EYE MOVEMENT DESENSITISATION

AND REPROCESSING

Part One Workshop

Training Manual

Sarah Dominguez

www.psychology-training.com.au
 Eye Movement Desensitisation and Reprocessing
Part One Training Manual, Revised Jan 2021.
© 1993-2017 Dr Chris Lee & Graham Taylor
© 2018-2021 Dr Chris Lee & Dr Sarah Schubert

These notes issued to ________________________________________________

as part of a Part One EMDR Training.

Sections of these notes designed as client handouts may be reproduced by the above named person, for
use in their clinical work. No other portions of the notes may be reproduced without permission of the
authors.

Note that the Part One Training does not cover all clinical applications of EMDR, nor does it cover
advanced variations on the EMDR method. Advanced applications and additional procedures are
covered in Part Two training.

These notes do not, in themselves, constitute an adequate treatment manual for EMDR. They are to be
used in conjunction with the material taught in the training, and the material contained in Dr Francine
Shapiro or Dr Andrew Leeds's books.

Contact Details
Email Tara : [email protected]
Phone Tara: 042 1131 042
www.psychology-training.com.au
CONTENTS
Eight Phases of Treatment ............................................................................................................ 4
Tape Transcript ............................................................................................................................. 5
A Model of Traumatic Memory and Resolution with EMDR ...................................................... 9
Information Processing Models .................................................................................................. 10
Possible Mechanisms in EMDR ................................................................................................. 11
Phase One: Client Suitability and History ........................................................................... 13
Client Assessment ............................................................................................. 16
Phase Two: Basic Procedural Preparation ............................................................................ 20
Safe Place .......................................................................................................... 22
Metaphors ......................................................................................................... 24
Calm Place Script .............................................................................................. 25
Calming Breaths................................................................................................ 26
Resource Development ..................................................................................... 27
Light Stream Script ........................................................................................... 29
Phase Three: Target Assessment ............................................................................................ 30
Negative & Positive Beliefs .............................................................................. 33
Vignettes ........................................................................................................... 34
Phase Four: Desensitisation .................................................................................................. 38
EMDR Procedural Flowchart ........................................................................... 39
When Processing Stops ..................................................................................... 40
Phase Five: Integration ......................................................................................................... 42
Procedure for Incomplete Sessions ................................................................... 43
Phase Six: Body Scan ......................................................................................................... 44
Phase Seven: Closure .............................................................................................................. 45
After EMDR – Handout .................................................................................... 46
Phase Eight: Revaluation ....................................................................................................... 47
Additional Protocols ......................................................................................... 48
Dissociative Disorders ................................................................................................................ 51
DES ................................................................................................................... 53
Guidelines for Facilitating Abreaction ....................................................................................... 55
Procedural Steps Outline ............................................................................................................ 56
Practicum Guidelines .................................................................................................................. 59
EMDR Case Note Sheets ............................................................................................................ 60
Impact of Events Scale (IES, IES-R & Notes) ........................................................................... 62
Joining EMDRIA ........................................................................................................................ 65
Fidelity Rating Scale................................................................................................................... 67
References ........................................................................................................................... 70
Internet Resources ...................................................................................................................... 75
Eight Phases of Treatment
1. Client History and Assessment
Detailed Assessment
Suitability for EMDR
Screen for Dissociative Disorder

2. Procedural Preparation
Therapeutic relationship
Explain EMDR
STOP signal
Safe Place, and other client safety strategies

3. Target Assessment
Memory or Image
Negative Belief
Positive Belief
VoC (Validity of Positive Cognition, i.e. how true it feels, on a 1 - 7 scale.)
Emotion / Feeling
SUDs (Subject of Units of Distress, measured on a 0 - 10 scale)
Location of Bodily Sensation

4. Desensitisation
Standard protocol
When processing stops – protocols – Cognitive Interweave (Part 2 Training)

5. Integration (Shapiro calls this Installation.)

Possible evolution of Positive Belief
6. Body Scan

7. Closure
Debrief and Client Log
At the following session.

8. Re-evaluation
Past > Present > Future

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TAPE TRANSCRIPT
CL: Last time when we were talking you were describing the most upsetting image that comes back is
either kind of the windscreen or flying through the air. Is that right?

JP: Yeah

CL: Do you kind of get those together or do they come separately?

JP: It usually just starts off as a feeling of getting hit by the windscreen usually follows on with what
happened after, just about every time

CL: OK. When you get those pictures in your mind what ideas go with that? What sort of thoughts?

JP: Guess confusion, feeling of being scared, unsure, basically feel pretty scared.

CL: Feelings of fear. What ideas go with that picture? Like if you had to put a caption or label on it
what would that be?

JP: That’s a tough one, I guess it virtually comes to mind is why? It’s hard to explain. Umm Yeah I
suppose it’s why I can’t shrug off that feeling of the whole thing, about getting hit and flying through the
air, and that.

CL: Do you think to yourself why am I still bothered by this? Is that part of it?

JP: Yeah that’s for sure.

CL: Can you tell me other thoughts or captions that you put to that scene?

JP: It’s a confusion thing, similar to my sense of not being able to work out why I feel the way I do,
when I appear to be OK...... umm.......Just quite a bit of confusion, I feel like I should be I had
surgery as well I should be over this and walk away.

CL: I should be over this by now.

JP: Yes. That’s for sure.

CL: I see. What does it mean to you John that you are not over this? That it is still bothering you, What
does?

JP: At one stage I was questioning whether it actually did happen, umm and now it’s been quite a while
now and still mostly I feel inferior or weak in some way, umm basically yeah.

CL: It’s the same thoughts that I should be over this by now, I’m inferior, I’m weak

JP: Yeah. CL: Any other

JP: Umm, Just in my past and I’ve seen other people with what appear to be more severe injuries like a
loss of leg or something like that , umm I’ve met other people who have got bigger reasons for um and I
compare myself with them and I think well that they should be worse than what I am

CL: I see.

JP: I can’t understand why. You know I still got two legs and two arms and still cant snap out of this
Arh feelings of guilt I suppose comes with that as well.

5
CL: Tell me a bit more about the guilt.

JP: Arh just not been able to like I say I’m 33 years old and this is really weird and I cant just sort of say
hey it’s happened it’s finished get over it
CL: How would you like to think about this instead? Or how do you think you’d think about this if you
were over this incident? Do you reckon would be going through your mind instead?

JP: Um, basically the first thing that comes to mind I’d like to think I’d be a better person for it. Um for
the experience I’m obviously lucky that I’m still in one piece. But that’s where it becomes hard because
arh even though I’ve told myself that I’m in one piece I would imagine a lot of people do when they see
me. Arh there are times when I have uncontrollable shakes um that happened today earlier on, and that
throws you back into your shell type of thing. You feel like everyone’s watching and everyone saw what
was going so you don’t wanna just pretty hard to sort of sit with people and accept you know. They
have really taken not much notice of it.

CL: So what do you think it would be - instead of thinking I should be over this by now I’m inferior I’m
weak. How do you think, what do you think your attitude would be to this event after you were finished
with it?

JP: Umm, I’m not sure that the longer it’s been going on the more I kinda feel sorry for anyone else in
the same position. It’s really confusing, it’s , I mean I’m supposed to be strong , I’m supposed to be a
male and at the moment I’m not quite feeling like that you know.

CL: I guess that was a part of sort of the things to about leading up to not getting back to work. You
didn’t feel that you were strong or could cope

JP: I was actually scared. CL: inferior, weak, scared.

JP: I was actually scared of going back to work because um. I don’t know whether I knew I was going
to get negative treatment from what happened or what but um maybe in the back of my mind I did.

CL: What about an idea like it’s over, I’m strong now, Would that be an idea you might be thinking
when your over this?

JP: Umm, I’ve tried to force myself into thinking that way.

CL: Tell me then.....What I want to get is an idea of how true that particular statement feels to you on a 1
to 7 scale where 1 is completely untrue and 7 is completely true. So not how true you think it is but how
true it feels. So how true does it feel to say “It’s over I’m strong now”?

JP: On a scale from 1-7, it be about a 3 I suppose.

CL: 3. OK. Going back to, when you get that image of hitting the windscreen or being hit by the
windscreen and thinking those ideas of I should be over this by now, I’m inferior, I’m weak. What sort of
feelings go with those thoughts......?

JP: Umm, Uncertainty is a big one. CL: Perhaps guilt that’s what you mentioned before.

JP: Guilt, yeah, Confusion and whether I actually do feel guilty or not is the confusion there.

CL: OK Now just as you think about that feeling is there any part in your body that you feel that is more
tense or tight. Like whereabouts in your body would you feel..........?

JP: Chest

6
CL: In your chest. OK. On a 0 - 10 scale how strong would you rate that feeling where 10 is as
uncomfortable as feelings get and 0 is no discomfort at all.

JP: Have to be around 8 . CL: OK Just tell me what your pulse monitor says?

JP: 88

CL: Right before I gave you an explanation of the EMDR procedure that we were going to try out today.
What is going to happen in the procedure is that I’ll ask you perhaps to focus on a particular image or
thought or fear, now you might find that sometimes the images that I’m asking you to concentrate on
change. Right. But they may not. I might ask you to focus on feelings and maybe they’ll go up or down
or they might not change at all. Sometimes I’ll ask you to think of thoughts and maybe they’ll change but
maybe not. The important thing to remember is nothing is supposed to happen here. After each set of
eye movements I’ll just stop and just ask you what comes up and all you have to do is tell me as
accurately as possible what you are experiencing at the time. So you can’t get anything right or wrong
because there are no shoulds with this. The other thing I want to get clear to is that if you get to a
particular point that you feel very distressed by what is happening and you feel you can’t go on any more
just raise your hand up to let me know and we can stop the process and then we will talk. Now in order to
do the eye movement with you, for you to follow my fingers I need to move the chairs closer Stay
where you are I’ll do the moving.

CL: That’s pretty uncomfortable, I’ll just change the chairs. OK the first thing we just have do is just
check out what is a comfortable distance for you to focus on my fingers. Now a lot people prefer there
but you may prefer to look at my fingers further away or closer what feels right for you.

JP: Further.

CL: There. There. Now I’d like to begin with if you could just try and get that picture back of the
windscreen actually hitting you. I’d like you, as you get that picture back to just say to yourself “I should
be over this by now, I’m inferior, I’m weak” also to think about those feelings in your chest, confusion
and just allow your eyes to follow.

CL: That’s good

CL: Close your eyes for a sec and take a deep breath. Now let it out. And what do you notice now?

JP: Trying at the moment, trying to think of it, doesn’t come through, not as easy to think about.

CL: Not as easy to think about. (Video statement). OK. And what feelings do you get in your body.
Stronger or weaker? (Video question)

JP: The umm, feeling like you have held your breath for a while.

CL: Whereabouts in the body do you feel the most tightness or tension?

JP: Just here

CL: Just stay with that.

CL: What do you notice now?

JP: The image of me sitting on the ground.

CL: Just stay with that

CL: What do you notice now?

7
JP: Arh, started thinking about it .......and the windscreen but didn’t go any
further. Usually once it starts just keeps going. CL: Ah hah

JP: I guess once it started it just keeps going on through the whole thing

CL: But now there is more of a sense like of just a complete thing that just .

JP: Yes. Yeah. You know I guess I was starting to think about it that it was umm, like I say easier to,
usually I continue on and see the whole thing. Like it was right in front of me.

CL: Right

JP: But now, I thought about the windscreen and that was it. It didn’t go any further.

CL: So, what less emotion.

JP: Yeah, That’s true. If I tried to think about it, I can’t get it started.

CL: What are you feeling?

JP: For want of a better word, a little bit better

CL: Right. OK. What about the statement “it’s over I’m strong now” how true does that feel to you
right now on a 1 - 7 scale?

JP: Yeah, a bit stronger.

CL: What score would you give it?

JP: feeling stronger would have to be a 6 for sure

One week later

CL: So , let’s .kind of. What I want to do now is just check the beliefs and the feelings associated with
the accident. So you were describing that the image that still does come back from time to time is kind
of being hit or landing or series of things in between. And when you...The thoughts that go with that is - I
shouldn’t be like this , I should be over it, I’m weak. They're still the most upsetting thoughts, is that
right?

JP: Yeah. I get a , when I think about it and like you say I don’t get the same emotion. I get that it’s
happening inside my head, CL: Right

JP: I get that feeling in my chest and my gut, then I go weak.

CL: And what about we were working towards last week, ideas like “it’s over, I’m strong now” how true
does that feel on the 1-7 scale where 1 is completely untrue and 7 is completely true?

JP: Yes. 6 to 6½. You know I’ve almost drummed that into me.

CL: What about the that butterfly feeling, the churning thing you described - how strong is that feeling
on a 0 - 10 scale where 0 is no discomfort at all and 10 is as uncomfortable as feelings can get?

JP: I’d say they are a 2-3. I still get --, it still makes me feel uncomfortable but not to the extent where I
don’t think I could handle it. I can handle it now and I’m going to be able to overcome it.

8
Traumatic Memory and Resolution with EMDR

Memory network, after Foa & Kozak. Links

between nodes may be via common sensory elements
of memory, common meaning, common
somatic/emotion.

Sensory
stimuli:
visual, Personal
auditory, Meaning
kinesthetic
etc.

Somatic &
Emotional
Response.

Current Trigger (event, thought, response) sets off the old

Memory Network, which activates responses which may include
behavioural (avoiding, escaping) and cognitive
(blocking, dissociating) responses.

During EMDR the Memory Network is reactivated, and the EM

facilitates the processing of information towards resolution.

Memory becomes Emotional/Bodily Distress subsides. Positive Thoughts about Self, now and
historical, a past event v/v the old memory.
(versus being relived), less 0 10 1 7
vivid, fragmented, faded,
etc.
Subjective Units of Distress (SUDS) Validity of Cognitions (VoC)

9
Information Processing Models
Consider a memory to be a node, containing sensory information about the event, the meaning a person
gives to the event, and their emotional / somatic response.

A memory network consists of connected nodes.

The connections between nodes may be by way of common elements of the stimulus, common meaning,
or common emotional/somatic response, or any combination of these.
The memory network can be activated by associated stimuli, associated interpretations, associated
affective/somatic state, or a combination of these.

Memory network, based on Foa & Kozak. Based on Lang’s work on the development of fear networks.
Recovery depends on

(1) the degree to which the memory network is reactivated

(2) the person is exposed to information which is incompatible with a threat interpretation

In EMDR a node is the memory or image of an event (stimulus), its associated cognition (meaning) and the
Emotional and Somatic response. A memory network consists of connected nodes. The connections
between nodes may be by way of common elements of the stimulus, meaning, or emotional / somatic, or
any combination of these. Memory network can be activated by any of the 3 channels (Stimuli, Meaning,
Emotional Response)

Associated Stimulus
Sounds Person Object Smell

Similar Interpretation

Schema (Core Beliefs)

Similar Affective State

Biological evidence

same somatic sensation

mood congruent learning

Implications for therapy

Important to activate all elements of the encoded memory (memory, meaning, affect)
However, too much affect will however impede processing - hence the need for careful client selection and
preparation.
Therapy target may represent many learning trials, with different events with similar
responses.
Try to facilitate clustering of events.
The same event may need to be processed through different channels.

10
Possible Mechanisms in EMDR

Psychobiology

A traumatic event causes changes in the brain’s structure that disrupts its ability to process material.
(Janet, Pavlov)

van der Kolk: amygdala inhibits prefrontal cortex & hippocampal functioning

largely mediated by norepinephrine (noradrenalin).

recent PET scan research (Levin et al., 1999; Lansing et al., 2005)

Natural healing:

role of REM - evolutionary significance

EMDR restores the balance, allowing accelerated information processing

EMDR improved hemispheric communications (Nicosia)

Stickgold 2002
• Role of REM – episodic onto semantic
• PTSD associated arousal effects REM
• EMDR allows information processing to occur unimpeded
Biological theories
• PTSD rises when the brain fails to appropriately consolidate and integrate episodic memory into
semantic memory and as a result associations between that event and other related events fail to
develop

Memory and sleep (Stickgold, 2002)

• REM enhances certain types of memory
– Procedural, texture, complex logical tasks, emotional
– Provides associative links

11
 Orienting response (Armstrong & Vaughan, 1996).

Orienting response

• Characteristic of OR • Phenomenon in EMDR

• Activate peripheral & • Increase in intensity of network

central processes information & stimuli in room

• Inhibition of pain response • Allows for continued dual focus

of attention

• Increase in arousal • Explains treatment effects and

followed by rapid procedural variations
habituation

Evidence and EMDR (covered in workshop or as part of preworkshop reading)

• Evidence for EMDR effectiveness
o Meta analysis
o Practice guidelines
o Recent outcome studies
• Why it is different to traditional exposure
• Proof that the eye movements matter
• Contemporary explanations of underlying mechanisms
o Bilateral stimulation enhances processing episodic memory
o OR response/ dream processing
o Working memory (Gunter & Bodner, 2008)

Other explanations
Only exposure
Conditioning paradigms (Dyck)
Cognitive intervention: Coping, control, distancing, expectancy

12
Phase 1. Client History
Summary from pre-workshop material and see also Shapiro (2018) Chapter 4.

Purpose:
▪ Obtain background information.
▪ Formal assessment of symptoms, behaviour, and dissociation.
▪ Begin establishing clear, realistic treatment goals for this episode of care.
▪ Assess suitability and readiness for EMDR.
▪ Assess stability and current safety.
▪ Assess resources, strengths, and create containment.
▪ Develop a targeting sequence.
▪ Identify potential target memories from events in client’s life according to standardized three-
pronged protocol: identify 1) past events that have laid the groundwork for the pathology, 2) current
triggers, and 3) future needs.
▪ Consider, is my level of expertise adequate to plan for trauma processing?

