Eye Movement Desensitization and Reprocessing (EMDR)

Eye Movement Desensitization and Reprocessing therapy, or EMDR, is an effective form of treatment for trauma. It is well-researched and considered an evidence-based practice for trauma treatment. Trauma can come in many forms and can be a single event such as a car accident and natural disasters, or chronic as in abuse, neglect, or domestic violence, or even long-term medical problems and medical trauma. Even common upsetting childhood events such as divorce, school issues, or peer relationship difficulties can be treated with EMDR therapy. EMDR can also be used to treat anxiety, depression, phobias, and complicated or traumatic grief. EMDR can also be used with pre-verbal trauma that occurred in the very early years that the child may not even have explicit memories of. 

When an upsetting, painful, or scary experience occurs, sometimes the brain does not know how to handle it and the memory stays stuck or frozen in the mind and body. These memories are also often encoded in fragments, which is why seemingly random things, like a smell, color, facial expression, tone of voice, or place, can be triggering. These traumatic events continue to be experienced in distressing and intrusive ways that don't always make sense to us. The child may learn to cope by avoiding everything associated with that experience or developing other maladaptive coping mechanisms that made sense when they were still in danger but are super unhealthy and unhelpful now. It can feel like they go from totally okay to totally NOT okay in what feels like milliseconds. The child may also experience distressing emotional, physical, sensory, and behavioral dysregulation that is difficult to understand, predict, or regulate. 

EMDR utilizes bilateral stimulation (BLS), a process that activates the left and right hemispheres of the brain. During EMDR therapy, bilateral stimulation can be in the form of eye movements, sounds, tapping, vibrations, or other movements incorporating both hemispheres of the brain. The bilateral stimulation processes events similar to the way the brain does at the end of the day while dreaming during REM sleep. For children, play therapy is also integrated with the addition of elements like puppets, magic wands, art, sand, movement, and games.

EMDR was developed beginning in 1987, when psychologist Francine Shapiro observed how eye movements reduced the intensity of negative disturbing thoughts. EMDR has been adapted and used worldwide to help children after such incidences such as the Sandy Hook school shooting, the tornadoes in Joplin, MO, and after 9/11.

Aside from helping children process disturbing events, EMDR can also strengthen confidence and feelings of regulation. This is how most EMDR sessions begin, resourcing positive emotions and sensations. Then, the child is asked to recall the upsetting event. Through the use of eye movements or other bilateral stimulation, the child eventually becomes desensitized or deactivated by the disturbing memory. Reprocessing happens as new emotions and sensations are paired in the brain with the past feelings and images. The goal being for the child to recall the events as something that happened with the present believe that it’s over and I’m safe.

Sometimes, with attachment trauma or early childhood trauma, parents or caregivers are involved in some of this desensitization and processing. For example, a common method used with children, particularly those very young children, those with pre-verbal trauma, or those who have a very difficult time talking about their trauma, is the Storytelling Method. In this method, the therapist helps the child create a story/narrative of both positive and negative memories and events in the child’s life. 

Sometimes the caregiver will need to give additional information to help finish the story. The story is then read aloud while using bilateral stimulation (such as a caregiver, if they are available, tapping on the child’s shoulders or knees or rocking them back and forth) to help reprocess and integrate the trauma. The caregiver is often asked to do the same at home regularly between sessions (often with an abridged version if there are multiple traumatic events) and help keep track of the child’s stress related with the traumatic events.

EMDR is structured into several phases to ensure a systematic and safe process of trauma resolution.

Phase 1: History-Taking and Treatment Planning: In this initial phase, the therapist works closely with the child and the caregiver(s) to gather information and develop a treatment plan. Key activities include:

• Assessment: The therapist assesses the child's trauma history, current symptoms, and      emotional state. This helps tailor the treatment to the child's specific needs. This may include directive, nondirective, or formal standardized assessments with parents and children. These assessments are often regularly completed throughout treatment to track progress.
• Building Rapport: Establishing a trusting and comfortable relationship between the child and therapist is crucial. This phase often involves play, conversation, and activities that help the child feel safe.
• Educating Parents: Parents are educated about the EMDR process and how they can      support their child during therapy. Their involvement is crucial in creating a supportive environment for healing.

