Integrated Approaches

Eye Movement Desensitization and Reprocessing (EMDR)

Eye movement desensitization and reprocessing emerged as a trauma treatment from the astute observations of Dr. Francine Shapiro in the late 1980s. It has been used since and has enjoyed empirical support as an effective treatment for PTSD. It is considered an integrated treatment because it combines cognitive, behavioral, neurophysiological, and information-processing elements. Eye movement desensitization and reprocessing has gone from being a heavily doubted and suspiciously acknowledged therapy to being more widely used in the years since its introduction and being used with a wide range of clinical populations. Some consider it a significant breakthrough and substantial advancement in the treatment of PTSD (Parnell, 1997).

Rationale and Theoretical Basis

Although EMDR has enjoyed both clinical and empirical success as an effective treatment, the underlying mechanisms by which it works are still unclear. Smith and Yule (1999) warn that the theoretical understanding of how EMDR works lags behind its clinical practice. They summarize the current theoretical understanding:

At the heart of EMDR is the notion that accelerated processing of disturbing material can be directly facilitated at a neurophysiological level using a variety of dual attention tasks. Accordingly, a by-product of resolution at the neurophysiological level is cognitive and emotional well-being. (p. 267)

The origins of EMDR seem part of a clinical myth of sorts told by the EMDR creator, Francine Shapiro. Dr. Shapiro states that essentially by accident, while walking through the woods one day, she discovered that some disturbing thoughts she had been having disappeared in conjunction with the rapid backward, forward, and upwardly diagonal movements of her eyes. From this discovery, EMDR was born. Shapiro (1995) proposes that the directed eye movements utilized in her treatment have a direct effect on the neurophysiological status of trauma material, resulting in desensitization and cognitive restructuring. Eye movement desensitization and reprocessing, to some, is viewed as another form of cognitive-behavioral therapy with a more direct physiological interface. Consider that food might be thought of as a form of chemotherapy (albeit slower) for cancer. Cognitive-behavioral therapy might be likened to food as chemotherapy, while EMDR might be considered the chemotherapy of trauma, simply a more direct form of mental change.

Lipke (1992) has proposed that EMDR elicits an orienting reflex that alters neurophysiological functioning by disrupting the configuration of the traumatic memory network, thus allowing proper information processing to resume. Marquis (1991) proposes that rapid eye movements (REMs) interrupt the neural connections between the frontal lobes, hypothalamus, and hippocampus and break the stimulus-response relationships produced by the symptoms. Shapiro herself in 1992 proposed that the eye movement procedure results in synaptic changes in mood-memory networks, lowering the bioelectrical valences within the network and allowing for more thorough processing. Smith and Yule (1999, p. 277) state, "The notion is that any shaking up of the neurophysiological system will automatically lead towards a more adaptive resolution." In some ways, then, EMDR might be related to the causal therapeutic mechanisms of electroconvulsive therapy (ECT), but this is solely conjecture at this point.

Work by Ross, Ball, Sullivan, and Caroff (1989), Winson (1993), and Nicosia (1994) suggest that EMDR's induction of alternating attention may have the same effects as REM sleep on the consolidation of memories. Shapiro (1989a)

and Nicosia (1994) propose that EMDR creates alterations in brainwave activity between cerebral hemispheres that allow for consolidation and interhemispheric communication. (For more on the biology of PTSD, see Chapter 6.) In 1995, Shapiro proposed an overall theory for EMDR coined the accelerated information-processing model in which distorted memory processes are integrated through EMDR's activation of a self-healing process of memory consolidation. Regardless of the findings, a fully empirically supported model of EMDR is yet to emerge; this should not, however, suggest that it is any less clinically effective.

The EMDR Process

Chemtob, Tolin, van der Kolk, and Pitman (2000a) outline the EMDR process in an eight-step process. Step one includes taking a patient's history, and, in addition to traditional clinical assessment, the EMDR clinician identifies trauma memories considered suitable targets for treatment. In the next stage, preparation, information about EMDR is provided, along with the teaching of coping skills for general functioning, for dealing with emergent traumatic material, and for keeping perspective when the trauma is reactivated. Following the preparation stage, in the assessment stage, the patient is asked to "bring together the components of the traumatic memory in a structured manner" (p. 141), including identifying distressing images, negative thoughts, and alternative positive thoughts; rating the validity of the positive thoughts; rating the subjective level of distress; and identifying physical sensations as they occur.