13
 Phase 1. Assess suitability and readiness for EMDR Therapy
by considering the following:
The points summarised below are covered in the pre-workshop material from EMDR training found at
https://psychology-training.com.au/wp-content/uploads/2017/12/transcripts-my-level-1.pdf
Adapted from Shapiro (2018, Chapter 4, pp. 87-96).
Level of rapport
In EMDR therapy a trusting therapeutic alliance is required prior to processing memories. The client needs to
feel safe that you are competently able to guide and empathetically hold them whilst processing high levels of
emotional disturbance associated with memories. It is important that the client is able to truthfully tell the
therapist about what they are experiencing, including feelings such as shame, guilt, vulnerability, lack of
control, and physical sensations. If there is insufficient trust, and the client is not able to be truthful about
what they are experiencing then you’re unable to guide them safely through the EMDR process. The risk is
that the session may terminate prematurely and then go on to process traumatic material after the session
without any clinical support.

Emotional Disturbance.
Ensure the client self-sooth and calm during periods of high level emotional distress, both within and after a
session. Ensure the client not just regulate high levels of emotional disturbance, but also tolerate, and be with
both negative and positive emotions, and a state of calm.

Stability, timing, and check for suicidal ideation.

Processing traumatic memories may initially involve increased arousal and disturbance. Ensure a level of
stability and support prior to commencing desensitisation, that will hold the client and ensure ongoing
functioning should processing lead to an initial higher level of stress. It’s not appropriate to commence
EMDR if there are major life pressures and stressors occurring in the client’s life. It is important to ask clients
“Is this a good time?” Can clients fit in sessions, and ensure therapy will not significantly impact on current
life commitments/responsibilities? That said, for some clients, where by constant crisis and instability is being
driven by earlier adverse life experiences, some processing of specific past experiences may need to occur to
obtain a level of stability and calm.
Where suicidal ideation is present debrief sessions with this in mind.
Life Supports
Ensure clients have social supports, and at least one person with whom they trust, and feel safe, and have a
good, healthy, stable attachment relationship with prior commencing memory processing phases. Consider not
only who is there for them, but whether they will seek support when needed. Also, as the therapist consider
your willingness and ability to be accessible.
General Physical Health
Ensure that the client taking care of themselves at a basic level, i.e. eating, sleeping, exercising.
It is important to assess whether the client able to withstand the stress of memory reprocessing. Consider age,
respiratory or cardiac conditions, late term or complicated pregnancy. It is advised to use caution and consult
with medical professionals should you be concerned about possible negative effects of high levels of stress on
physical health.
Office versus Inpatient Treatment
Assess if there is a need for appropriate medication, hospitalisation, or medical attention. If there risk of self-
harm or extreme levels of dysregulation or destabilisation, consider admitting to an inpatient facility to engage
in particular psychological work.
Eye problems
Check for retinal damage. Contact lens wearers to bring lens case.
Under no circumstances should eye movements continue to be used in EMDR if a client reports eye pain.
Neurological impairment and epilepsy
While EMDR processing has been effective with client with a range of neurological complaints, caution
should be observed in that there may be some forms of brain damage that may lead to either no response, of

14
 extreme discomfort during desensitisation phases. Consult with medical professionals prior to processing.
Again, clients with epilepsy have been successfully treated with EMDR, however, as with any client who is
neurologically impaired, caution should be observed.

Drug and Alcohol Abuse

Clients with substance abuse concerns need to have appropriate supports in place. EMDR may evoke
distressing material, which may lead to exacerbation of abuse behaviours. Consider client emotional
regulation and distress tolerance skills. Ensure there is a level of trust and honesty in regards to use, and
monitoring of possible lapses to ensure safety.

Legal Requirements
After EMDR a client may not be able to access a vivid picture of the event, and they may not have strong
affect associated with the event. EMDR may be regarded by the Court as comparable with hypnosis.
Australian clients, See Supreme Court Ruling (in dropbox link). Discuss the above with the client, and
together with the Director of Public Prosecutions and the client's solicitor, consider the possible consequences
for the client as a witness. If treatment proceeds before Court, ensure that detailed objective measures of
symptoms and distress are obtained before and after treatment. E.g., structured interview schedule for PTSD,
Impact of Events Scale, Depression and Anxiety measures, behavioural measures of avoidance. Consider
attaining a signed consent to commence EMDR therapy.

Secondary Gains and Systems Issues

Consider what it will it mean for the client to be without the problem. At present, does the problem have a
positive function (payoff) for the client (i.e. monetary compensation)? If symptoms are effectively treated will
it mean that the client will be expected to engage in things they are currently able to avoid (i.e. work) Consider
the identity of the client should their trauma related symptoms be lost. Also, how will change (i.e. increased
independence, new choices, assertiveness) impact on others in the client’s life – especially partner, children,
parents, family.

Session Length
Following assessment and preparation sessions, it is recommended that desensitisation sessions be 90 minutes.
This allows for memories to be adequately processed, and the client to be debriefed, calm, and leave the office
feeling stable and safe. Shorter sessions disproportionately lengthen treatment. Under no circumstances
should a client leave a session with an unresolved abreaction. To accelerate treatment, processing sessions can
be scheduled on consecutive days, rather than weekly.

Timing
EMDR may involve emotionally intense work. Assess that the timing is right for clients, i.e. that there is no
major life changes, stressors, work commitments, holidays, exams etc. Clients frequently feel tired after an
EMDR session, thus consider this when scheduling appointment times. Therapist availability.

Medication
State dependent learning effects with Benzodiazepine medication may necessitate further EMDR therapy after
medication is discontinued. SSRIs do not appear to inhibit treatment effects. Once medications are reduced
or discontinued, reassess the desensitisation of prior processed memories.

Dissociative Disorder
See the more detailed section in this manual for a discussion of EMDR therapy and dissociation. It is important
that appropriate safeguards are in place when working with high levels of dissociation and DID.

15
 Client assessment
General Considerations
EMDR is not a cure all. Client problems may be remedied by education, problem solving, stress
management techniques, and skills training etc. A full history is required, as you would do in order to
formulate a person’s presentation and problems, before planning an intervention.

Single incident PTSD problems can be treated by targeting the traumatic memory, but a good history is
still required. In more complex presentations, including multiple trauma (e.g. abusive or neglected
childhood origins), current and past events will require reprocessing, as will the integration of more
adaptive responses.

A useful detailed framework for a comprehensive assessment is given by Lazarus, A. & and Lazarus, C.
(1991) Multi Modal Life History Inventory, Research Press. (Available in Australia from Footprint).
Following the collection of general information about the client, the assessment follows the seven
modalities of behaviour, affect, physical sensation, imagery, cognition, interpersonal relations and
biological factors.

The following summary provides basic guidelines for the assessment necessary to use EMDR.
See pages 91 - 108 of Shapiro’s (2001) book for a detailed example, with commentary.

Description of Presenting Problems

Client describes the nature of their main problems, the degree of severity, and impact on their current life.
• Dysfunctional behaviours, emotions, beliefs
• Duration of problems “How long have you had these problems?”
• Factors which make things better/worse
• Repeating patterns
• Clusters of similar events – different memories, with same associated Core Belief.
• The earliest example
• The worst example as recalled now
• Additional past occurrences “What are your worst memories?”
• Are there present factors which mitigate against change
• What is the desired state. How will the client know that therapy has been successful?
• What will be the effects of effective therapy- for the client, and the client’s systems?

General Information including

• Family history of psychological therapy and problems.
• Father’s personality and attitude toward client, past and present.
• Mother’s personality and attitude toward client, past and present.
• Family history of emotional or mental disorder, including suicide.
• Methods of discipline or punishment.
• Ability to confide in parents.
• Was client loved and respected by parents.
• Childhood/adolescence problems : deaths, medical problems, school , religious issues, drug /
alcohol use, physical / sexual / emotional abuse.
• Work, present and past. Reasons for leaving.
• Previous therapy, and outcome. Client’s expectations of therapy and the therapist.
Modality Analysis of Current Problems – (A. Lazarus).

Behaviours:
• What would you like to start doing, or do more of?
16
 • What would you like to stop symptoms, particularly those unexplained by medical opinion?
Especially headaches, abdominal pain, bowel, fatigue, nausea, flushes, blackouts, excessive
sweating, and other symptoms of excessive autonomic arousal.

Imagery
• Check for flashbacks associated with unpleasant sexual images, unpleasant childhood images, or
images related to previous trauma.
• Check for persistent or disturbing images that interfere with daily functioning, and nightmares.
Ask client to describe their image associated with positive emotions, i.e. place of safety, feeling loved
feeling competent.

Cognitions
• Explore for themes and cognitions related to abandonment, mistrust, abuse, emotional deprivation,
defectiveness, social isolation, dependence, vulnerability to danger, enmeshment, failure,
entitlement, insufficient self-control / self-discipline, subjugation, self-sacrifice, approval seeking,
unrelenting standards of performance, taking excessive risks, inhibiting emotional expression.
The Schema Questionnaire (Young, 1990) may be used to identify dysfunctional schema (Core Beliefs).
An exploration of the origins of these schema, and how they play out currently in the client’s life may
provide useful information for targeting with EMDR.

Interpersonal Relationships
• Friendships, extent of support and how easy are they maintained? Common patterns?
• Romantic relationships: degree of support, how well do they feel understood, history of good and
bad connections. Check for communication styles, how problems are solved, how conflict is
managed, any problems related to children doing or do less of.
• Assess problems of excessive consumption (food, alcohol, cigarettes, drugs, workaholism)
• Check for suicidal attempts, sleep disturbance, behaviours associated with aggression or
depression.

Affect (Feelings)
• Assess presence of negative emotions (too many, too often, too strong, for too long).
• Check for blocked emotions.
• Free association techniques may be used to elicit early memories associated with particular
emotions.
• Check for positive emotions, and the activities that generate these.
• Explore memories, imagery, or skills that the client can use to evoke a sense of calm or relaxation.
These can be used in the construction of a Safe Place, or other resourceful state.

Somatic Sensations
• Check for physical, or extended family, sexual relationship.

Biological Factors
• Current health concerns and treatments. Medications and their effects
• Diet and physical exercise.

17
 My Personal Goals
Identify goals, and rate how much I feel I have achieved that goal at this point in time.

Goals How much Date

do I want
this? 0-10
1 100

50

0
2

3 100

50

0
4

5 100

50

18
 Things that are calming and make me feel better:
1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

5. _________________________________________________________________________

6. _________________________________________________________________________

7. _________________________________________________________________________

8. _________________________________________________________________________

9. _________________________________________________________________________

10. ________________________________________________________________________

Calm Place
Whenever you feel stressed or down, think of your safe calm place to help you feel more calm, relaxed, and peaceful. Your
calm place is with you always and you can return to it at any time.

Name: ____________________________________________________________________________
What I can see: _____________________________________________________________________
__________________________________________________________________________________
What I can smell: ___________________________________________________________________
What I can hear: ____________________________________________________________________
What I can feel: _____________________________________________________________________
What I can taste: ____________________________________________________________________

Use this information to remind you of your calm place when you need to return to it.

19
Phase 2. Preparation
Adapted from Shapiro (2018, Chapter 5, pp. 113-124).

Following on from the history and treatment planning phase, in this phase you will clarify:

▪ Goals for this episode of care.

- Ask the client: what changes would they like to make in the time that we have?
▪ Resources that the client has, and supports.
▪ Resources the client needs, specifically in order to be able to tolerate and regulate affect so that processing of trauma
material can be achieved, and daily functioning can be maintained. i.e. develop self-soothing skills and affect
tolerance.
▪ Create a calm (safe) place
▪ Adopt a clinical stance and establish trusting rapport with the client
▪ Explain EMDR
- Provide a rationale and describe the theory behind EMDR, mechanisms, and explain what trauma
processing is going to look like.
▪ Test the eye movements
▪ Set expectations of therapy and trauma processing
- Provide instructions for memory processing, including teaching a stop signal.
▪ Address client fears

Main objective: To expand the client’s ability to tolerate both negative and positive affect.

Clients with complex trauma, and attachment and dissociation disorders will require more work during this phase.

20
Phase Two: Procedural Preparation
All suggested explanations below are adapted from Shapiro (2018, Chapter 5, p. 113-124).

Adopt a clinical stance and rapport

Clients must feel safe, confident, a reassuringly held, yet in control of the process.
The therapist takes a position that they are there to facilitate the client’s self-healing process.
Encourage an approach that there is no right or wrong and to just notice what happens.
Emphasise the importance of feeling able to tell the truth about experiences in and out of session.
Suggested explanation:
“There is no way for you to do EMDR wrong. We start with a memory, thoughts, emotions and body
sensations. From there on some things will change or they may not, other things may come up or they may
not.
All you need to do is tell the truth about whatever you are experiencing so I can make the proper choices.
Just give accurate feedback about what is happening, without judging what is happening.
Also, it’s your brain and body doing the healing - you are in control.
If you need to stop, just let me know. Just tell me what is happening for you.”

Explaining EMDR theory

Provide a rationale and a general understanding of EMDR in language they can understand.

• For what to say to explain EMDR prior to processing a memory see procedural script on p. 49.
• For an example of how to explain memory and memory processing in the preparation phase see p. 22.
• Also, see the metaphors for EMDR in the pre-workshop reading and in this workbook, p. 23.

Testing the eye movements

Prior to processing test the clients ability to engage in eye movements,
Set up the “passing cars” position of therapist and client, and test eye movements immediately following moving chair towards
client. The middle of your L/R span of hand movement is at the client’s midline.

• Distance of hand – adjust for client comfort.

• Speed of movement – generally, as fast as the client can follow. Subtle variability of spread, span, height to avoid
habituation. Speed / span will be reduced with higher arousal.
• Eye movement alternatives: tap back of hands, sounds, butterfly hug, Theratapper (buzzies).

Stop signal
Describe its purpose, being that if they need to stop during processing they can hold up their hand as a signal. The stop signal
provides a sense of control to the client, comfort and safety.
Model the stop signal for the client.
Have the client practice it.

21
 Safe / Calm Place
See Shapiro (2018), pp. 117-119, and a calm (safe) place script in this workbook.

The calm place exercise is designed to provide the client with a skill to manage distressing feelings and thoughts. The aim is to
create a calm place in their imagination that they can draw on to regulate in and out of session. The Calm place can be particularly
useful at the end of an EMDR session or as a way to facilitate closing an incomplete session or on a day to day basis for managing
distress.

Describe the model to the client

Adjust the explanation to suit the needs of the client.
• How to explain memory and memory processing is scripted in the procedural steps outline on p. 49.

It may be useful to explain to clients how the brain has stored negative or traumatic life events.
This is an example from Shapiro (2018, p. 119):
“Disturbing events can be stored in the brain in an isolated memory network. This prevents new learning from taking
place. The old material just keeps getting triggered over and over again. In another part of your brain, in a separate
network, is most of the information you need to resolve it. Its just prevented from linking up to the old stuff. Once we
start processing with EMDR, the two networks can link up. New information can come to mind and resolve the old
problems”.

Remind clients also that processing memories means emotions may come up.
This is an example adapted from Shapiro (2018, p. 121):
“Unpleasant picture, sensations, or emotions may come up as we do the eye movements. If you have developed ways of
blocking these out, they may emerge during EMDR. Remember, like a wave of emotions come, peak, and then
subsides. I’ll help you through the peaks if you have them. But you can stop the process whenever you want by raising
your hand like this (demonstrate). It is best however, to allow the eye movements to continue. The idea is that if you
want to drive through a dark tunnel quickly, you keep your foot on the accelerator. If you take your foot off, the car
slows and coasts. So, to get through unpleasant emotions, keeping the eyes moving will get us through more quickly.
As we do the sets of eye movements, try to remember that we are only processing old stuff. It may feel real, but it’s just
the old memories locked in the brain. Just because you feel fear, does not mean there’s a real tiger in the room. The
idea is to let the brain become unlocked, and let the information process through.”

Encourage clients to “make room” for their experiences. The Guest House (used in Mindfulness Based Cognitive Therapy for
Depression) may be helpful. It is in your drop box link.

Set expectations
Remind clients that nothing will be imposed upon them in EMDR. They are in control. Their mind and body is doing the healing,
and they can stop and rest at any time.
Clients should be encouraged to be mindful, and to observe their experienced during processing,
Say, “be mindful, be aware, don’t try to change anything, just notice.”

