Eye Movement Desensitization and Reprocessing (EMDR) is a specialized therapy approach, involving 8 Phases, that first requires screening and an assessment process to evaluate appropriateness and readiness before beginning the 8 Phase process. This is determined by a protocol that is mandated by EMDR International Association, which governs the standards and ethics of EMDR practice. The screening and assessment process can take up to 2-4 sessions, just as any other therapy approach, to formulate a diagnosis and treatment recommendations. Afterwards we can determine whether to proceed with EMDR, using the 8 Phase protocol. Note that the protocol and pacing can vary depending on the person and the needs that arise both in and out of sessions.
THE EIGHT PHASES OF EMDR THERAPY ACCORDING TO FRANCINE SHAPIRO
In the first sessions, your history and an overall treatment plan are discussed. During this process I will help identify and clarify potential targets for EMDR. Target refers to a disturbing issue, event, feeling, or memory for use as an initial focus for EMDR. Maladaptive beliefs are also identified (e.g., ʺI canʹt trust peopleʺ or ʺI canʹt protect myself.ʺ)
Before beginning EMDR for the first time, it is recommended that we identify and create a ʺsafe place,” an image or memory that elicits comfortable feelings and a positive sense of self. This safe place can be used later to bring closure to an incomplete session or to help with being able to tolerate a particularly upsetting session.
In developing a target for EMDR, prior to beginning the eye movement, a snapshot image is identified that represents the target and the disturbance associated with it. Using that image is a way to help you focus on the target. A negative cognition (NC) is identified, a negative statement about the self that feels especially true when you focus on the target image. A positive cognition (PC) is also identified, a positive self‐statement that is preferable to the negative cognition.
I will then ask you to focus simultaneously on the image, the negative cognition, and the disturbing emotion or body sensation. At this point I will typically guide you to follow two fingers with your eyes; my hand will move alternately from side to side so that your eyes also move back and forth. After a set of eye movements, you’ll be asked to report briefly on what has come up; this may be a thought, a feeling, a physical sensation, an image, a memory, or a change in any one of the above. In the initial instructions, I’ll ask you to focus on this thought, and begin a new set of eye movements. Under certain conditions, however, I may direct you to focus on the original target memory or on some other image, thought, feeling, fantasy, physical sensation, or memory. From time to time I may query about your current level of distress. The desensitization phase ends when the SUDS (Subjective Units of Disturbance Scale) has reached 0 or 1.
Installation: I’ll ask you about the positive cognition, and if it is still valid. After Phase 4, the view you may have had on the event/the initial snapshot image may have changed dramatically. Another PC may be needed. Then you’ll be asked to ʺhold togetherʺ the snapshot and the (new) PC. I will ask, ʺHow valid does the PC feel, on a scale from 1 to 7?ʺ New sets of eye movement are issued.
Body scan: I’ll then ask if anywhere in your body there is any pain, stress or discomfort. If so, you’ll be asked to concentrate on the disturbance or whatever may arise and new sets are issued.
Debriefing: I will give appropriate info and support.
Re‐evaluation: At the beginning of the next session, you will review the week, discussing any new sensations or experiences. The level of disturbance arising from the experiences targeted in the previous session is assessed. An objective of this phase is to ensure the processing of all relevant historical events.
Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment developed by Marsha Linehan, PhD, ABPP. It emphasizes individual therapy and group skills training classes to help people learn and use new skills and strategies to develop a life that they experience as worth living. DBT includes skills for mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.
DBT was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD). It is now recognized as the gold standard psychological treatment for this population. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.
COMPONENTS OF TRADITIONAL DBT
1) Enhance Capabilities with DBT Skills Training
DBT skills training focuses on enhancing people’s capabilities by teaching behavioral skills. Skills training is frequently taught in groups; the group is run like a class where the group leaders teach the skills and assign homework. The homework helps individuals practice using the skills in their everyday lives. There are four modules in skills training:
- Mindfulness: the practice of being fully aware and present in this one moment
- Distress Tolerance: how to tolerate pain in difficult situations, not change it
- Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others
- Emotion Regulation: how to change emotions that you want to change
2) Enhance Motivation with Individual Therapy
DBT individual therapy is focused on enhancing motivation and helping people to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as a person is in therapy, and it runs concurrently with DBT skills training.