Phase 2: Preparation: During this phase, the therapist helps the child develop coping skills and teaches them how to manage distressing emotions. Key components include:

• Emotional      Literacy: Emotional literacy involves recognizing, understanding,      expressing, and effectively managing emotions in ourselves and others. The therapist and child work together to expand emotional vocabulary, develop insight into their emotions, recognize different triggers for different emotions, and better interpret and identify the physical sensations in our bodies associated with various emotions. 
• Coping Strategies: The therapist and child work together to develop healthy coping strategies that can be used during distressing moments. It is key that these are also practiced at home during both calm and stressful times!
• Resource Building: Children are encouraged to identify internal and external resources (e.g., strengths, support systems) that they can use to manage their feelings.
• Explanation of EMDR: The therapist explains the EMDR process in an age-appropriate      way, ensuring the child understands what to expect.

Phase 3/4: Assessment and Desensitization: These phases involve processing and desensitizing the traumatic memories, as well as identifying the negative beliefs they have about themselves because of the traumatic experiences. The child also identifies alternative, positive beliefs they would like to have instead. This is often when the child will begin crafting their narrative story with the therapist. Key steps include:

• Target Identification: The child, with the therapist's guidance, selects specific traumatic memories or distressing experiences to target during EMDR sessions. In EMDR, targets are the specific memories, images, thoughts, or sensations associated with distressing experiences that your child wants to address during therapy. Children are asked to rate their distress associated with the traumatic memories through Subjective Units of Distress (SUDs) 0-10. Subjective Units of Distress (SUDs) is a scale used in EMDR therapy to measure the intensity of distress experienced by your child when recalling specific memories or experiences. SUDs range from 0 to 10, with 0 representing no distress and 10      representing extreme distress. Your child may be asked to rate their level of distress before and after processing a particular memory to track their progress and the effectiveness of EMDR therapy. The goal of EMDR therapy is that your child will be able to have effectively participated in the desensitization activities that their SUDs level will reach and maintain      0, or as close as possible to 0. This means that those traumatic or stressful events and experiences will no longer overwhelm your child and a healthier integration of those events has been able to occur. For younger children, the therapist may create a more developmentally-appropriate scale to help assess and monitor the SUDs level, such as a “small, medium, big” scale or one that involves pictures of animals or other concepts to      represent different severity levels.
• Identifying Negative Cognition(s): Negative Cognitions (NC) refer to the negative beliefs or thoughts your child holds about themselves, others, or the world as a result of distressing experiences. These negative cognitions often contribute to feelings of low self-esteem, helplessness, or worthlessness.
• Identifying Positive Cognition(s): Positive Cognition (PC) is the opposite of your child’s identified negative cognition and involves identifying and reinforcing positive beliefs or thoughts that your child can adopt to replace negative ones. These positive cognitions reflect your child's strengths, resilience, and ability to cope with challenging situations.      Usually your child’s therapist will ask the child “what would you like to believe/think instead?” after they have identified their negative cognition related to their traumatic experiences. Through EMDR therapy, your child can develop and internalize more positive beliefs about themselves and their abilities, leading to greater self-confidence and      emotional well-being. The strength of these PCs is monitored and assessed with the Validity of Cognition (VOC) scale.
  • The Validity of Cognition (VOC) is a term used in EMDR therapy to assess the       accuracy and truthfulness of the beliefs associated with distressing memories. It involves evaluating whether the beliefs your child holds about themselves or the world are valid or based on accurate information.  During EMDR therapy, the therapist helps your child examine the validity of these negative beliefs and encourages the development of more realistic and adaptive perspectives. In traditional EMDR, their Positive Cognition, or their more positive, helpful thought/belief, is regularly       assessed on a 1 to 7 scale, with 1 being that the thought feels totally false and 7 meaning it feels totally true. The goal of EMDR therapy is for the child’s VOC of their Positive Cognitions to reach and maintain a  7. For younger children, the therapist may create a more developmentally-appropriate scale to help assess and monitor the VOC       level, such as a “small, medium, big” scale or one that involves pictures of animals or other concepts to represent different strength levels.
• Bilateral Stimulation (BLS): Using techniques such as eye movements, sounds, or      tapping, the child processes the chosen memory while maintaining bilateral (left-right) stimulation. BLS is often used on a faster or higher intensity while processing stressful or traumatic events and memories.
• Self-Regulation: The child is taught to notice and manage any distress that arises during      the processing.