See the procedural steps outline, specific instructions, on p. 49 for a scripted explanation for clients.

Address client fears

Do not commence EMDR processing until the client is ready. Respect all unwillingness and concerns. For some clients
readiness may take some time - weeks or months for severely emotionally dysregulated clients.
All questions and doubts should be addressed and normalised prior to commencing processing, i.e. fears of going crazy,
loosing control, shame and guilt, fears of not being able to handle the treatment experiences.

22
 Introducing and explaining memory and EMDR (an example).
This is an alternative example to the procedural steps to provide further psychoeducation if needed.

To explain to clients why past negative experiences still bother them now:
Normally when things happen in our lives our mind naturally makes sense of things, because that’s how we
are wired as humans, we need to make sense of things. And normally when things are a little bit hard to
understand we think about things a bit, talk about things with friends, family, partners, parents, work
colleagues, and then if we still don’t understand, or if things still don’t quite make sense, we go to bed at
night and in our deep sleep our minds make sense of things for us. When we are in deep sleep, called REM
sleep, our minds go over everything that happened that day, and all our memories from the day get slotted
away with all the things we already know – and then the next morning when we wake up, the world continues
to make sense, and we’re ready to have new experiences and learn more things!

But our minds have a really hard time making sense of negative, bad things: things that frighten us; make us
feel scared; unsafe; things that maybe we feel guilty and really ashamed about. It’s more difficult to make
sense of these kinds of experiences because, firstly, during the day we don’t like to think about it, we avoid
anything or anyone that reminds us of the bad stuff, and we don’t like talking about it. So, nothing gets made
sense of during the day. Then at night when our minds try to make sense of it our body starts feeling stressed,
and we get adrenaline in our bodies, we have nightmares, have really wrestles sleep, we toss and turn, have
bad dreams and nightmares, and we wake up. Trying to make sense of really negative or frightening stuff
creates such high levels of stress in our bodies that it actually impacts our brains ability to process
memories, it actually cuts off the pathway where our memories move the short-term memories from our day
to our long-term memory store. So, we are not making sense of things during the day, and we are not making
sense of things at night either.

So, the memories just get stuck in the front of our minds. And they stay there in their original form, really
detailed, really vivid, with all the big feelings, and body sensations, like when the event first actually happened.
And because the memories aren’t processed, and they are sitting in the front of our minds these memories get
easily triggered by things, people, places, sounds, smells, touch. And when they are triggered it can feel like
the event is happening again, again, and again ...., with the same big feelings and body sensations. Scary,
frightening, bad memories can sit there for weeks, months, even years – They stay there until we can make
sense of them.

.... and my job is to be here for you so that together we can make sense of them, so that they no longer bother
you in the way that they bother you now.

23
 Metaphors for EMDR
"You can outrun the lion chasing you, but you cannot outrun the lion in your head."
Old African proverb.

Metaphors are used to assist a client in understanding the process of EMDR and the client’s role in the process.
Metaphors can be drawn on during the desensitisation phase when processing starts becoming overwhelming.

ONION/ARTICHOKE METAPHOR

Processing in EMDR therapy can be a bit like peeling back layers, like of an onion. As we make sense of one layer,
another layer underneath can then come to the surface. We can then make sense of this.
Explaining using an artichoke is nice, as underneath all the layers, you can find the heart; the true, perfect, you.

THE ROOM OF A THOUSAND DEMONS

Once in the life of every Buddhist monk in Tibet, there is a ceremony called the Room of a Thousand
Demons. This ceremony gives the participants the opportunity to obtain rapid Enlightenment.
Participation is optional, but the chance comes only once in a lifetime. If the opportunity is not taken, the
faithful must make the longer path towards enlightenment, going through perhaps several reincarnations
along the way. But there is a price to be paid for rapid enlightenment, and the ceremony is not named the
Room of a Thousand Demons for nothing. This is what the faithful are told.

The Room of a Thousand Demons is well named. The demons which inhabit this room have the ability to
enter every corner of your mind, and take on your deepest fears and traumas in their most vivid form.

The Room of a Thousand Demons has two doors. You enter the room at one side, and that door cannot be
re-opened from the inside. The only exit is a door on the other side of the room. Many people have made
it through the door on the other side, to enlightenment, but some people have never made it out. They
remain tortured by the Demons. In order to help you choose whether you will enter the Room of a
Thousand Demons, here are two pieces of advice.

Whatever you experience in the Room of a Thousand Demons, always remember that your experience is
only a projection of what is in your own mind. If you have a fear of heights, you will not really be
standing on a narrow ledge above a 1000 foot drop, it will only seem that you are. If you have a fear of
spiders, it will only seem to you that the room is filled with spiders. The experience however, seems so
real that most people forget this advice.

So remember this. The second piece of advice is simply: keep your feet moving. For whatever you
experience in the Room of a Thousand Demons, if you keep your feet moving, you will get to the other
side of the room, open the door, exit, and experience enlightenment.

During EMDR I will be with you, in your Room. I cannot see your Demons for they are yours, not mine.
Of course, I do have my own Demons, but they are in my Room. But I can see your struggle, and I can
be with you, and remind you to keep your feet moving, and help you through.
Acknowledgement. This version is adapted from a story from Bill O’Hanlon’s audio tape, “Keep Your Feet Moving:
Favourite Teaching Stories from Bill O’Hanlon”, available from Possibilities, 7914 West Dodge #387 Omaha NE 68114,
USA. Bill O’Hanlon is a well-known therapist and trainer, specialising in the areas of Ericksonian Hypnosis and Solution
Oriented Therapy.

24
 Calm place script
This exercise is designed to provide the client with a skill to manage distressing feelings and thoughts. This can be
particularly useful at the end of an EMDR session or as a way to facilitate closing an incomplete session or on a day to day
basis for managing distress.
Caution. Be aware that clients with dissociative symptoms and who have adapted to very high levels of arousal can have
negative experiences during a safe place exercise. The clinician needs to be alert to this possibility and if the imagery
component stimulates aversive experience then use an alternative procedure, for example a physical relaxation procedure
such as diaphragmatic breathing.

Step 1. Picture - Image. Identify an image of a place associated with calm, warmth, safety, and control.
What I’d like you to do is to think of a place, it can be real or it can be imaginary, a place that is completely calm,
warm, it feels good, comfortable, and happy. Can you picture it in your mind?
Good, now have a look at your calm place and I want you to notice what you can see in your calm place.
Now notice if there are any sounds, … what can you hear in your calm place.
Now take a second to notice what you can smell, …
And also notice if there is anything you can taste in your calm place.
Now in your calm place I want you to notice what you can feel/touch.
Now I want you to notice your calm place, and make it just perfect for you. If there is something there that you don’t
want there anymore, take it out. If there is something that you want to bring it to make it better, bring it in. I want you
to make this place as calm and as perfect for you as it possibly can be.
Step 2. Emotions and sensations. Focus on the image, feel the emotions, and notice positive body sensations.
Now as you think about your calm place, what feelings go with it? Notice how it makes feel when you think of it?
What is the feeling that you have? And where do you feel those ____ feelings in your body?
If the client looks confused say .... Sometimes people feel the nice feelings in their hearts, or their stomach, or in
their heads. Notice where you feel them?
Step 3. Enhancement. The positive image is enhanced with short, slow BLS.
Now what I’d like you to do is think of your calm place, notice the _____ feelings, and where you feel it in your body,
and just notice [enhance with 5-10 seconds of BLS using buzzies or tapping]. Then ask the client, how do you feel
now? [Repeat as the positive feelings keep being enhanced, until the positive experience plateaus].

Step 4. Cue word. The client identifies a single word to name the image, and repeat it several times.
If you could give your calm place a name, what would that be? Ok, so when I say _____, what do you notice?

Step 5. Self-cueing. Ask the client to bring up the image. Highlight that they can use it in times of stress.
Now I’d like you say the name of your calm place, ______, bring up the image, and when you say it and think of it
notice what you feel.

Step 6. Cue with disturbance. Bring up a minor disturbance, and practice using the calm place to calm.
Ok, now I want you to think of something really small that bothers you, or upsets you a bit. Think about it and notice
where you feel that in your body. Got something? Now I’m going to say the name of your calm place, _____. What do
you feel now? [think of the calm place until the client feels the good feelings in their body again].
Step 7. Self-cue with disturbance. Client practices, with disturbance, without the clinicians assistance.
Now I’d like you to try it on your own. So first, think of something really small that bothers you, notice where you feel
that in your body. Then after, say the name of your calm place, and notice how you feel.
Step 8. Outside of session practice.
Remember, this is your very own calm place. It’s always with you in your mind and heart. No one can ever take it from
you and it’s always with you whenever you need, either in here with me, or you can think of ___ [repeat cue word] on
your own, whenever you feel down or stressed. Thinking of __ [repeat cue word] will bring good, calm feelings back.
It is important to practice thinking of your calm place every day. The more you think of it the stronger the good feelings will
become.

This is an adapted version of creating a safe place by Shapiro (2018, pp. 117-119).
25
 Calming breaths
Over-breathing is a faster than normal rate of breathing, with the breaths focused in the upper chest and overall, more air is
pumped in and out of your lungs. Calming Breaths is the reverse of this. It involves a slower rate of breathing, a smaller
volumes of air per breath, and the focus of your breath is in your stomach area, rather than in your chest and shoulders. Thus,
we have the formula for Calming Breaths.

Slower than normal rate of breathing. Stay within your limits of comfort.
Stomach focus, rather than chest and shoulders.
Slightly Smaller than normal volume per breath. Stay within your limits of comfort.

A normal breathing rate for a relaxed adult is 10 - 12 breaths per minute, or 5 to 6 seconds per breath. Anything faster than 4
seconds per breath (15 breaths per minute) is over-breathing, and the faster the breathing rate, the closer you are to extreme
over-breathing or hyperventilation. Check your breathing rate after you have been physically resting for 10 minutes. Use a
clock with a sweep hand to count how many breaths you take in 30 seconds, and multiply by 2. It may be easier to ask a
partner to time you.

Begin by getting the stomach focus of the breath established. To start with, the easiest position is lying down. Rest one hand
on your stomach, between your navel and the bottom of your rib cage. Rest the other hand on your upper chest. Both elbows
should be resting on the surface, so you don’t tense up your shoulders. Bend one leg to take the strain off your lower back. To
begin with, some extra weight on your belly is useful, to have something to breath against. About 2 – 3 Kg. is about right.
Aim for a normal sized breath, not the popular “big, deep breath”.

Now try to deliberately bring your breath down to your stomach so that it rises as you breathe in (lift the weight) , and relax as
you let the breath go and feel your stomach drop. Don’t concern yourself initially with the speed and size of your breath, but
just work at getting the feel of breathing with the stomach focus. Now remove the weight, and maintain that pattern. When
that is comfortable, try taking slightly slower breaths, with slightly smaller amounts of air, but again remember to keep the
speed and size of your breath within your limits of comfort.

Once you can do it lying down, try it standing up, and sitting in a chair. Also master it walking, linking 3 or 4 steps on each of
the in-and out- breath. That way you can keep a calm body even as you move around.

Aim to be able to eventually slow your rate of breathing down to about 8 seconds per breath. If you breath at 20 breaths per
minute initially, that’s 3 seconds per breath. Your initial goal would be to breathe comfortably at 4 seconds per breath, and
then 5 seconds per breath, and then slowly work towards your goal of 8 seconds per breath.

Don’t try and force yourself to breathe more slowly than is comfortable, you will only feel like you are suffocating. Work at
getting a good comfortable relaxed pattern to your breathing, and slow it down gradually. Remember, it’s not just the speed of
your breath that you are learning to control, but also the volume and breathing with a stomach focus. Reduce the volume of
each breath, again keeping within your limits of comfort.

Controlled breathing is a skill of muscle co-ordination, just like serving a tennis ball or driving a car. It takes practice, and
remember, “Practice …. makes Progress”.

Your aim is to be able to switch to controlled breathing in any situation, in any physical position, so practice is necessary in a
variety of settings and physical positions. Practice 2 or 3 times every hour for 30 to 60 seconds at a time, right through your
day. Other good times to practice are at a red light, on an escalator, standing in a queue, pausing for a couple of rings before
answering the phone. Controlled breathing is unobtrusive, and no-one will notice you are doing it, so you can practice it
anywhere, anytime.

A word of warning. Don’t try too hard to master controlled breathing. You cannot “force” yourself to learn to balance on a
bicycle, but by practice you “let it happen”. Controlled breathing is just like that.
© Graham Taylor, 1986 – 2011.

26
 Resource development and installation (RDI)
Resource Development and Installation (RDI) was the name suggested by Dr Andrew Leeds, to describe
the systematic creation and installation of positive resource states prior to processing traumatic material
with EMDR. RDI is indicated where clients lack internal resources due to excessive emotional
deprivation in childhood, and where clients have insufficient resources to defend against or tolerate
negative affect which precipitate dissociative defences or stop processing.

Clients who demonstrate “emotional dysregulation”, a term coined by Marsha Linehan to describe the
core dysfunction of clients with severe borderline personality disorder features would be candidates for
RDI, along with the other strategies described by Linehan (mindfulness, emotional regulation and distress
tolerance skills).

RDI has similarities to the calm/safe place exercise described earlier in this manual.

• ask the client to focus on a current life situation which is presenting some difficulty.
• identify with the client what emotional resources might make handling the situation easier. Eg.,
courage, self-discipline, perseverance, honesty, independence, self-sufficiency, etc.
• from the client history find an example where such a state was experienced. Note that the cognitive
distortions which help maintain dysfunctional schema may overlook or minimise such experiences. If
no such experiences can be found from within the client’s reported history find a significant person
who modelled such a state, or create an imaginary or symbolic representation of such a state. Note that
animals can represent a potent source of symbolic resources. Eg., eagle, lion or lioness, elephant, etc.
• develop this memory / model / image / symbol in rich sensory detail (visual, auditory, kinesthetic,
gustatory, olefactory)
• link this developing sensory detail to positive emotions and their attendant physical sensations.
• develop with the client a cue word or phrase that can be linked with the developing internal experience
/ emotions / physical sensations.
• invite the client to be in the experience, or to become part of the of the symbolic representation. Eg.,
"Step into the lion, become the lion, see as the lion sees, hear as the lion hears, feel yourself moving as
the lion."
• have the client focus on the experience, emotion, physical sensations and cue word. Do a short set (6 -
10 saccades) of eye movement (EM).
• ask the client “What do you get now?”
• continue with short sets of EM, to strengthen the positive emotions / physical sensations, until
strengthening reaches a plateau. If negative material emerges, discontinue EM, and develop an
alternative or modified resource with does not link with negative material.
• have the client rehearse using the installed resource in an imagined situation, with self-cueing. Get
feedback.
• have the client use the installed resource, in vivo. Get feedback on the usefulness of the installed
resource in real life settings, away from the therapist. Encourage the client to keep a log.

Repeat this protocol for each positive resource state.

In processing trauma material, first reactivate each installed resource and strengthen with EM. Do this
with all the resources considered necessary to permit direct processing of traumatic information.

27
Notes on RDI
RDI can be overused. Doing so may have several undesirable consequences. E.g.
• convey the message that the client is too weak to tolerate processing trauma, thus reinforcing avoidance and anxiety
about EMDR.
• Use up client resources (i.e. Medicare rebated sessions), thus preventing patient receiving treatment.
• It can be used by therapists to avoid distress (their’s or client’s).

Less than 5% of adult PTSD clients need RDI (Korn et al. 2004). The majority of such clients will present with complex
PTSD with Borderline features. (Sometimes known as DESNOS – Disorders of Extreme Stress, Not Otherwise Specified.)

Indications for RDI before starting standard EMDR for PTSD

Client cannot control tension, or avoidant or aggressive behaviours that involve
• risk of serious self-injury, mutilation, death.
• life threatening abuse of dangerous substances.
• harm to others.
• loss of economic stability, housing or essential social support with no acceptable alternatives.

Client is afraid or unwilling to start EMDR and

• standard self-care and self-regulation methods do not alleviate their distress
• inability to regulate emotion leaves client vulnerable to emotional flooding or acting out during and between treatment
sessions.

Although client is willing to proceed with EMDR the therapist determines there is a substantial risk the client would abruptly
terminate therapy due to
• poor ego strength
• inability to tolerate suppressed or dissociated material
• observed shifts from idealisation to devaluing the therapist (Borderline features)
• intolerable shame

The client has episodes where they cannot speak or barely articulate their thoughts. Client is confused or overwhelmed by
emotional states at this time.

Client cannot give a coherent narrative account of the events of the week (even with therapist prompting) such as stressful
interactions with others, and lapses into fragmentary accounts, with self-critical comments.

Invalid reasons for using RDI before starting standard EMDR for PTSD

Client meets criteria for PTSD, and readiness for EMDR, and therapist has
• a vague sense the patient is “unstable”.
• anxiety about possible abreaction.
• aversion to the content of client memories.
• preference for helping the client “feel good”.
• fear of not being able to complete the session.

