medication hypothesis, patients said that it was important that EMDR helped them to access their core emotional issues that had prompted them to use drugs.|
Journal of EMDR Practice and Research
|Compulsive behaviors||No data on trauma history or PTSD||AF-EMDR (FSAP): positive targets (feeling states) related to compulsive behaviors (Unknown number of sessions)||No other interventions. No sobriety required. The patient continues the behavior for further enquiry.||All participants reported that their compulsive behavior was eliminated after the intervention. In three patients the link between the processing and reduced reactivity to the visualized behavior was demonstrated.||Nice example of multiple baseline design: two compulsive behaviors were treated in random order.|
|Shapiro, Vogelmann-Sine, and Sine (1994)
Journal of Psychoactive Drugs
|Opiates||Trauma history (physical/emotional abuse)||TF-EMDR||Individual outpatient treatment with trauma-, coping- and addiction-related goals||18 months sober after start of therapy. EMDR therapy seemed to have accelerated recovery from opioid addiction.||First case documentation of combining trauma treatment and treatment for addiction|
|AF-EMDR: triggers for relapse (Unknown number of sessions)|
|Zweben and Yeary (2006)
Journal of Chemical Dependency Treatment
|Alcohol||Trauma history/PTSD||SPP, RDI, TF-EMDR: triggers (Unknown number of sessions)||The authors argue that EMDR therapy may provide a powerful addition to addiction treatment in traumatized patients.|
EMDR and Negative Flash-Forwards
Many PTSD patients are not only affected by memories and thoughts past traumatic events, but also by disturbing visions of possible future events. These future-oriented thoughts, or memory representations, take the characteristics of flashbacks and apply them to possible future events. These visions can be emotionally charged as well as intrusive and are a direct symptom of the traumatic memories in the person’s mind. EMDR research suggests these future-based flash-forwards can be removed of their emotional impact on the mind with EMDR.
Flash-forwards should not be confused with “future templates”. These are visualizations of successfully managing an anticipated future event. In contrast, flash-forwards are visualizations of “worst-case scenarios”. These flash-forwards are unrealistic because the thought is extremely negative so the probability it will occur is overestimated.
Clinical research has identified two main kinds of negative flash-forwards that may add to the difficulty addicts experience when attempting to break their addiction to drugs or alcohol. These include flash-forwards of abstinence, as well as flash-forwards of a future relapse. It has been found that both the fear of abstinence and the fear of relapse may be driven by emotionally thoughts and images which may interfere with EMDR therapy goals.
Can You Benefit from EMDR Therapy?
EMDR is an effective treatment for psychological trauma. This therapy is recommended by the World Health Organization for treating Post-Traumatic Stress Disorder. There are many studies that show this treatment is safe and effective for PTSD. PTSD has been identified as an underlying cause for substance abuse disorder. If you are suffering from PTSD and Substance Abuse Disorder, you may be a good candidate for EMDR therapy in an addiction treatment environment. The effectiveness of EMDR in standard clinical addiction treatment programs has been compared to the effectiveness of addiction treatment programs alone. Many benefits were identified within the group receiving EMDR therapy. EMDR is more effective than standard medical treatment alone in reducing psychological trauma, in improving health-related quality of life, and improving the outcome of those in a long-term addiction treatment program. If you have been the victim of traumatic events that may have added to the cause of your addiction, we advise you to seek EMDR treatment in an addiction treatment setting.