| 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.
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