The therapist should seek additional education, training, supervising, and resolved their own issues.

Indications for RDI after starting standard EMDR

Due to increased recall of disturbing memories client may be flooded with affect, or maladaptive urges after standard EMDR
such that their day-to-day functioning is affected.

In standard EMDR some clients occasionally have chronic incomplete desensitization of selected targets due to blocked
responses. Some RDI may overcome this difficulty and permit effective processing of previously blocked material.

Acknowledgement: Andrew Leeds (2006) Criteria for assuring appropriate clinical use and avoiding misuse of Resource
Development & Installation when treating complex posttraumatic stress syndromes. EMDRIA Annual Conference. Full notes,
with examples available from http://www.andrewleeds.net/training/prodownloads_files/Criteria%20for%20RDI.pdf

28
 Light stream script

Used in EMDR as a grounding technique to reduce negative affect

If client reports upsetting bodily sensations, ask:

“If it had a shape, what shape would it be?”

“If it had a size, what size would it be?”
“If it had a colour, what colour would it be?”
“If it had a temperature, what temperature would it be? Hot or cold?”
“If it had a texture, what texture would it be?”
“If it had a sound, what sound would it make? High or low pitch?”

Then direct an imagery exercise:

“I would like you to imagine some healing light coming down from above and moving in through
the top of your head. This healing light is directing itself at the shape in your body. I would like you
to give this wonderful healing light your favourite colour (make sure it is a different colour from the
shape). I would like you to decide whether this light is warm or cool. Now imagine this light
coming in from above, through your head, into your body. The light directs itself towards the shape
in your body and notice how it resonates with it, vibrates with it, in and around it. And just notice as
it does this what happens to the shape”

Repeat the suggestion and seek feedback about what is happening to the shape. Repeat variations on
the suggestion until the shape is gone/neutralised. After the shape has gone facilitate bringing light
into the person’s whole body.

Further examples of suggestions.

Try and picture that light continuing to flow down from above through your head, down through
your body working its way down into your muscles, soothing any tension or tightness, relieving
aches. Let it flow through your back…. your legs…. right through the bones and the muscles. In
and around your feet …. and spreading its light all the way through, down the muscles of your
feet and out to the very tips of your toes. And as you continue to just experience that light
flowing down and into your body, and all through your body, focusing the light on that area of
discomfort, and just noticing that shape as it gets bathed in healing light, … perhaps shrinking,
… perhaps changing its temperature, … its texture, … its colour, … its shape.

Re-orientate now to the outside world just by gently opening your eyes in your own pace and
time, becoming more aware of [incorporate details of background noise, tactile sensations
associated with body position, the natural increase in tension on the in-breath, etc.] … and re-
orientating all your senses back to the present.

29
THREE: TARGET ASSESSMENT
The Target Assessment Phase consists of assessing the
1. Picture/Image/Memory
2. Negative Belief (Shapiro uses the phrase Negative Cognition)
3. Positive Belief (Shapiro uses the phrase Positive Cognition)
4. VoC Validity of Positive Belief; on a 1 - 7 scale.
5. Emotion / Feeling. (Generated by pairing the memory (1) with the Negative Belief).
6. SUDs of the emotion(s), on a 0 - 10 scale.
7. Location of Body Sensation - where the emotion is felt in the body.

Picture / Memory:
“When you think of (the incident), what picture/image do you get?”
“What aspect of (the incident) represents the most traumatic part of it?”

For non-visual clients say “when you think of the incident what do you get now”. Some clients may
not be visualisers, others may be defensively blocking on the imagery. A non visualiser will have a
general inability to visualise, a blocker will be able to visualise non traumatic images.

Negative Belief:

"What thoughts do you have about yourself now as you think about that memory?"
or
"What words best go with the memory that express your negative belief about yourself or the
experience?"
or
“ If you think of the memory as a picture, what caption would you put to the picture which best
expresses your thoughts about yourself now?”

Criteria for Negative Belief. (Shapiro uses the phrase Negative Cognition.) A Negative Belief is

1 A negative, self-referencing belief which is

2 Presently held, and which

3 Accurately focuses the clients presenting issue, and

4 Generalises to other related issues of concern.

5 Has Affective resonance. That is, it has the painful bite of an emotional truth.

It is not

1. A description of events or circumstances, (Ask "How does that you make you feel about
yourself now ?" and from the emotion, ask for the Negative Belief behind the emotion.)

2. The attributes of others, (Ask "What does that say about you now ?")

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3. An expression of a feeling, (Ask "What thoughts produce that feeling of _______ ?” , or
"How does that make you feel about yourself? Then go for the associated belief.)

4. A wished for set of events that differed from reality. (Empathetically pace and lead. E.g. "It
would have been nice if there had been better security, but what you had at the time was all
you had then. What thoughts do you have about yourself now when you acknowledge what
happened ?"

Shapiro notes (page 131) that “when the thoughts, emotions, or situation appear too confusing or
complex, it is appropriate to continue without the negative cognition. However, if at all possible, one
should be specified.”

The Vertical Arrow technique from cognitive therapy is one way of leading to a negative belief. It is
well described by David Burns in his book “Feeling Good”.

The technique involves :

1. A repeating series of prompts or questions that search for client's meaning of an event.

2. A non-challenging acceptance of any of the cognitive distortions in the client’s story of the event.

3. An acknowledgement of the emotions experienced, but these not explored in detail. Return to
search for the client's meaning that gave rise to these emotions.

Other strategies for eliciting a NB

Ask “Has (the event) changed the way you now think about yourself? Other people? The
world in general? Events like this often change the way people think about themselves, and
these thoughts continue to affect their lives long after the event, like an unwanted legacy.
Has your thinking about yourself changed as a result of (the event)?
Has your thinking about others changed?
Has your thinking about the world in general changed?
If you could get back to a better way of thinking, what would those thoughts say? If we could
write them out, what would they look like?

Positive Belief
Ask “What would you like to believe about yourself now?”
or
“When you have resolved this, how will your thinking be different. What would you like to
believe?”

Criteria for Positive Belief (Shapiro uses the phrase Positive Cognition.) A Positive Belief is

1. A positive, self-referencing belief.

2. It is the same theme as the Negative Belief, and

3. Accurately focuses the client’s desired direction of change, moving in a positive direction.

4. It begins by being believable to some extent (VoC>1, or greater than 0% ), but need not be a perfect
expression of mental health. (See point 3.)

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5. It is not the negation of a negative, and it avoids “never” or “always.”

6. It is generalisable to other, possibly related, issues for the client, and

7. Realistically adaptive for the client now, and for the future.

A weak Positive Belief generally becomes more true during processing. Often an even more positive
belief emerges. By the end of successful resolution the Positive Belief has a positive emotional
resonance, it feels true, and is not just intellectually true.

It may not be possible in the Assessment phase to arrive at a strong Positive Belief. Such a belief
might be so foreign to the client’s personal beliefs as to be completely unbelievable (VoC = 1).
For abuse victims, the best that might be obtained at this stage might be a statement about present
safety (I’m safe now), or ïts in the past its over”. A more self-referenced belief will likely emerge
during the Desensitisation and Integration phases.

Acknowledgement: The notes on Negative and Positive Beliefs have been developed from “Selection Criteria for
Negative and Positive Cognitions in EMDR” by Andrew Leeds, Senior Trainer with the EMDR Institute, and included
with his permission.

Rate the Validity of the Positive Belief (VoC)

VOC - This abbreviation refers to Shapiro’s phrase Validity of Cognition.

"When you picture the (note the incident), how true do the words (insert Positive Belief) feel, on
a scale from 1 to 7, where 1 is completely false and 7 is completely true."

If a client gives a 1, check the appropriateness of the positive belief. It needs to be believable to some
degree. Example. If a client gives a VoC of 1 to "I am loveable", then "I can learn to love myself"
may be a good starting point, so long as it has a VoC greater than 1. The PC may evolve
spontaneously into a healthier variant during processing.

Note the questions is "How true does it feel." (It may be useful to distinguish between a truth in the
head and a truth in the heart.)

Emotion:
“When you concentrate on the memory and repeat the words (insert Negative Belief), what
emotions come up now?”

The client may offer more than one emotion.

Clients will often give a somatic response. Their distress level may be quite high, so it may not be
time to get a verbal label.

Subjective Units of Disturbance (SUD):

“And how strong is this on a scale of 0 (being no distress) to 10 (the worst you can think of)?”

If there are multiple emotions present, rate the overall level of disturbance, not each individual
emotion.

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Identify body location of emotion

“And where do you feel it in your body?”

Don’t ask for a description of the sensation, just the location.

A feeling of numbness or being blocked is a sensation, “Whereabouts do you feel numb?”

Sensation awareness exercises may be useful or necessary for some clients who struggle with this as
part of preparing for EMDR.

Examples of Negative and Positive Beliefs (adapted from Leeds)

Ideas related to core schema
I don't deserve love. I deserve love; I can have love.
I am a bad person. I am a good (loving) person.
I am worthless (inadequate). I am worthy; I am worthwhile.
I am not lovable. I am lovable.
I am not good enough. I am deserving (fine/okay).
I deserve only bad things. I deserve good things.
I am permanently damaged. I am (can be) healthy.
I am ugly (my body is hateful). I am fine (attractive/lovable).
I am stupid (not smart enough). I am intelligent (able to learn).
I am insignificant (unimportant). I am significant (important).
I am a disappointment. I am okay just the way I am.
I am different (don't belong). I am okay as I am.
I am a failure (will fail). I can succeed.
I cannot succeed. I can succeed.
I have to be perfect (please everyone). I can be myself (make mistakes).
I am inadequate. I am capable.
I cannot trust anyone. I can choose whom to trust.

RESPONSIBILITY / I DID SOMETHING "WRONG"

I should have done something. I did the best I could.
I did something wrong. I learned (can learn) from it.
I should have known better. I do the best I can (I can learn).
It was my fault It wasn’t my fault

SAFETY/VULNERABILITY
I cannot be trusted. I can be trusted.
I cannot trust myself. I can (learn to) trust myself.
I cannot trust my judgment. I can trust my judgment.
I cannot trust anyone. I can choose whom to trust.
I cannot protect myself. I can (learn to) take care of myself.
I am in danger. It's over; I am safe now.
It’s not OK to feel (show) my emotions. I can safely feel (show) my emotions.
I cannot stand up for myself. I can make my needs known.

CONTROL/CHOICE
I am not in control. I am now in control.
I am powerless (helpless). I now have choices.
I am weak. I am strong.
I cannot get what I want. I can get what I want.
I cannot stand it. I can handle it.

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VIGNETTES
For each vignette, consider each Negative Belief and each Positive Belief. Based on the criteria given
earlier, decide if each is suitable for using with EMDR. If not, how would you respond to the client,
in order to arrive at a more suitable NC and PC. Write out your response as you would make it to
the client.

Vignette 1.

A twenty five year old pharmacy assistant is seen two months after a holdup. She presents with PTSD
symptoms, marked anxiety at work, secondary depression, and some generalised avoidance of public
and social settings. The target for EMDR is the memory of the holdup.

Negative Beliefs:

1. How can people get away with this?

2. It was so scary.

3. I knew it wasn’t a safe place to work, I shouldn’t have taken the job.

4. I am not safe.

5. The boss has been so horrible to me since.

Positive Beliefs:

1. I suppose I will get over it.

2. It won’t happen again.

3. I can take care of myself.

4. That’s life, these things happen.

5. I am safe now, it is over.

Vignette 2.

The client is a thirty eight year old woman, of German background. Both her parents were
stereotypically rigid and perfectionistic. She was trained in her profession by a punishing and
perfectionistic mentor. She suffers episodes of depression, and drinks heavily to moderate negative
feelings. The target for EMDR is a recent occasion where her son didn’t do well. She sees herself
as a failure as a mother.

Negative Beliefs:

1. I should have done a better job.

2. He’s just like his father.

34
3. I am a failure.

4. He should know better.

Positive Beliefs:

1. He makes many mistakes, but he is not a total failure.

2. I have taught him some positive things.

3. I am not a failure.

4. I can do better in future.

5. I am a worthwhile person.

Vignette 3.

The client is a twenty year old woman who has been involved in six motor vehicle accidents in a two
year period.. On each occasion her car has been stationary at traffic lights, boom gates, or a STOP
sign, and she has been struck from behind. She evidences PTSD symptoms, and is hypervigilant
when driving. Her driving is now limited to essential journeys. The target memory for EMDR is a
recent experience, seeing the sight of a vehicle in her rear vision mirror.

Negative Beliefs:

1. He’s going to hit me.

2. The roads are full of idiots.

3. I must have done something wrong. (after a friend gave her a book on Past Lives therapy.)

4. I am not safe.

5. Everyone is out to get me.

Positive Beliefs:

1. I am no more at risk than anyone else.

2. I am as safe as anyone else.

3. I have had my share, they won’t get me again.

4. The accidents are over, I have survived.

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Vignette 4.

44 year old grader operator depressed for two years following some difficulties with his supervisor
at work and his daughter leaving home. His diagnosis is major depression and his disorder has not
responded to various pharmacological and psychological treatments. The most remarkable aspect of
his presentation is his agitation and tendency to punch himself in the head when distressed. His target
image involved overhearing a family friend say “their is something the matter with Paul, he looks
like he is retarded.” This occurred when he was nine.

Negative beliefs:

1. She should never have said that.

2. I am useless.

3. There is something wrong with me.

4. I am embarrassed.

5. My mother should have told her to mind her own business.

Positive beliefs:

1. I want people to judge me as a normal person.

2. I am worthwhile.

3. I am OK.

4. How you look shouldn’t matter.

Vignette 5.

A 45 year old woman who has obsessive compulsive disorder avoids preparing family meals for fear
of poisoning them. Her rituals involve washing vegetables and fruit excessively. She avoids cooking
whenever possible and frequently feels guilty. The EMDR target is the most recent incident of
preparing a meal.

Negative beliefs:

1. I might kill my family.

2. I am a bad person.

3. I am going crazy.

4. I have done something wrong to deserve this.

36
Positive beliefs:

1. I would know if there is anything poisonous on the food.

2. I don’t mean to hurt anyone.

3. I am OK as I am.

4. What ever happens happens.

Vignette 6.

50 year old woman presents with irritable bowel syndrome. She has a history of sexual abuse by her
uncle. The EMDR target is an incident of sodomy.

Negative beliefs:

1. It should never have happened.

2. I am dirty.

3. No one deserves to be treated in this way.

Positive beliefs:

1. I wish it had never happened.

2. I am attractive and loveable.

3. Deep down my uncle loved me.

4. He was a really sick person.

37
PHASE 4 DESENSITISATION
Length of sets. One eye movement is one back and forth movement. Use around 30 seconds of back
and forth movements as a starting point. If heightened arousal is observed, extend the length of the
set.

Include the occasional supportive comment. E.g., “Just noticing”, or “being aware”, or “just
observing”.

Generally, go as fast as the client can track.

Small variations of speed, span and height of EM to avoid habituation.

If heightened arousal seen, keeping going, increase supportive comments as needed. E.g. “it’s old
stuff”, “just notice it”, “make room for it as best you can”, “let what’s there be there” “ it will pass”.

During heightened arousal, speed and span may be considerably reduced.

Bilateral stimulation – other modalities. E.g., sound, taps, butterfly hug.

At the end of a set of EM stop at mid point, pause, lower hand, and probe. “Take a deep breath, let
it go … what do you notice now ? Alternative wordings “Rest … let it go … What do you notice
now?” or “What do you get now ?”

If the client says they get “nothing”, ask “When you think of the incident, what do you get now?”

Don’t ask the client “what are you thinking, or “what are you feeling?” as such probes will set up
expectancies.

Don’t paraphrase or reflect the client’s response. Their verbal report may just be a small fraction of
what they have experienced, and paraphrasing selective reinforces their report, and may create
expectancies.

If client reports dizziness or nausea, change the direction of EM. Diagonal or Vertical are useful.
As a general rule, whenever positive shifts are reported, do another set.

The flow chart on the following page summarises the possible client responses.

Note if a Positive idea  do one more set:- If significant change  process

If no significant change  check original target

Check target , if SUDs 0 or 1  Integration phase

Check Target if SUDs >1+ continue to reprocess

38
EMDR PROCEDURAL FLOWCHART

Integration
Original Target
Phase SUDS = 0 or 1

Process with Eye Movement

Incident
Unrolls

New
Negative
Picture

Shift
Bodily
Sensation

New
Negative
Idea

New -ve
Emotion

"Where do you feel it in

your body ?"

Positive or Neutral
idea or image

One more set

Substantial No substantial
change change

39
 Blocked processing: When processing stops
See Shapiro (2018, ch. 7, pp. 171 – 190)

Processing is considered to have stopped when, over two successive sets of eye movement, there is no
change in any of the following: memory, beliefs, emotions, or its location, or the VoC of the positive belief.