So what are some examples of ways that the therapist will help my child in Phase 4-Desensitization to process the traumatic or stressful experiences? Play-based desensitization and processing activities are particularly effective in EMDR therapy with children as they engage the child in a way that feels natural and non-threatening.

· Storytelling: The therapist may use storytelling as a way to help the child externalize and process their experiences. They may read or create stories that reflect the child's feelings and experiences, allowing the child to explore difficult topics in a more abstract and metaphorical way.

· Drawing or Art Therapy: The child may be encouraged to express their feelings and experiences through drawing, painting, or other forms of artistic expression. The therapist can then guide the child in discussing and processing the artwork, helping them make connections between their emotions and the traumatic memories.

· Sand Tray Therapy/Sand Play: The child is provided with a tray filled with sand and a variety of miniature objects. They can use the objects to create scenes or representations of their experiences. The therapist facilitates discussion and processing of the scenes, helping the child explore their feelings and perceptions in a safe and nonverbal way.

· Writing or Journaling: The child may write about their thoughts, feelings, and experiences related to the traumatic memories. The therapist can then guide the child in processing the written material and identifying patterns or themes that emerge.

· Creative Visualization: The child is guided through creative visualization exercises where they imagine themselves in a safe and comforting place or visualize positive outcomes related to their traumatic experiences. This can help the child build a sense of safety and empowerment during desensitization. The therapist can also guide the child to visualize and imagine various elements of the traumatic memories or experiences and guide them through various techniques and activities to process and desensitize the stress related to them. 

· Role-Playing with Dolls, Action Figures, or Puppets: The child uses dolls, action figures, puppets, or stuffed animals to act out different roles and scenarios related to their traumatic experiences. This allows the child to explore and express their feelings in a safe and controlled environment. The therapist encourages the child to incorporate elements of their own experiences into the stories, allowing for exploration and processing in a playful context.

Phase 5: Installation: In this phase, positive beliefs and emotions are reinforced to replace negative ones associated with the traumatic memories. This includes:

• Positive Cognitions: The child identifies and strengthens positive beliefs about      themselves, their safety, and their ability to cope. The child is asked to rate the strength of their positive thoughts through a scale called the Validity of Cognition (VOC) 1-7.
• Bilateral Stimulation: Similar to Phase 3, bilateral stimulation is used to reinforce these positive beliefs; however, a slower intensity of BLS is used for more positive thoughts and events.

Phase 6/7: Body Scan and Closure: The therapist helps the child focus on any remaining physical tension or discomfort associated with the trauma. This phase also involves:

• Calm and Comfort: The child is encouraged to feel calm and safe. Any residual distress is addressed, ensuring the child leaves the session feeling as comfortable as possible. This often involves enjoyable/calming activities or free play.

*A complete treatment of EMDR therapy will often involve multiple courses of phases of desensitization, installation, and body scans/closure for multiple traumatic events or stressors until the Subjective Units of Distress (SUDS) are self-reported as 0s for each traumatic stressor and the Validity of Cognition (VOC) of each positive thought is a 7/7.

Phase 8: Reevaluation: In this final phase, the therapist assesses the child's progress and addresses any remaining issues. It involves:

• Reassessing Symptoms: The therapist and child review the child's symptoms and      functioning to ensure that positive changes have occurred. The therapist will also consult with you to acquire feedback.
• Closure: The child, therapist, and you will discuss the progress made and plan for future support if necessary.