The fourth stage of the procedure is identified as desensitization and reprocessing. The patient is instructed to hold the disturbing image, negative thoughts, and physical sensations in the mind. While doing this, the clinician moves his or her fingers back and forth about 12 inches in front of the patient's eyes while the patient is instructed to follow the fingers. After 20 or so back-and-forth movements, the clinician stops and instructs the patient to "let go of the memory, take a deep breath, and provide feedback" (p. 142) about any experienced changes, such as new memories, sensations, or thoughts.

The fifth stage involves instructing the patient to think of his or her earlier generated positive thoughts while focusing on the target image. While doing this, another eye movement session is performed, followed by an assessment of the validity of the positive thought. This process is repeated until the positive thought is eventually rated as high on the validity scale as possible. Similarly, in the sixth stage, this process is undergone with focus on the physical sensations, tension, and discomfort until subjective distress is substantially reduced.

The final two stages involve closure and reevaluation. In stage seven, the patient is instructed on how to use a variety of relaxation techniques to maintain calm between sessions. Journaling is also encouraged. Finally, stage eight involves an assessment of whether treatment goals have been reached, and additional sessions are planned and arranged to address what remains and what has emerged between previous sessions.

Feminist Therapy for Trauma

Feminist therapy is about many things, but its core is designed to bring about healing through the development offeminist consciousness, defined as "awareness that one's own suffering arises not from individual deficits but rather from the ways in which one has been systematically invalidated, excluded, and silenced because of one's status as a member of a nondominant group in the culture" (Brown, 2004, p. 464). Many people understand feminist therapy in general and for trauma specifically as more of a philosophy of treatment than a specific treatment per se. Although it is the case that the role of the overarching philosophy within treatment is a critical guiding point in feminist therapy, there are specific treatment techniques and approaches as well.

Feminist therapy is considered an integrated treatment primarily because of a therapist's ability to utilize any therapeutic technique or method that furthers the overarching feminist goal. Interpretations, behavioral techniques, exposure, relaxation training, and numerous others are all possibilities. As long as a technique helps the client move toward empowerment and an increase in self-care capacities, it can be used. Let's break down the goal of developing feminist consciousness into more practical terms. In essence, the development of feminist consciousness in practical therapy-goal terms involves more than simply the alleviation or elimination of PTSD symptoms. Brown (2004) states:

For many treatment models, once symptoms have diminished, treatment is deemed complete. However, in feminist trauma treatment, the therapist will return to some of the themes that derive from the client's context as they resonate within the "why me" questions that are so common for trauma survivors. Many of the responses to "why me" that clients develop on their own reflect internalized oppression. Self-blame, while a coping strategy that appears to be an attempt to insert a sense of control into an otherwise out-of-control experience, frequently contains the themes of sexism, racism, heterosexism, and so on. Feminist trauma treatment will address the need for a reassertion of control and work with clients to make meaning out of their experiences without further adding to preexisting patterns of internalized oppression. The simple absence of symptoms is not the goal of feminist trauma treatment. Consciousness of one's kinship with other trauma survivors and the creation of nonblaming means of asserting one's sense of control are construed as equally important to symptom remission. (p. 469)

What exists at the heart of feminist therapy appears to be the belief that specific interpretations of traumatic experiences and the posttrauma behavior of both the survivor and those around him or her in terms of sociopolitical feminist terms are therapeutic in and of itself. As Brown (2004) states, "feminist strategies create powerful validation of clients' hunches that their victimization is indeed inextricably linked to their position in the social hierarchy of value" (p. 469). Specific techniques for accomplishing this include the believing game (Clinchy, 1996), in which the therapist adopts a position of believing the client's account of the trauma while avoiding the risk of reacting in a judgmental, invalidating, and unbelieving manner, and Comas-Diaz's (2000) ethnopolitical approach.