Signs of blocked processing:

• Looping – the same thing is reported over and over
• Numbing – “nothing”
• Flooding – overwhelmed by activation of memory networks

The strategies for blocked processing below may be used to re-stimulate processing.
Generally, when change is reported, meaning that the client has recommenced processing, revert to standard
protocol, unless otherwise indicated.

CHANGE EM:
• Speed and width To prevent habituation
• Diagonal If habituation to horizontal has occurred.
• Longer set
• Vertical More useful to use for calming, rather than reprocessing.

FOCUS ON BODY SENSATION: This is what to do when a client is stuck with a body sensation.
• Movement, During sets, have the client add their own movement e.g. Tapping on their
knees, Butterfly Hug. This increases the load on working memory, and will also ground
dissociative clients more in the present.
• Press location – hold, then let go. Say, “Can you place your hand on that area where
you feel tense or tight. Focus just on that.” Begin the set with faster and short
movements. After about 10 – 15 movements, say “When you are ready and in your own
time, take your hand away and let it go.” Simultaneously slow down and LENGTHEN
the EM. Add, “Just notice … just notice”. Stop after a further 10 – 15 movements. You
may need to tell client to drop their hand if they haven’t by end of set.
• Unspoken words – that express the emotions/body sensations. This is particularly useful
with stuck tension in the jaw and throat. i.e. ask the client, “Just say whatever you need to

40
 say”, During this set become a cheerleader, encouraging the client to say and/or do whatever
is necessary. At the end if didn’t say anything just ask what did you notice or was there
anything that you thought needed to be said or anything you need to do to express that
tension. .
• All body sensations or primary body sensation. Direct the client to drop the image and
thought and just focus on body sensations, or just focus on the specific body
sensation/tension that is stuck.

SCANNING - When a client is stuck on the target incident and image.

• Visual cues.
Ask the client to focus just on the visual aspect of the memory, and say, “Is there anything
else coming up?, or “is there something about that scene that is more disturbing or
particularly distressing now?” Continue to process the new, distressing aspect of the
memory.
• Sound effects and dialogue.
Sounds and what was said during a trauma is usually processed spontaneously, but if
processing is stuck you can ask, “Are there any particular sounds?”. Or ask about what’s
being said, “Was there anything that was said at the time that makes you really upset?”

ALTERATIONS - When the image is stuck, the therapist could also ask the client to alter the
image they see in their mind. For example:
• Perceptual change. Evoke perceptual changes, to facilitate reduced arousal, i.e. Grow
yourself in size and stature, make the other person smaller, or older, sound like Mickey
Mouse. See the scene as a Black & White photo or freeze the frame.
• No action. Freeze the perpetrator, or see them as just a head and shoulders image, contained in
a frame.
• Hierarchy. Use a hierarchy, as in Systematic Desensitisation.
• Redirect to target image and Negative Belief. This can restimulate the distress associated
with the memory and allow processing to continue.
• Add a Positive Statement. Only introduce a positive belief when processing is stuck at low
levels of disturbance. This can activate other positive memory networks that may allow
continued processing.
• Check Positive Belief. If the client is stuck during the installation phase and the VoC is not
going up. Ask, “Can this ever be true, does it need modification.”

ANCILLARY TARGETS
• Feeder memories. Earlier memories linked to target memory or cognition. Is there an
earlier memory which fits the NB. “Where did you begin to learn …(NB) ... “. Affect
Bridge may be used to identify an earlier memory.
• Blocking beliefs. Beliefs that block processing may be identified by asking “What stops
your (i.e. anxiety …) being lower?” “What is stopping the idea (repeat their positive belief,
i.e. I’m competent) from being true?” Blocking beliefs will have their own history, thus
giving rise to an ancillary target.
• Fears – relating to change. Consider, if change occurs what might the client fear.

Most common unblocking techniques

o Add focus and/or pressure to apply tension to primary body sensation.
o Unspoken words / actions.
o Scanning for other visual cues.
o Perceptual change.
o If change occurs what might the client fear
o Redirect to new image / negative belief (Check for Feeder memories.)

41
PHASE 5 INTEGRATION
See Shapiro, 2018, pp. 151 – 153.

Shapiro calls this phase "Installation". We prefer a term that suggests linking the now desensitised
memory to existing resources, rather than “installing” something new.

AIM: Full integration of a positive self-statement with the targeted information.

Install the positive cognition to a VOC = 7, and strengthen.

During desensitisation the original Positive Belief may have undergone reported positive shifts. If so, use
the better positive belief in the next steps:

1. Check the PC still fits, choose most adaptive PC. Ask,

a. Do the words (repeat PB) still fit, or is there a better positive belief?
b. If there is 2 or more positive beliefs, go with the one that has the lowest VoC as this needs
the most work to strengthen.
2. Check the VoC of the positive belief: “Think about the original incident and those words
(repeat the selected PB). From 1 (completely false) to 7 (completely true), how true do they
feel?”
3. Have the client hold the original memory and the positive belief together, state, “Hold those
words and that original incident together.” do EM.
4. After the eye movements ask either “On a scale of 1-7, how true does (PC) feel to you now
when you think of the original incident?” or use percentages.
Or ask, “Did the belief get stronger, weaker or stay the same?”
5. Install PB to a VOC = 7 – and beyond. Then move to the body scan.

If the VoC appears to be stuck at 5 or 6, ask “What prevents it from being a 7?”

Note. Inappropriate positive belief. - A PB which is "ecologically invalid" cannot be integrated. For
example, “I’m liked by everyone.”

Blockages

If the strength of the positive belief does not improve it may be because:
1. The PC links to other memories of negative experiences related to the schema. This is sometimes
referred to as a blocking experience. A blocking beliefs has a history. Ask “When was the first
time you remember feeling this way?” Target this memory. In essence this is returning to the
desensitisation phase. Once this event has been processed, by re-evaluating the original target
memory as SUDs 0 or 1, return to Integration and check believability of the positive belief.
2. There may also be real current reason that a PB will not install. Check for this.

42
Procedure for Closing an Incomplete Session
An incomplete session is one in which a client’s material is still unresolved, i.e., they are still obviously
upset or the SUDs is above 1 or VoC is less than 6.

The following is a suggested procedure for closing down an incomplete session. The purpose is to
acknowledge clients for what they have accomplished and to leave them well grounded before they leave
the office.

A Body Scan should not be done.

STEPS

Ask the client’s permission to stop and explain the reason.

“We are almost out of time and we will need to stop soon. How comfortable are you about
stopping now?”

Give encouragement and support for the effort made.

“You have done some very good work and I appreciate the effort you have made. How are you
feeling?”

Skip the Installation of Positive Belief and the Body Scan. It is evident that there is still material to be
processed so there is no point in doing these phases.

Do a relaxation exercise.
“I would like to suggest we do a relaxation exercise before we stop. Would you like to do … ?(clinician
suggests a form of relaxation, e.g., Imagery, Safe Place, Light Stream, etc). A script for the Light
Stream meditation is given later in this manual.

Do Closure steps as above.

Debrief, as for Phase 7.

43
Phase Six: Body Scan

See Shapiro, 2018, p. 154-155

AIM: Clear all physical tension associated with the target memory + the positive belief.

Begin this phase by asking the client to, "Close your eyes and keep in mind the original memory and
the words (repeat Positive Belief). Then bring your attention to the different parts of your body,
starting with your head and working downward. Any place you find tension, tightness or unusual
sensation, tell me."

An alternative wording, more permissive than Shapiro's instructions is suggested below.

"Just settle back, … close your eyes … and just allow yourself to think about the original incident
and allow the words (repeat Positive Belief) to repeat themselves in your mind as you allow yourself
to scan your entire body from top to bottom, … and from bottom to top, … and anywhere you
notice any tension, … any tightness … any resistance to this idea, just indicate to me by raising the
finger of your hand or shaking your head.
You have got all the time in the world, there is no rush, just take your time with this one."

• Watch the client carefully during the Body Scan. Look for signs of tension or increased arousal.
When finished, ask the client for a report. Does the verbal report match the nonverbal signals?

• Any discomfort or unusual physical sensations is processed with further sets.

• The body scan is completed when the client, holding the target memory in mind and the positive
cognition, can mentally scan the body and notice no residual tension or other negative sensations. If a
positive or comfortable sensation is reported, sets can be done to strengthen it.

Note. Before asking permission to end, ensure that any positive feelings, i.e. calm in the body, is an ok
feeling for the client. Remember, calm may be a foreign feeling, even an unsafe feeling for someone who
has life-long trauma. Not feeling tension in the body may lead to a feeling of vulnerability and no longer
being on guard. Ensure the client feels ok with the positive feelings that result from clearing tension in the
body scan.

Note. If you are nearly out of time, and you suspect the discomfort reflects further somatic memory, do not
target the discomfort, but close the session. You do not want to open another channel of information if you
do not have time to process it. Debrief carefully.

44
Phase 7: Closure
See Shapiro, 2018, pp. 155 - 160.

Allow sufficient time for this.

• Reward client
• Warn re-continued processing.

“During EMDR therapy your brain begins to process stored information, moving it towards a state
of resolution. It is not uncommon for processing to continue in the 24- 48 hours or so following EMDR
therapy.
You may experience other memories, images, dreams, thoughts or emotions in some way related to
the information that was worked on during the EMDR session. These experiences may reflect further
natural information processing in your brain.

• Encourage log
• It may be useful or necessary to work on this information at your next appointment. Please
bring this sheet to your next appointment.
• Remind to self sooth
Remember to use your (name self-soothing skills), if any distressing experience or reaction occurs. If
it is strongly distressing, you can contact me.
• Options for emergency contact

45
After Eye Movement Desensitisation and Reprocessing
During EMDR therapy your brain begins to process stored information, moving it towards a state of
resolution. It is not uncommon for processing to continue in the hours and days following EMDR therapy.
You may experience other memories, images, dreams, thoughts or emotions in some way related to the
information that was worked on during the EMDR session.
These experiences may reflect further natural information processing in your brain. It may be useful or
necessary to work on this information at your next appointment. Please bring this sheet to your next
appointment. If some of these experiences are upsetting, use your relaxation strategies to help you. If any
experience or reaction is strongly distressing, contact me on the numbers below.
Use this sheet to record any experiences related to your EMDR session. Record the date, the event which
triggered the experience, and any memory, image, thoughts, or emotions.

DATE TRIGGER MEMORY, IMAGE, DREAMS, THOUGHTS, EMOTIONS

Therapist name ___________________________________________________________________________

Work:______________________________________ Home: ______________________________________

46
 Phase 8 Re-Evaluation
Past issues

1. Memory that worked on last session

2. What happened in the 24-48 hours post
3. What about the rest of the week
2. If SUDS ˃3 then stay with original target, check –ve cog if spiked likely new domain

If SUDS 0 or 1 and VOC 6 or 7 then….

If SUDS ≤ 2 but VOC ˂5 if simple then…

Check Client Log

Administer and check Impact of Events Scale, or other PTSD measure. Explore relevant items in
more detail.

Present:
Current triggers linked to the original trauma which stimulate distress. IES intrusion items handy
here.

Focus on each image, do a Target Assessment, assess if EMDR is necessary. You may want to
consolidate Positive Belief with EM.

System issues – changes to change. Need for other therapies, assertion training, communication,
social skills, etc.

Future:
This phase focuses on the client’s ability to make more adaptive choices in the future. Targets should
include

Anticipatory fears. If present, target these first. Then move to Positive Template

Positive template to guide future events

Follow up
Check for adaptive changes, consolidation and generalisation

Space out review appointments.

Work through relapse prevention issues, and therapy termination issues. Discuss possibility of new
material unfolding. Leave the door open for future contact.

47
ADDITIONAL PROTOCOLS
How to determine targets & stimuli to reprocess. All protocols have a past, present, and future orientation.

Single Trauma:

a) past: 1. Traumatic memory images & channels

b) present: 1. Nightmare/dream images
2. Triggers
c) future: 1. Positive belief
2. Healthy coping with triggers
3. Healthy coping with related challenging situations

Recent Trauma (less than 2-3 months old):

1. Does the person report a single image of the traumatic experience?

If Yes, use basic protocol
If No, then continue below

2. If client reports multiple image, does one represent the whole experience, or the worst part of it?
Yes Use basic protocol
No Continue

3. If the client reports multiple images of equivalent intensity or the client reports no images but the
remembered fragments have equivalent intensity. Then use the Recent Events protocol

Recent Events protocol:

Take a chronological narrative of the whole experience. Have them do a movie from moment first
knew something might be wrong to the end of the event.

At each target assessment identify hot spots instead of whatever they notice. Get negative and
positive cognition at each of these points. Continue until all hot spots treated.

For more elaborate recent events protocol see Recent Events protocol: Shapiro, E., Laub, B., The Recent
Traumatic Episode Protocol (RTEP): An Integrative Protocol for Early EMDR Intervention (EEI), 2008.
Available online: http://emdrresearchfoundation.org/toolkit/rtep-luber-ch12.pdf

Multiple Trauma:

a) past: 1. First traumatic memory images & channels

2. Worst one(s)
3. Most recent (if applicable)
4. All the rest of them (sequentially, during eye movements)

b) present: 1. Nightmare/dream images

2. Triggers

c) future: 1. Positive belief

2. Healthy coping with triggers
3. Healthy coping with related challenging situations

48
Grief:

a) past: Memories of the loss & related events: Being told of the death, images of the death
or suffering, the funeral, negative memories of loved one, intrusive images etc.

b) present: 1. Triggers
2. Ongoing issues of personal responsibility, guilt, blame, regret,
or previous unresolved losses

c) future: 1. Good memories/images

2. Honour the dead

Current Anxiety:

a) past: 1. Initial memory or memories

b) present: 1. Recent or representative example of current anxiety situation

c) future: 1. Rehearsal of desired way of coping with this situation

Simple Phobia:

First: Teach self control procedures to handle the fear of the fear. (This should include a breathing
technique and in the case of blood-injury-injection phobia, applied tension)

a) past: Any ancillary events that contribute to the phobia.

* The first time the fear was experienced.
* The most disturbing experiences.
*
b) present: The most recent time it was experienced.
Any associated present stimuli.
* The physical sensations or other manifestations of fear including
hyperventilation.
*
c) future: Incorporate a positive template for fear-free future action.

Process Phobia:

a) past: 1. Initial trauma-type memory, if any

2. First, worst, and most recent times the fear was experienced

b) present: 1. Current triggers, associated stimuli, etc.

2. Physical & other manifestations of fear

c) future: 1. Arrange contract for action

2. Movie of each step in sequence
3. Re-evaluate from one session to next; contract for greater action

Children

Adapt to suit developmental level and to maintain interest. (See Shapiro, 1995, Chapter 11).

Simplify beliefs. Eg, “I’m fine”, “I’m safe now.”, “It’s OK to tell.”

Use drawings for targets, innovation needed for other components

49
 Shorter session (45 minutes),

Eye tracking. Use of puppets

Hold the child’s attention.

Couple work

EMDR is an individual therapy. Treat individual trauma that impacts on the couple dynamic.

Systems issues. Discuss impact of change in one or other partner on the relationship.

Joint versus individual session.

Self Use

Client cautions
Mechanics
Therapist healing

50
DISSOCIATIVE DISORDERS
Clinical signs:
Depersonalisation and derealisation.
He/she does not feel like him/herself (e.g., smaller or larger)
His/her surroundings do not look the same.
Look in mirror and see something other than usual reflection.
Floating above or alongside self.
Life as dream-like.

Memory lapses
Example: How one got to the store; finding unfamiliar items in the house; or missing narrative history of
life. However, this may be due to substance abuse, illness, depression, or dementia. A highly organised
DID system can fill in blanks.

Somatic symptoms
Headaches intractable to over the counter remedies.
Illnesses that physicians cannot account for may be somatic memories.

Sleep disorders
Frequent nightmares or night terrors.
Sleepwalking usually associated with DD.

Flashbacks
Recent traumatic events, childhood events, multiple, serial PTSD ->MPD.

Therapy history
Clients with many different diagnoses over the years.
Multiple psychiatric hospitalisations with varying diagnosis.

Internal conversations
Frequently hearing voices in head, not externally (as in schizophrenia)
Feelings that come out of the blue without any way to explain them.

Given the possible under-reporting of dissociative disorders, and the risk to the client if therapy
proceeds without their identification, it is considered mandatory that a screening for dissociative
disorders be undertaken prior to doing EMDR therapy.

The Dissociative Experience Scale (DES) is provided as a separate handout, together with an excerpt from
the DES Manual.

The EMDR Institute has issued guidelines for the use of EMDR with dissociative disorders.
If a Dissociative Disorder is present, carefully consider the following factors in your decision with respect
to providing therapy. (Taken from Shapiro (2001), Appendix B.

Are you sufficiently trained in the treatment of dissociative disorders?

Do you have adequate supervision and backup?
Can you anticipate and deal with multiple transference issues?
Can you work with hypnotic and dissociative phenomenon?
Do you have considerable EMDR experience, including Level II training?

There are also a number of green and red flags with respect to the patient.