3) Ensure Generalization with Coaching
DBT uses telephone coaching and other in vivo coaching to provide in-the-moment support. The goal is to coach individuals to use their DBT skills to effectively cope with difficult situations that arise in their everyday lives. Coaching means that it is optional for someone to call their individual therapist between sessions to receive coaching during the times when they need help the most.
4) Structure the Environment with Case Management
Case management strategies help people manage their own life, such as their physical and social environments. The therapist applies the same dialectical, validation, and problem-solving strategies in order to teach individuals to be their own case manager. This lets the therapist consult-to-the-client about what to do, and the therapist will only intervene on someone’s behalf when absolutely necessary.
5) Support Therapists with the DBT Consultation Team
The DBT consultation team is focused on the clinicians and supports who provide DBT, including individual therapists, skills training group leaders, case managers, and others who help treat an individual. The consultation team is intended to support DBT providers in their work; it’s almost like therapy for the therapist. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. This is especially important when they are treating people with severe, complex, difficult-to-treat disorders so the team can help one another manage burnout and share their knowledge.
STAGES OF TREATMENT
DBT is divided into four stages of treatment. Stages are defined by the severity of someone’s behaviors, and therapists work within this frame to support people in achieving their specific goals. There is no set timeframe allotted to each stage; instead, an individual and their therapist will spend as much or as little time as needed, based on identified goals.
- In Stage 1, a person is often miserable and behavior is out of control: they may be suicidal, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When individuals first start DBT treatment, they often describe their experience of their mental welfare as “being in hell.” The goal of Stage 1 is for a person to move from being out-of-control to achieving behavioral control.
- In Stage 2, someone may feel they are living a life of quiet desperation: their life-threatening behavior is under control, but they continue to suffer, often due to past trauma and invalidation. Their emotional experience may be inhibited. The goal of Stage 2 is to help someone move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated if it is part of the diagnosis.
- In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that a person leads a life of ordinary happiness and unhappiness.
- In Stage 4, for some, a fourth stage is needed: finding a deeper meaning through a spiritual existence. Dr. Marsha Linehan has posited a Stage 4 specifically for those individuals for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for a person to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
Behavioral Tech. (2018). What is Dialectical Behavior Therapy (DBT)?. [online] Available at: https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/ [Accessed 7 Jan. 2018].
SMART Recovery is a 4-Point Program® that helps people recover from all types of addictive behaviors, including: alcoholism, drug abuse, substance abuse, drug addiction, alcohol abuse, gambling addiction, cocaine addiction, and addiction to other substances and activities. SMART Recovery (Self-Management And Recovery Training) is not a 12-step group, like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA).
To support individuals who have chosen to abstain, or are considering abstinence from any type of addictive behaviors (substances or activities), by teaching how to change self-defeating thinking, emotions, and actions; and to work towards long-term satisfactions and quality of life.
- Teaches self-empowerment and self-reliance.
- Encourages individuals to recover and live satisfying lives.
- Teaches tools and techniques for self-directed change.
- Meetings are educational and include open discussions.
- Advocates the appropriate use of prescribed medications and psychological treatments.
- Evolves as scientific knowledge of addiction recovery evolves.
SMART Recovery (Self Management And Recovery Training) helps individuals gain independence from addiction (substances or activities). Efforts are based on scientific knowledge and evolve as scientific knowledge evolves. The 4-Point Program offers specific tools and techniques for each of the program points:
- Point 1: Building and Maintaining Motivation
- Point 2: Coping with Urges
- Point 3: Managing Thoughts, Feelings and Behaviors
- Point 4: Living a Balanced Life
SMARTRecovery.org. (2018). Get Started | SMART Recovery. [online] Available at: https://www.smartrecovery.org/get-started/ [Accessed 7 Jan. 2018].