Judith Herman's Integrated Approach

Dr. Herman (1992), while employing to a large degree the preceding feminist approaches, has provided a very comprehensive and widely respected form of psychotherapy and treatment for PTSD as well as for complex-PTSD that incorporates components of other modalities, such as cognitive-behavioral therapy and psychodynamic approaches. Herman characterizes treatment within the context of stages of recovery and a healing relationship. She states:

The core experience of psychological trauma is disempowerment and disconnection from others. Recovery, therefore, is based upon the empowerment of the survivor and the creation of new connections. . . within the context of relationships, it cannot occur in isolation. (p. 134)

Throughout the course of treatment, basic faculties that are damaged by the trauma and its aftermath are redeveloped. These include the ability to trust, a sense of competence, and a solid sense of identity. The survivor must be empowered and encouraged to be in charge of his or her own recovery. Herman cautions against trying to control the patient. Instead of external control, the therapist must facilitate the learning of self-control. The feeling of having a choice should be an integral part of the treatment. The therapeutic relationship is a critical component in this process. Herman identifies several unique aspects of the therapeutic relationship from her perspective:

■ Its only purpose is to promote recovery for the patient.

■ The therapist is a skilled ally.

■ There must be respect for autonomy.

■ The therapist does not attempt to gratify his or her own personal needs and should not advance a personal agenda.

■ The therapist should not take sides in "inner conflicts or try to direct the patient's life decisions" (p. 135).

■ The relationship is both intellectual and relational, with the therapist serving as a protective parent of sorts.

To the extent that Herman's treatment is feminist, she states in her own words quite eloquently:

Therapy requires a collaborative working relationship in which both partners act on the basis of their implicit confidence in the value and efficacy of persuasion rather than coercion, ideas rather [than] force, mutuality rather than authoritarian control. These are precisely the beliefs that have been shattered by the traumatic experience. (p. 136)

Herman's (1992) model of treatment consists of three stages of recovery: (1) establishing safety, (2) remembrance and mourning, and (3) reconnecting. The focus of the first stage involves restoring a sense of safety, and, for Herman, this task takes precedent over all others. This is accomplished by helping the patient regain his or her sense of control over his or her thoughts, emotions, relationships, and bodies. Medication and relaxation training can help the patient begin to establish a sense of control in the early goings. Confusion from the disorder and its symptoms can be addressed by self-guided monitoring, daily logs of symptoms, and concrete safety plans. The focus on control begins with the body and then progresses to the environment. Body issues include sleep, eating, exercise, symptom management, and control of self-destructive behaviors such as suicide and self-mutilation.

In the second stage of recovery, remembrance and mourning, the survivor retells his or her story and reconstructs the event in minute detail. The therapist serves as a supportive ally in bearing witness to the event and facilitates the emergence of a coherent narrative from the often-encountered fragmented pieces of trauma narrative that first emerge. Once the trauma story has become clearer, the next step within this stage is to facilitate the mourning of any loss the survivor attaches to the trauma. This may include a loss of relationships, a loss of naïveté, a loss of bodily integrity, or a loss of a sense of identity.

In the final stage of Herman's (1992) approach, the task becomes the development of a new self, new relationships, and new beliefs. Part of this process involves the patient learning to face danger while being cognizant of their exaggerated sense of danger. The issue of whether to face danger becomes a matter of conscious choice. Herman characterizes this step as learning to fight. The process of creating a new self involves the survivor learning to value, utilize, and emphasize those aspects of him- or herself prior to the trauma, during the trauma, and during the recovery period. Relationships are approached with a sense of competence, trust, and intimacy but also from a position of autonomy. Finally, Herman states that at some point, although resolution and recovery are probably never complete, the survivor learns to turn his or her focus away from the trauma and toward ordinary life. Herman states:

The survivor who has accomplished her recovery faces life with few illusions but often with gratitude. Her view of life may be tragic, but for that very reason she has learned to cherish laughter. She has a clear sense of what is important and what is not. Having encountered evil, she knows how to cling to what is good. Having encountered the fear of death, she knows how to celebrate life. (p. 213)

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