51
Green flags
Good affect tolerance.
Stable life environment.
Tolerance of short term discomfort for long term gain.
Good ego strength.
Adequate social supports.
History of treatment compliance.

Red flags would include :

Ongoing self mutilation.
Active suicidal or homicidal intent.
Uncontrolled flashbacks.
Rapid switching between alters
Extreme age or frailty
Terminal illness
Need for concurrent adjustment of medication
Ongoing abusive relationships.
Alters strongly opposed to abreaction
Severe narcissistic/sociopathic/borderline features.
Serious dual diagnoses e.g. schizophrenia, active substance abuse.

From 2011 Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision:
Summary Version. Published by The International Society for the Study of Trauma and
Dissociation. (The complete Summary Version of the Guidelines are in the Dissociation folder on
your DVD/CD.

EMDR was developed in 1989 and became known for facilitating the rapid resolution of traumatic
memories in uncomplicated PTSD, among other uses. However, early use of standard EMDR for patients
with unrecognized DID resulted in serious clinical problems, including unintended breaches of dissociative
barriers, flooding, abrupt emergence of undiagnosed alternate identities, and rapid destabilization. Current
expert consensus is that the original EMDR protocols must be modified for safe and effective use with DID
patients.

Modified EMDR procedures, when imbedded into an overall phase-oriented framework, can be used for
specific work on particular traumatic material, symptom reduction and containment, ego strengthening, and
working with alternate identities. EMDR procedures should be used only by clinicians knowledgeable in
the treatment of dissociative disorders, and only when the patient is generally stable and has adequate
coping skills, enough internal cooperation among alternate identities, and the ability to maintain a dual
focus of awareness that is necessary in EMDR procedures. Ongoing abusive relationship(s); strong
opposition from alternate identities to processing; and serious comorbid diagnoses such as schizophrenia,
active substance abuse, or severe character pathology are contraindications to the use of EMDR.

It is essential to reduce the risks of breaching dissociative barriers and flooding when using EMDR with
DID patients. Unlike in the usual EMDR procedure, associative processing (i.e., allowing the processing
to bridge to associated memories) is discouraged with DID patients. Instead, the target memory should be
procedurally isolated as much as possible. Various techniques have been developed to modulate the
intensity of EMDR work, including fractionated abreaction and serial desensitization, which involves
processing the different elements of a memory held by separate ego states. Other protective modifications
of EMDR for DID involve the pacing and the use of shorter alternating bilateral stimulation sets and/or
audio or tactile alternating bilateral stimulation.

52
The Dissociative Experience Scale. (DES)
Introduction
The Dissociative Experience Scale was developed to serve as a clinical tool to help identify patients with
dissociative psychopathology, and as a research tool to provide a means of quantifying dissociative
experiences. The DES is a brief, self report measure of the frequency of dissociative experiences. It is a
screening tool, not a diagnostic instrument. The scale was conceptualised as a trait measure (as opposed
to a state measure) and it enquires about the frequency of dissociative experiences in the daily lives of
subjects. High DES scores should not be interpreted as defining the existence of a dissociative disorder,
but should serve as a signal for further careful investigation.
The DES was developed for use with adults (persons 18 or over), and the language used and the experiences
described are appropriate for adults, but may not be appropriate for younger persons.

Administration and Scoring

The scale is a self report measure, so it is self administered. The scale is scored by calculating the average
score for all items. Add all 28 item scores (0, 10, 20, … 100) and divide by 28.
Norms
Numerous studies have collected DES data on a wide range of clinical and non-clinical populations. The
means and standard deviations (or medians) and the number of subjects (in parenthesis) for a selection of
samples from various studies are shown below.
Mean or median DES scores across populations for various studies.

Study Number
Population 1* 2* 3 4 5 6 7 8* 9* 10
Sampled
gen.population 4.4 4.9 7.8 6.4 3.7
(adults) (34) (28) (415) (30) (25)
anxiety 6.7 3.9 10.4
disorders (53) (13) (97)
affective 12.7 6.0
disorders (102) (14)
eating 16.1 12.7 16.7 17.8
disorders (120) (30) (30) (25)
late 14.1 23.8 11.8
adolescents (31) (259) (108)
schizophrenia 20.6 12.6 17.7 10.5
(20) (20) (61) (15)
borderline 20.1 18.2
pers.dis. (19) (13)
inpatient/child 19.9
hood (62)
abuse
PTSD 31.3 30.0 26.1 41.1 27
(10) (116) (26) (35) (53)
DDNOS 40.8 29.8 38.3
(29) (99) (6)
MPD (now 57.1 40.7 55 42.8 45.2
DID (20) (17) (33) (228) (20)
in DSM-4.)

* Denotes median scores shown; Studies numbered as follows: 1 = Bernstein & Putnam, 1986, 2 = Ross,
Norton, & Anderson, 1988, 3 = Frischholz et al., 1990, 4 = Carlson et al., unpublished data; 5 = Coons et
al., 1989; 6 = Branscomb, 1991; 7 = Bremner, Southwick, Brett, Fontana, Rosenheck & Charney, 1992; 8
= Chu & Dill, 1990; 9 = Demitrack et al., 1990; 10 = Goldner et al., 1991.
53
Reliability
Three studies reporting tests - re-test reliability return correlation co-efficients of between 0.79 and 0.96.
Internal reliability using split halves returns co-efficients in the range 0.83 to 0.93.

Use of Cut Off Scores

Using a score of 30 or above to identify those who may be severely dissociative will result in the correct
identification of 74% of those who are DID and correct identification of 80% of those who are not DID.

Because of the low base rates for DID in the general population, care must be taken in interpreting scores
in excess of 30. Many of these high scorers will be persons with PTSD or a dissociative disorder other than
DID.

It was once thought that there is a continuum of dissociation. However, recent data suggest that certain
dissociative symptoms are characteristic of pathological dissociation.. (See Waller, Putnam & Carlson
(1966). In the DES pathological dissociation is identified by items 3, 5, 7, 8, 12, 13, 22, 27.

It bears repeating that the DES is not a definitive tool for diagnosing patients with DID, but it is a screening
tool to identify those who may have high levels of dissociation. Reliable and valid structured clinical
interview schedules are available for the formal diagnosis of dissociative disorders.

The Dissociative Disorders Interview Schedule (DDIS) (Ross et al, 1988) and the Structured Clinical
Interview for DSMIIIR Dissociative Disorders (Steinberg et al, 1990) can both be used to assist in making
or ruling out a diagnosis of a dissociative disorder. The DDIS is found on your CD.

There are Child and Adolescent versions of the DES, found on your CD.

54
GUIDELINES FOR FACILITATING ABREACTION
See Shapiro (2001) Chapter 7.

1. EMDR is not causing the client’s distress; it is simply releasing it.

2. An abreaction has a beginning, middle and an end.

3. In most instances, the abreaction is occurring as the information is being processed.

4. The clinician should maintain a position of detached compassion in relation to the client.

5. To increase the client’s sense of safety, follow the “golden rule” of do unto others............

6. Before treatment, clients should be reminded that they are safe in the present.

7. It is vital that the clinician reads the non verbal cues to determine whether the disturbing information
has reached a new plateau and the set can be ended.

8. Client’s non verbal cues should also be used to ascertain if a set should be ended before a new plateau
is achieved.

9. The clinician should reinforce the client’s dual focus of attention.

10. During the abreaction, clinicians should treat a sense of dissociation as they would any other emotion
that presents itself to be metabolised.

11. Clinicians can try to decrease the client’s disturbance by inviting him/her to engage in certain visual
manipulations of the target memory.

12. To ensure the greatest possible emotional stability, the clinician should encourage clients to make
whatever personal arrangements are necessary for the session or afterward.

13. Clinician should change to auditory stimuli or hand taps, if appropriate.

14. When the client is not processing information, despite the use of eye movements, hand taps, or
auditory stimulation, the clinician should use strategies designed to deal with “blocking”.

15. If the above strategies, and those for dealing with blocked responses have been tried, and met with
failure, the clinician should revert to a safe place exercise, or a closure procedure. Cognitive interweave
strategies should be used only when considerable experience and Part Two training have been
completed.

55
PROCEDURAL STEPS OUTLINE (Chapter 3, 4 and Appendix A)
(Acknowledgement to Dr Francine Shapiro.)

SET UP
Clinician places chair to the side of the client (“passing cars” position).

RAPPORT
We will assume rapport has been established with client.

EXPLANATION OF EMDR
Explanation of the EMDR method is dependent upon age, background, experience and sophistication of
client.

“Often when a traumatic event occurs, the memory of that event is stored in the brain differently
from a normal memory, because of the high level of distressing emotion at the time of the event.
So trauma memories are often “frozen in time, locked in the nervous system” Since the memory
is locked there, it continues to be triggered when a reminder comes along. Emotions come up
which we can’t seem to control. The eye movements we use in EMDR somehow unlocks the
memory, and our brain’s natural processing system can start to work. This might be a very
similar process to what occurs during REM sleep. Given this its important for you to remember,
it’s your brain that’s doing the healing. You are in control. ”

SPECIFIC INSTRUCTIONS
“What we will be doing often is a simple check on what you are experiencing. I need to know from you
exactly what is going on with as clear feedback as is possible. Sometimes things will change and
sometimes they won’t. I’ll ask you how you feel from 0 to 10 – sometimes it will change and sometimes
it won’t. I may ask if something else comes up – sometimes it will and sometimes it won’t. There are
no “supposed to’s” in this process. So just give as accurate feedback as you can as to what is happening,
without judging whether it should be happening or not. Let whatever happens, happen. We’ll do the
eye movement for awhile, and then we’ll talk about it”.

STOP SIGNAL
“If at any time you feel you have to stop, raise your hand”.

ESTABLISHING THE APPROPRIATE DISTANCE

“As you focus on my fingers, where do they appear clearest to you?” or “Where does it feel most
comfortable to have my hand?” or “” (Clinician slowly moves hand toward and away from the client’s
face).

METAPHOR

ESTABLISH A SAFE PLACE

PRESENTING ISSUE OR MEMORY

‘What issue would you like to work on today?”

PICTURE
“When you think of that what image comes to mind?”

NEGATIVE BELIEF (Negative Cognition)

“When you think of that picture, what judgement do you make about yourself?” or
“What words best go with the picture that express your negative belief about yourself or the experience.”

56
Try and have client make the statement in the form of an “I” statement in present tense. Try for a
presently held negative self-referencing belief.
Reminder: Please write NB on worksheet.

POSITIVE BELIEF (Positive Cognition)

“When you bring up that picture/incident, what would you like to believe about yourself now?” or
“What would you like to believe about that event or yourself instead.”

The PC must be a present desired, self-referencing belief.

Reminder: Please write PB on worksheet.

VoC (Validity of Cognition)

“When you think of that picture/incident, how true does (repeat the Positive Belief) feel to you now
on a scale of 1-7, where 1 feels completely false and 7 feels totally true?”

EMOTIONS/FEELINGS
“When you bring up that (describe memory/ image) and those words (repeat negative belief), what
emotion(s) do you feel now?”

SUDs
“On a scale of 0-10, where 0 is no disturbance or neutral and 10 is the highest disturbance that
you can imagine, how disturbing does it feel to you now?”

LOCATION OF BODY SENSATION

“Where do you feel the disturbance in your body?”

WORKSHOP NOTE: At this point stop to have your work checked by your Facilitator, unless they have
already done so, and told you to proceed.

DESENSITISE
“So beginning with the picture of (describe picture), repeating the words (repeat the negative belief),
notice those feelings in your (body location) and then just allow your eyes to follow my fingers”.

1. Begin the eye movements, quickly increase the speed as fast as the client can comfortably tolerate
the movement. Vary the speed, span and height up / down to avoid habituation, but not so much variation
that the external focus is too demanding. Aim for a dual focus of attention, internal and external.

2. Approximately every 12 saccades, or when there is an apparent change, comment to client with such
remarks as: “Just be aware. That’s it. Good. Just notice … making room for it”.

3. It is helpful to comment to the client, (especially if the client is abreacting): “That’s it. It’s old stuff.
Just notice it”. (Also use the metaphor used in the Procedural Preparation phase.)

4. After a set of EM, instruct client to: “Take a deep breath” or “take a break” or “rest there” …

5. Ask: “What are you noticing now?” or “What do you get now?”

6. After the client reports, say: “Go with that” or “Stay with that” (without repeating the client’s
words/statements.)

RECHECKING THE TARGET

57
 After you feel the client has been desensitised, check the SUDs. Ask the client to: “Recall the original
incident. What do you notice now. Assess for perceptual changes in the memory itself. If unclear ask
as you focus on the incident what do you see now?

Then check the SUDs. “On a scale of 0-10, where 0 is no disturbance or neutral and 10 is the highest
disturbance that you can imagine, how disturbing does it feel to you now?” or a simpler version “As
you recall it now, what is the level of distress you notice now, from 0 none to 10 max.”

If SUDs is 0 or 1, proceed to Integration of the Positive Belief.

If SUDs is 2 or more, then say:

“Where do you feel that in your body?” . Then say

“Focus on that and notice what happens next.”
Or

“What’s the worst part of it now?” . Then say:

“Focus on that and notice what happens next.”

REMINDER: If there is no movement or client is “looping”, change the direction of the EM or speed
in the next set (it is not recommended to change direction during a set).

INTEGRATION OF POSITIVE BELIEF

This is linking the desired positive belief (PB) with the original memory/incident/or picture:

1. “Do the words (repeat the PB) still fit or is there another positive statement you would like to
believe?” - rework the PB if necessary. Use this new version in the next step.

2. “Think about the original incident and those words (repeat the selected PB). From 1 (completely
false) to 7 (completely true), how true do they feel?”

3. “Hold those words and that original incident together.” Do EM.

From time to time, assess the VoC. Say “On a scale of 1-7, how true does (PC) feel to you now
when you think of the original incident?” OR Ask Did the belief get stronger, weaker or stay the
same?

4. Continue to process/strengthen until the client obtains a 6 or 7, do EM again to strengthen and

continue until it no longer strengthens.
Then Go on to the Body Scan.

If client reports less than a 6 and it is not moving, change the BLS (eg diagonal EM), check for blocks
such as feeder memory and then reprocess, or check appropriateness of positive belief.

BODY SCAN
“Close your eyes; concentrate on the incident and the idea (PB), and mentally scan your ENTIRE
body. Tell me where you feel anything.” If any sensation is reported, do EM ask if feeling got stronger
weaker or stayed the same.
If a positive/comfortable sensation, do EM to strengthen the positive feeling.
If a sensation of discomfort is reported , reprocess, focusing on the discomfort, until it subsides.

58
CLOSURE/DEBRIEF THE EXPERIENCE
Debrief experience with encouragement and reward effort/process,
- warn of further processing next 24 up to 48 hours,
- encourage to write down experiences (perhaps give log),
- reminder to use self calming skill,
- discuss telephone or email availability.

59
PRACTICUM GUIDELINES
Work in pairs or triads: Client, Therapist, (Observer in triad).

The Observer keeps a records using the Case Notes page from the Clients’ manual, so each person gets
a record of their first EMDR experience.

Therapist follows the detailed Procedural Steps given earlier in the manual.

Day 1: Use an old memory only. No family issues, no current therapy issues, no lifetime struggle
issues, no dysfunctional core beliefs, no present referents, and SUDs no higher than 5.

Day 2: Simple phobia, trauma memory, present anxiety or behaviour. No current therapy issues,
no lifelong family issues, no dysfunctional core beliefs. SUDs may be higher than 5.

60
EMDR CASE NOTES – Practicum Day 1
Client:____________________________________ Date:___________ Session No. ______ Therapist: _______

Containment Strategies:______________________________________________________ Stop Signal: _____

Safe Place Cue:_________________________________________________ Client Role reminder _________

Memory/Image (Past / Present / Future) _________________________________________________________

Negative Belief meets criteria __________________________________________________________________

Positive Belief meets criteria

___________________________________________________________________VoC :_________

Emotion: __________________________________________________________________

SUDS: (0-10) _______________ Body Location:________________________________________________

Process Ask: “What do you get now / notice now?” Response: “Stay with that / Notice that.”
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
(T) Target Check. (S) Stuck (CI) Cognitive Interweave Use reverse side if more sets required.

Final Positive Belief :________________________________________________________ VoC : _________

Body Scan: ________________________________________________________________________________

Closure:___________________________________________________________________________________

Debrief and give client “After EMDR” handout.

61
EMDR CASE NOTES Practicum Day 2
Client:____________________________________ Date:___________ Session No. ______ Therapist: _______

Containment Strategies:______________________________________________________ Stop Signal: _____

Safe Place Cue:_________________________________________________ Client Role reminder __________

Memory/Image (Past / Present / Future) _________________________________________________________

Negative Belief meets criteria __________________________________________________________________

Positive Belief meets criteria ____________________________________________________VoC :_________

Emotion: _____________________________________________________________SUDS: (0-10) _________

Body Location:___________________________________________________

Process Ask: “What do you get now / notice now?” Response: “Stay with that / Notice that.”
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
(T) Target Check. (S) Stuck (CI) Cognitive Interweave Use reverse side if more sets required.

Final Positive Belief :________________________________________________________ VoC : _________

Body Scan: ________________________________________________________________________________

Closure:___________________________________________________________________________________

Debrief and give client “After EMDR” handout.

62
 IMPACT OF EVENT SCALE
(After Horowitz, Wilmer & Alvarez, 1979)

Name: .......................................................................... Today’s Date ....................................

Date of Event ............................... Brief Description of Event ..............................................

...................................................................................................................................................

..................................................................................................................................................
Below is a list of comments made by people after stressful life events. Please check each item, indicating
how frequently these comments were true during the past seven days. If they did not occur during that
time, please mark “Not At All”.

FREQUENCY

Not At All Rarely Sometimes Often

1. I thought about it when I didn’t mean to.

2. I avoided letting myself get upset when I thought

about it or was reminded of it.
3. I tried to remove it from memory.

4. I had trouble falling asleep or staying asleep,

because of pictures or thoughts about it that came into
my mind.
5. I had waves of strong feelings about it.

6. I had dreams about it.

7. I stayed away from reminders of it.

8. I felt as if it hadn’t happened or it wasn’t real.

9. I tried not to talk about it.

10. Pictures about it popped into my mind.

11. Other things kept making me think about it.

12. I was aware that I still had a lot of feelings about

it, but I didn’t deal with them.
13. I tried not to think about it.

14. Any reminder brought back feelings about it.

15. My feelings about it were kind of numb.

63
 IMPACT OF EVENT SCALE - REVISED
INSTRUCTIONS: Below is a list of difficulties people sometimes have after stressful life events. Please read each
item, and then indicate how distressing each difficulty has been for you DURING THE PAST SEVEN DAYS with
respect to ____________________________, how much were you distressed or bothered by these difficulties?

Not at A little Moderately Quite a Extremely

All Bit Bit

1. Any reminder brought back feelings about it. 0 1 2 3 4

2. I had trouble staying asleep. 0 1 2 3 4

3. Other things kept making me think about it. 0 1 2 3 4

4. I felt irritable and angry. 0 1 2 3 4

5. I avoided letting myself get upset when I 0 1 2 3 4

thought about it or was reminded of it.

6. I thought about it when I didn't mean to. 0 1 2 3 4

7. I felt as if it hadn't happened or wasn't real. 0 1 2 3 4

8. I stayed away from reminders about it. 0 1 2 3 4

9. Pictures about it popped into my mind. 0 1 2 3 4

10. I was jumpy and easily startled. 0 1 2 3 4

11. I tried not to think about it. 0 1 2 3 4

12. I was aware that I still had a lot of feelings 0 1 2 3 4

about it, but I didn't deal with them.

13. My feelings about it were kind of numb. 0 1 2 3 4

14. I found myself acting or feeling like I was 0 1 2 3 4

back at that time.

15. I had trouble falling asleep. 0 1 2 3 4

16. I had waves of strong feelings about it. 0 1 2 3 4

17. I tried to remove it from my memory. 0 1 2 3 4

18. I had trouble concentrating. 0 1 2 3 4

19. Reminders of it caused me to have physical 0 1 2 3 4

reactions, such as sweating, trouble breathing,
nausea, or a pounding heart.

20. I had dreams about it. 0 1 2 3 4

21. I felt watchful and on guard. 0 1 2 3 4

22. I tried not to talk about it. 0 1 2 3 4

In J.P. Wilson & T.M. Keane (eds.), Assessing psychological trauma and PTSD: A Practitioner's Handbook. New York: Guilford
© 1995: Daniel S. Weiss & Charles R. Marmar

64
Notes on Impact of Events Scale and the Revised version

The Impact of Events Scale (Horowitz, Wilner & Alvarez, 1979) was designed as a self report measure to
tap the level of current symptomatic response, over the previous seven days, to a specified traumatic event.

The original 15 items tapped signs and symptoms of intrusive thoughts, emotions, and aspects of avoidance
including denial and blocking. The two subscales of intrusion and avoidance have demonstrated excellent test retest
correlation (0.87 and 0.79 respectively). Factor analytic studies confirmed the two factor structure of the
questionnaire. The original IES has been used with clients exposed to earthquakes, fire storms, floods, hurricanes,
rail and motor vehicle accidents, homicide, rapes, sexual abuse, cancer, and stress responses in emergency service
workers.

In the original IES clients asked to report the frequency of symptoms. The original IES was scored
as follows: "not at all" scores 0, "rarely" scores 1, "sometimes" scores 3, "often" scores 5.

The Revised Impact of Events Scale (Weiss & Marmar, 1997) added seven additional items, 6 focusing on
hyperarousal, and one associated with DSM IV criteria. These seven items were randomly interspersed with
the existing 7 intrusion and 8 avoidance items. The original IES item "I had trouble falling asleep or staying
asleep, because pictures or thoughts about it that came into my mind" was deleted and replaced with two
separate items, "I had trouble staying asleep" and "I had trouble falling asleep". The first of these items
correlated most highly with the intrusion subscale, the second of these items falls in the hyperarousal
subscale.

The Revised IES adopts an equal interval scoring format of 0 to 4, and rather than reporting on the
frequency of the symptoms, asks the respondents to indicate how distressing each of the difficulties has
been in the last seven days. "Not at all" scores 0, "a little bit" scores 1, "moderately" scores 2, "quite a bit"
scores 3, "extremely" scores 4. The total scores is the sum of the 22 individual item responses. The IES has
been used extensively with many population groups. The backwards compatibility of the revised IES with
the IES is statistically yet to be established.

An interpretation of the scales has been suggested as follows:

IES IES-R
Subclinical 0-8 0-9
Mild 9-25 10-29
Moderate 26-43 30-50
Severe 44-75 51-88

In the IES-R the intrusion subscale is tapped by items 1,2,3,6,9,16,20. The avoidance subscale is tapped by
items 5,7,8,11,12,13,17,22. The new hyperarousal subscale is tapped by items 4,10,14,15,18,19,21.

Weiss & Marmar describe the psychometric properties of the IES-R. The scale demonstrates high internal
consistency, each of the items is positively correlated with its designed subscale. High test retest correlation
co-efficients have been demonstrated: intrusion = 0.94, avoidance = 0.89, hyperarousal = 0.92.

References.
Horowitz, M.J., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A Measure of Subjective Stress.
Psychosomatic Medicine, 41, 209-218.
Weiss, D.S., & Marmar, C.R., The Impact of Event Scale - Revised in Wilson, J.P. & Keane, T.M. (1997).
Assessing Psychological Trauma and PTSD. Guilford Press, New York.

65
Eye Movement Desensitisation and Reprocessing International Association (EMDRIA)
Information and checklist for joining

If you want to become a member of EMDRAA which is the Australian affiliate of EMDRIA, then you need to complete 40 hours
of practicum training and 10 hours of supervision/consultation. Having completed the EMDRIA approved 40 hours of practicum
training (unusually delivered in two 20 hour workshops) you need to receive another 10 hours of supervision from an EMDRIA
approved consultant. The list of these consultants in Australia and their contact numbers is provided on the EMDRAA website
which can be found at https://emdraa.org/accredited-consultants/

Listed below is a supervision checklist to ensure that you have met the membership requirements. You need to attach this
document together with your certificate of completion of the 40 hour EMDR training and submit to EMDRIA Australia in order
to complete requirements for international registration.
1st Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant
2nd Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant
3rd Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant
4th Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant

5th Consultation Hour Date Place

Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant
6th Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant
7th Consultation Hour Date Place
Focus of Content

66
Approved EMDRIA Name (Print) Signature
Consultant
8th Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant
9th Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant
10th Consultation Hour Date Place
Focus of Content

Approved EMDRIA Name (Print) Signature

Consultant

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EMDR FIDELITY RATING SCALE
The full Fidelity Rating Scale is included in your dropbox link. Below is a sample of the items and how they are
scored. It is a useful tool for self-monitoring fidelity to the EMDR method and for peer supervision. It is based on a
scale proposed by Andrew Leeds (2017) and further refined in our research.

Assessment Phase
5 Did the clinician select an appropriate target from the treatment plan? 0 1 2
0 – No target was selected.
1 – Selected target was irrelevant to presenting problems and case
formulation OR was fundamentally flawed in some way (e.g., was
not a sensory event).
2 – Selected target was relevant and appropriate.

Did the clinician elicit a picture (or other sensory memory) that
6 represented the entire incident or the worst part of the incident? 0 1 2
0 – Clinician did not elicit a sensory representation of the event.
1 – Clinician elicited a sensory representation of the event in a
fundamentally flawed way (e.g., selected multiple representations at
once, chose the most tolerable sensory representation).
2 – Clinician elicited and chose an appropriate sensory representation of
the event.

7 Did the clinician elicit an appropriate negative cognition (NC)? 0 1 2

0 – NC is not obtained or is suggested by clinician and does not appear
to resonate with subject.
1 – NC is missing a couple of essential elements.
2 – NC is derived from the subject and is self-referencing, presently
held, accurately focuses on presenting issue, generalizable, is a true
cognition (i.e. not a feeling, like “I am frustrated”) and has affective
resonance.
8 Did the clinician elicit an appropriate positive cognition (PC)? 0 1 2
0 – PC is not obtained or is suggested by clinician and does not appear
to resonate with subject.
1 – PC is missing a couple of essential elements.
2 – PC is derived from the subject and is self-referencing, in the same
theme as the NC, accurately focuses on desired direction of change,
generalizable, is a true cognition (i.e. not a feeling, like “I am
happy”), is realistically adaptive and 1 < VoC < 5.

Did the clinician assure that the NC and PC address the same
9 thematic domain: responsibility, safety, choice? 0 1 2
0 – NC and PC are in different thematic domains.
1 – NC and PC did not clearly address the same thematic domain.
2 – NC and PC clearly addressed the same thematic domain.

Did the clinician obtain a valid VoC by referencing the felt confidence
10 of the PC in the present while the subject focused on the picture (or 0 1 2
other sensory memory)?
0 –VoC is absent or invalid (i.e., VoC < 1 or VoC > 5).
1 – Valid VoC obtained but not while focused on image or other sensory
68
 memory OR invalid VoC obtained while focusing on image or other
sensory memory.
2 – Valid VoC obtained while focusing on image or other sensory
memory.

11 Did the clinician elicit the present emotion by linking the picture and 0 1 2
the NC?
0 – Did not elicit the present emotion (or physiological response).
1 – Elicited present emotion (or physiological response) from the image
or the NC but not both.
2 – Elicited present emotion (or physiological response) from both the
image and the NC.

Did the clinician obtain a valid SUD (i.e., the current level of
12 disturbance for the entire experience 0 1 2
0 – Did not obtain a SUD.
1 – SUD obtained but not valid (i.e., SUD <= 2 during a 1st processing
session, although continuing with a SUD <= 2 may be appropriate
during a reprocessing session).
2 – Valid SUD obtained on present emotion (or physiological response).

13 Did the clinician elicit a body location for current felt disturbance? 0 1 2
0 – Did not elicit a body location for current disturbance.
1 – Elicited a vague body location for current disturbance.
2 – Elicited body location for current disturbance.

14 Did the clinician follow the standard assessment sequence listed 0 1 2

above? NB suds can be done on emotion or body location.
Note: Although some leeway on the standard sequence is acceptable
during this phase, the sequence of eliciting is the Image -> NC -> PC ->
VoC -> Emotion -> SUD -> Location is recommended
0 – Did not follow the sequence ie did not link get check an NC to a
target image
1 – Mostly followed the sequence
2 – Followed the essential sequence

Assessment Phase average score (items 5–14):

Total of 10 items.
Desensitization Phase
15 Before beginning bilateral eye movements or alternate bilateral 0 1 2
stimulation, did the clinician instruct subject to focus on the
picture, NC (in the first person), and the body location?
0 – Did not instruct subject to focus on any of these areas.
1 – Clinician instructed subject to focus on 1 or 2 items (image or
sensory memory, NC and body location).
2 – Clinician instructed subject to focus on all 3 items (image or sensory
memory, NC and body location).

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EMDR Therapy Fidelity Rating Scale for Reprocessing Session
Did the clinician provide bilateral eye movements or alternate bilateral
16 stimulation of at least 24 to 30 repetitions per set as fast as could be 0 1 2
tolerated comfortably? (Note: Children and adolescents and a few
adult subjects require fewer passes per set, e.g., 14–20.)
0 – Did not administer any bilateral eye movements or alternate bilateral
stimulation (EM/ABS) or offered a speed of stimulation that was
significantly too slow or far too few repetitions, e.g. only 12saccades.
1 – Most times, most sets missing an essential element of EM/ABS
somewhat too slow or somewhat too few saccades.
2 – Most times, most sets were at least 24 EM/ABS of relatively constant
and sufficient speed, width and direction.

During bilateral eye movements or alternate bilateral stimulation,

17 did the clinician give some periodic nonspecific verbal support 0 1 2
(perhaps contingent to nonverbal changes in subject) while
avoiding dialogue?
0 – Gave no nonspecific verbal support or was overly directly with
specific feedback or excessive dialogue during most sets (i.e. spoke
during >50% of the set).
1 – Gave limited nonspecific verbal support or only slightly overly specific
feedback or excessive dialogue during some of the sets (i.e. <50% of
the set).
2 – Most time, most sets, avoided excessive dialogue and specific
feedback and did offer nonspecific verbal support (i.e., if subject is
not emotional, at least 1 comment per set. If subject is emotional,
then more frequently).

At the end of each discrete set of bilateral eye movements or

alternate bilateral stimulation, did the clinician use appropriate
18 phrases to have the subject, “Rest, take a deeper breath, let it 0 1 2
go”(while not asking the subject to “relax”) then make a general
inquiry (“What do you notice now?”) while avoiding narrowly specific
inquiries about the image, emotions, or feelings?
0 – Used inappropriate phrases after most sets (i.e. >50% of the set).
1 – Used inappropriate phrases after some sets (i.e. <50% of the set).
2 – The clinician used appropriate phrases for all three items after most
sets, most of the time (i.e., deep breath instruction, general inquiry,
avoided specific inquiry).

70
Reference List

Books on EMDR
Adler-Tapia, R. & Settle, C. (2017). EMDR & the Art of Psychotherapy with Children; Treatment Manual
and Text. 2nd edition. NY: Springer Publishing.
Dworkin, M. & Shapiro, F. (2005). EMDR and the Relational Imperative: The Therapeutic Relationship
in EMDR
Forgash, Carol, Copely, Margaret (2007). Healing the Heart of Trauma and Dissociation with EMDR and
Ego State Therapy.
Gomez, A. M. (2013). EMDR therapy and adjunct approaches with children: Complex trauma,
attachment, and dissociation. New York: Springer.
Greenwald, R. (1999). Eye Movement and Desensitization Reprocessing (EMDR) in Child and
Adolescent Psychotherapy.
Greenwald, R. (2007). EMDR: Within a Phase Model of Trauma-Informed Treatment (Maltreatment,
Trauma and Interpersonal Aggression)
Hartung, John G, Galvin, Michael D,& Gallo, Fred P (2003). Energy Psychology and EMDR:
Combining Forces to Optimize Treatment
Leeds, A.M. (2016). A guide to the Standard EMDR Protocols for Clinicians, Supervisors and
Consultants, 2nd Edition. ISBN: 9780826131164
Lipke, H. (1999). EMDR and Psychotherapy Integration: Theoretical and Clinical Suggestions with Focus
on Traumatic Stress by
Lovett, J. (1999). Small wonders: Healing Childhood Trauma with EMDR. New York: The Free Press.
Lovett, J. (2015). Trauma-attachment tangle: Modifying EMDR to help children resolve trauma and
develop loving relationships. New York, NY: Routledge.
Luber, M. (2009). Eye Movement Desensitization and Reprocessing (EMDR) Scripted Protocols: Basics
and Special Situations.
Maiberger, B. (2009). EMDR Essentials: A Guide for Clients and Therapists.
Manfield, P. & Maxfield, L. (2003). EMDR Casebook: Expanded Second Edition
McGuiness, V. (2003). Integrating Play Therapy and EMDR with Children
Parnell, L. (1998). Transforming Trauma: EMDR: The Revolutionary New Therapy for Freeing the Mind,
Clearing the Body, and Opening the Heart
Parnell, L. (1999). EMDR in the Treatment of Adults Abused as Children
Parnell, L. (2007). A Therapist’s Guide to EMDR: Tools and Techniques for Successful Treatment. New
York: W.W. Norton & Company, Inc.
Parnell, L. (2013). Attachment focused EMDR. Healing relational trauma. New York: W.W. Norton &
company, Inc.
Paulsen, S. (2009). Looking Through the Eyes of Trauma and Dissociation: An illustrated guide for
EMDR therapists and clients. South Carolina: Booksurge Publishing.
Rogers, S. & Silver, S. (2001). Light in the Heart of Darkness: EMDR and the Treatment of War and
Terrorism Survivors.
Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy, 3rd Ed. New
York: Guilford Publications.
Shapiro, F. (2002). EMDR as an Integrative Psychotherapy Approach: Experts of Diverse Orientations
Explore the Paradigm Prism
Shapiro, F., Allen, J G., Keller, M.W., & Console, D. A. (2006). DVD: EMDR: A Closer Look.
Shapiro, F., Kaslow, F.W., & Maxfield, L. (2007). Handbook of EMDR and Family Therapy Processes.
New Jersey: John Wiley and Sons, Inc.
Shapiro, R. & Grand, C. (2009). EMDR Solutions II: For Depression, Eating Disorder, Performance, and
More
Shapiro, R. (2005). EMDR Solutions: Pathways to Healing
Struik, A. (2014). Treating chronically traumatized children: Don't let sleeping dogs lie! New York, NY:
Routledge.

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Tinker, R. & Wilson, S. (1999). Through the Eyes of a Child: EMDR with Children. New York: WW
Norton & Company.
Wesselmann, D., Schweitzer, C., & Armstrong, S. (2014). Integrative team treatment for attachment trauma
in children. Family therapy and EMDR. New York: W.W. Norton & Co. Inc.

EMDR books for clients:

Parnell, L. (2008). Tapping In: A Step-by-Step Guide to Activating Your Healing Resources Through
Bilateral Stimulation
Shapiro, F. (2013) Getting past your past. Take control of your life with self-help techniques from EMDR
therapy. Pennsylvania, U.S.: Rodale Incorporated.
Shapiro, F., Forrest, Margot Silk (2004). EMDR: The Breakthrough “Eye Movement” Therapy for
Overcoming Anxiety, Stress and Trauma

The Francine Shapiro Library (FSL) is the premier repository for scholarly articles and other important
writings related to EMDR. The intent of the FSL is twofold: (1) to electronically house documents related
to EMDR or AIP and (2) to maintain a comprehensive, accurate, and up-to-date list of citations related to
AIP and EMDR.
The library can be found at https://emdria.omeka.net/

CLINICAL GUIDELINES (Most recent)

WHO, World Health Organization. (2013). Guidelines for the Management of Conditions Specifically
Related to Stress. Geneva
ACPMH, Australian Centre for Posttraumatic Mental Health (2013). Australian guidelines for the
treatment of acute stress disorder and posttraumatic stress disorder. Melbourne
International Society of traumatic Stress Studies (2019). https://www.istss.org/treating-trauma/new-istss-
prevention-and-treatment-guidelines.aspx

EMDR Journal articles

Andrade, J., Kavanagh, D. & Baddeley, A. (1997). Eye-movements and visual imagery: a working
memory approach to the treatment of post-traumatic stress disorder. British Journal of Clinical
Psychology, 36 ( Pt 2):, 209-223.
Armstrong, M. & Vaughan, K. (1996). An orienting response model of eye movement
desensitization. Journal of Behavior Therapy & Experimental Psychiatry, 27(1), 21-32.
Boterhoven de Haan, K.L., Lee, C.W., Fassbinder, E., Voncken, M.J., Meewisse, M., van Es, S.,
Menninga, S., Kousemaker, M., & Arntz, A. (2017). Imagery Rescripting and Eye Movement
Desensitisation and Reprocessing for Treatment of Adults with Childhood Trauma-Related Post-
Traumatic Stress Disorder: IREM Study Design. BMC Psychiatry, 17:165. DOI 10.1186/s12888-017-
1330-2
Boterhoven de Haan, K. L., Lee, C. W., Fassbinder, E., van Es, S. M., Menninga, S., Meewisse,
M. L., . . . Arntz, A. (2020). Imagery rescripting and eye movement desensitisation and reprocessing as
treatment for adults with post-traumatic stress disorder from childhood trauma: randomised clinical trial.
Br J Psychiatry, 1-7. doi:10.1192/bjp.2020.158
Carlson, J.; Chemtob, C.; Rusnak, K.; Hedlund, N. & Muraoka, M. (1998). Eye movement
desensitization and reprocessing (EMDR) treatment for combat-related posttraumatic stress disorder.
Journal of Traumatic Stress, 11(1), 3-24.
Chen, Y. R., et al., (2014). Efficacy of Eye-Movement Desensitization and Reprocessing for
Patients with Posttraumatic-Stress Disorder: A Meta-Analysis of Randomized Controlled Trials. PLoS
ONE, 9(8), e103676. doi:10.1371/journal.pone.0103676
Chen, L., et al., (2015) Eye Movement Desensitization and Reprocessing Versus Cognitive-
Behavioral Therapy for Adult Posttraumatic Stress Disorder: Systematic Review and Meta-Analysis. The
Journal of Nervous and Mental Disease, 03(6), 443-451. doi:10.1097/nmd.0000000000000306
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 Christman, S. D., R. E. Propper, et al. (2004). "Increased interhemispheric interaction is associated
with decreased false memories in a verbal converging semantic associates paradigm." Brain and
Cognition 56(3): 313-319.
de Jongh, A.; Ten Broeke, E. & Renssen, M. (1999). Treatment of specific phobias with eye
movement desensitization and reprocessing (EMDR): protocol, empirical status, and conceptual issues.
Journal of Anxiety Disorders, 13(1-2), 69-85.
de Jongh, A., Resick, P. A., Zoellner, L. A., Minnen, A., Lee, C. W., Monson, C. M., . . . Feeny,
N. (2016). Critical Analysis of the Current Treatment Guidelines for Complex PTSD in Adults.
Depression and anxiety. DOI: 10.1002/da.22469.
de Jongh, A., Amann, B. L., Hofmann, A., Farrell, D., & Lee, C. W. (2019). The status of EMDR
therapy in the treatment of posttraumatic stress disorder 30 years after its introduction. Journal of EMDR
Practice and Research, 13(4), 261-269.
de Jongh, A., Bicanic, I., Matthijssen, S., Amann, B. L., Hofmann, A., Lee, C.W., . . . Maxfield,
L. (2019). The current status of EMDR therapy involving the treatment of complex posttraumatic stress
disorder. Journal of EMDR Practice and Research, 13(4), 284-290.
Devilly, G. & Spence, C. (1999). The relative efficacy and treatment distress of EMDR and a
cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal
of Anxiety Disorders, 13(1-2), 131-157.
Dominguez, S., & Lee, C. W. (2019). Differences in International Guidelines Regarding EMDR
for Posttraumatic Stress Disorder: Why They Diverge and Suggestions for Future Research. Journal of
EMDR Practice and Research, 13(4), 247-260. doi:10.1891/1933-3196.13.4.247
Dominguez, S., Drummond, P., Gouldthorp, B., Janson, D., & Lee, C. W. (2020). A randomized
controlled trial examining the impact of individual trauma‐focused therapy for individuals receiving
group treatment for depression. Psychology and Psychotherapy: Theory, Research and Practice.
doi:10.1111/papt.12268
Edmond, T., L. Sloan, et al. (2004). "Sexual Abuse Survivors' Perceptions of the Effectiveness of
EMDR and Eclectic Therapy." Research on Social Work Practice 14(4): 259-272.
Engelhard, I.M., et al., Eye movements reduce vividness and emotionality of “flashforwards”.
Behaviour Research and Therapy, 2010. 48(5): p. 442-447.
Ho, M., & Lee, C.W. (2012), Cognitive behaviour therapy versus eye movement desensitization
and reprocessing for post-traumatic disorder - is it all in the homework then? Revue Europeene de
Psychologie Appliquee, 62, 4, Pages 253-260.
Ironson, G., B. Freud, J. L. Strauss and J. Williams (2002). “Comparison of two treatments for
traumatic stress: A community-based study of EMDR and prolonged exposure.” Journal of Clinical
Psychology 58(1): 113-128.
Jaberghaderi, N., R. Greenwald, et al. (2004). "A Comparison of CBT and EMDR for Sexually-
abused Iranian Girls." Clinical Psychology & Psychotherapy 11(5): 358-368.
Lansing, K., D. G. Aemon, et al. (2005). "High Resolution Brain Spect Imaging and EMDR in
Police Officers with PTSD." Journal of Neuropsychiatry and Clinical Neurosciences 17(4): 526-532.
Laugharne J, Kullack C, Lee CW, McGuire T, Brockman S, Drummond PD, et al. Amygdala
volumetric change following psychotherapy for posttraumatic stress disorder. The Journal of
neuropsychiatry and clinical neurosciences. 2016;28 (4):312-8.
Lee, C., Gavriel, H. & Richards, J. (1996). Eye movement desensitisation: Past research,
complexities, and future direction. Australian Psychologist, 31, 168-173.
Lee, C., H. Gavriel, P. Drummond, J. Richards and R. Greenwald (2002). “Treatment of PTSD:
Stress inoculation training with prolonged exposure compared to EMDR.” Journal of Clinical Psychology
58: 1071-1089.
Lee, C., H. Gavriel, et al. (2002). "Treatment of PTSD: Stress inoculation training with prolonged
exposure compared to EMDR." Journal of Clinical Psychology 58(9): 1071-1089.
Lee, C.W., Taylor, G., & Drummond P. (2006) The active ingredient in EMDR; is it traditional
exposure or dual focus of attention? Clinical Psychology & Psychotherapy 13:97-107.
Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in
processing emotional memories. Journal of Behavioural Therapy and Experimental Psychiatry 44, 231-
239.

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 Lee, C.W. (2012) EMDR: treatment research and practice. In Encyclopaedia of Trauma. Editor
Charles Figley. 253-255, Sage publication.
Lee, C., & Cuijpers, P. (2014). What does the data say about the importance of eye movement in
EMDR? Journal of Behavior Therapy and Experimental Psychiatry, 45, 226-228. doi:
http://dx.doi.org/10.1016/j.jbtep.2013.10.002
Levin, P.; Lazrove, S. & van der Kolk, B. (1999). What psychological testing and neuroimaging tell
us about the treatment of posttraumatic stress disorder by eye movement desensitization and reprocessing.
Journal of Anxiety Disorders, 13(1-2), 159-172.
Marcus, S., P. Marquis, et al. (2004). "Three- and 6-Month Follow-Up of EMDR Treatment of
PTSD in an HMO Setting." International Journal of Stress Management 11(3): 195-208.
Matthijssen, S. J. M. A., Lee, C. W., de Roos, C., Barron, I. G., Jarero, I., Shapiro, E., . . . de
Jongh, A. (2020). The Current Status of EMDR Therapy, Specific Target Areas, and Goals for the Future.
Journal of EMDR Practice and Research. doi:10.1891/emdr-d-20-00039
Meysner, L., Cotter, P., & Lee, C. W. (2016). Evaluating the Efficacy of EMDR With Grieving
Individuals: A Randomized Control Trial. Journal of EMDR Practice and Research, 10(1), 1-11. doi:
http://dx.doi.org/10.1891/1933-3196.10.1.2.
Rothbaum, B. O., M. C. Astin, et al. (2005). "Prolonged Exposure Vs Eye Movement
Desensitisation and Reprocessing (EMDR) for PTSD Rape Victims." Journal of Traumatic Stress 18(6):
607-616.
Scheck, M.; Scheffer, J. & Gillette, C. (1998). Brief psychological intervention with traumatized
young women: the efficacy of eye movement desensitization and reprocessing. Journal of Traumatic Stress,
11(1), 25-44.
Schubert, S. J., Lee, C. W., & Drummond, P. D. (2011). The efficacy and psychophysiological
correlates of dual-attention tasks in eye movement desensitization and reprocessing (EMDR). Journal of
Anxiety Disorders, 25(1), 1-11.
Schubert, S., Lee, C. W., de Araujo, G., Butler, S., Taylor, G., Drummond, P. D. (2016) The
effectiveness of eye movement desensitization and reprocessing (EMDR) to treat symptoms following
trauma in Timor Leste. Journal of Traumatic Stress. DOI: 10.1002/jts.22084
Shapiro, F. (2002). "EMDR 12 years after its introduction: Past and future research." Journal of
Clinical Psychology 58(1): 1-22.
Shapiro, F. (1989a). Eye movement desensitization: a new treatment for post-traumatic stress
disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211-217.
Shapiro, F. (1989b). Efficacy of the eye movement desensitization procedure in the treatment of
traumatic memories. Journal of Traumatic Stress,
2, 199-223.
Silver, S. M., S. Rogers, et al. (2005). "EMDR Therapy Following the 9/11 Terrorist Attacks: A
Community-Based Intervention Project in New York City." International Journal of Stress Management
12(1): 29-42.
Smeets, M. A. M., Dijs, M. W., Pervan, I., Engelhard, I. M., & van den Hout, M. A. (2012). Time-
course of eye movement-related decrease in vividness and emotionality of unpleasant autobiographical
memories. Memory, 20(4), 346-357. doi: 10.1080/09658211.2012.665462
Solomon, R. (1998). Utilization of EMDR in crisis intervention. Crisis Intervention, 4(2-3), 239-
246.
Stickgold, R. (2002). “EMDR: A putative neurobiological mechanism of action.” Journal of Clinical
Psychology 58(1): 61-75.
van den Hout, M. A., Rijkeboer, M. M., Engelhard, I. M., Klugkist, I., Hornsveld, H., Toffolo, M.
J. B., & Cath, D. C. (2012). Tones inferior to eye movements in the EMDR treatment of PTSD. Behaviour
Research and Therapy, 50(5), 275-279. doi: 10.1016/j.brat.2012.02.001
Van Woudenberg, C., Voorendonk, E.M., Bongaerts, H., Zoet, H.A., Verhagen, M., Van Minnen,
A., Lee, C.W., & De Jongh, A. (2018). The effectiveness of an intensive treatment program combining
prolonged exposure and EMDR for severe posttraumatic stress disorder (PTSD). European Journal of
Psychotraumatology. 9(1), https://doi.org/10.1080/20008198.2018.1487225
Van Etten, M. & Taylor, S. (1998). Comparative efficacy of treatments for posttraumatic stress
disorder: a meta-analysis. Clinical Psychology and Psychotherapy, 5, 126-144.

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 Vaughan, K., Armstrong, M., Gold, R., O'Connor, N., Jenneke, W., & Tarrier, N. (1994a). A trial
of eye movement desensitization compared to image habituation training and applied muscle relaxation in
post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 25(4), 283-291.
Wilson, D., Silver, S., Covi, W. & Foster, S. (1996). Eye movement desensitization and
reprocessing: effectiveness and autonomic correlates. Journal of Behavior Therapy & Experimental
Psychiatry, 27(3), 219-229.

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OTHER TRAUMA REFERENCES

Van der Kolk, B.A. (1994). The body keeps the score: memory and the evolving psychobiology of
post-traumatic stress. Harvard Review Psychiatry: 1:253-265.

Dissociation references for measures

Bernstein, E.M., & Putnam, F.W. (1986). Development, reliability, and validity of dissociation
scale. Journal of Nervous and Mental Disease, 174, 727-735.
Carlson, E.B. & Putnam, F.W. (1993) An update on the Dissociative Experiences Scale.
Dissociation, 5, 16-27. NB. This publication contains a manual and a complete DES-II.
Frischholz, E.J., Braun, B.G., Sachs, R.G., Hopkins, L., Shaeffer, D.M., Lewis, J., Leavitt, F.,
Pasquotto, M.A., & Schwartz, D.R. (1990). The Dissociative Experiences Scale: Further replication and
validation. Dissociation, 3(3), 151-153.
Goldner, E.M., Cockhill, L.A., Bakan, R, & Birmingham, C.L. (1991) Dissociative Experiences and
eating Disorders. American Journal of Psychiatry, 148, 1274-1275.
Ross, C.A., Norton, G.R., & Anderson, G. (1988). The Dissociative Experiences Scale: A
replication study. Dissociation, 1(3), 21-22.
Ross. C., Heber.S, Norton. G, Anderson. D, Anderson. G, and Barchet. P., (1989) The Dissociative
Disorders Interview Schedule: A Structured Interview. Dissociation, 2, 169-189.

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 Internet resources
Chris Lee [email protected] or [email protected]
Web page www.psychology-training.com.au

EMDR Association of Australia: http://emdraa.org/

Francine Shapiro Library: http://emdr.nku.edu/

Trauma Websites
Bessel van der Kolk’s Trauma Centre: http://www.traumacenter.org/
Bob Tinker and Sandra Wilson www.tinker-wilson-emdrs.com
Child Trauma Academy: http://childtrauma.org/
Children and War Foundation: http://www.childrenandwar.org/about-us/
David Baldwin’s Trauma page: http://www.trauma-pages.com/ (This site contains hundreds of useful
links to all matters related to trauma and mental health in general.)
Headspace – handouts on trauma:
http://headspace.org.au/search/SearchForm?Search=trauma&action_results=Go
International Society for Traumatic Stress studies: http://www.istss.org/
International Schema Focused homepage: https://schematherapysociety.org/
Phoenix Australia. Centre for Posttraumatic Mental Health: http://phoenixaustralia.org/recovery/
The National Child Traumatic Stress Network: http://www.nctsnet.org/
Trauma Institute and Child Trauma Institute (Ricky Greenwald): www.childtrauma.com

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