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EMDR Therapy and the Treatment of Substance Abuse and Addiction

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Addiction is not a failure of will or of strength of character. Addiction is a disorder of the brain that given the right set of circumstances could affect anyone. The authors of this chapter, and the majority of experts agree, that addictions arise from uniquely individual and complex interactions between biology, the environment, and experience that lead to the compulsive misuse of alcohol and other substances. Once established, these patterns have traditionally proven difficult to alter. Substance abuse is frequently found co-occurring with untreated trauma, posttraumatic stress disorder (PTSD), and other mental disorders and physical conditions. EMDR therapy is a comprehensive, A-rated, empirically validated psychotherapy for the treatment of PTSD and other trauma related symptoms. This chapter proposes that integrating treatments for co-occurring trauma and addiction with EMDR therapy will help resolve the traumatic experiences that contribute to addiction and restore people to the promise of a sober and healthy life.
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Chapter 5
EMDR Therapy and the Treatment
of Substance Abuse and Addiction
Susan Brown, Julie Stowasser and Francine Shapiro
Most experts today agree, as do the authors of this chapter, that substance abuse
arises from complex interactions between genetics, environment, and experience.
Substance dependence is not a failure of will or of strength of character, but a
medical disorder that could affect any human being. Dependence is a chronic and
relapsing disorder, often co-occurring with other physical and mental conditions
(World Health Organization 2004).
The question remains, however, Why has it been that over the course of human
history, where people and cultures have had access to alcohol and potent
mind-altering substances, that only some become addicted while the rest are able to
regulate their use?
We are closer to answering this question based upon current research that has
demonstrated a clear relationship between early adverse life experiences and later
addictionplease see Felitti et al. (1998), Felitti (2004) and Shapiro (2005).
Further, the drugs that individuals select are not chosen randomly, but result
from an interaction between the psychopharmacologic action of the drug and the
dominant painful feelings with which they struggle. Edward Khantzian, M.D.,
professor of Clinical Psychiatry at the Harvard University, observed that opiates are
often preferred because of their powerful numbing action on the affects of rage and
S. Brown (&)
4700 Spring Street, Suite 204, La Mesa, CA 91942, USA
J. Stowasser
Post Ofce Box 15101, San Luis Obispo, CA 93406, USA
F. Shapiro
Mental Research Institute, Palo Alto, CA, USA
©Springer International Publishing Switzerland 2016
A.L.M. Andrade and D. De Micheli (eds.), Innovations in the Treatment
of Substance Addiction, DOI 10.1007/978-3-319-43172-7_5
aggression. Cocaine has its appeal because of its ability to relieve distress associ-
ated with depression. Although ill fated, addicts discover that the short-term effects
of their drugs of choice help them cope with distressful subjective states and an
external reality otherwise experienced as unmanageable or overwhelming
(Khantzian 1985, p. 1263). Thus emerges a compelling hypothesis, which proposes
that people use psychoactive substances in an attempt to control painful symptoms
resulting from psychological trauma. This is referred to as self-medication(Ibid.).
Some studies in the USA show that more than 50 percent of people with mental
disorders also suffer from substance dependence compared to 6 percent of the
general population (World Health Organization 2004). It is from our interest in
providing integrated treatment for the complex interaction of genes, environment,
trauma, and psychological pain as a driving force behind co-existing disorders, that
this chapter is written.
Co-occurring Mental Health and Substance Abuse
No one ever died from their feelings, but millions of people have died from taking drugs,
alcohol, and other toxic substances to help them avoid their feelingsWeinhold &
The co-existing problems of Mental Health (MH) and Substance Abuse
(SA) disorders ignore age, gender, intellect, marital status, economic, social class,
race, and nationality, leaving no one immune from their impact. The prevalence of
co-occurring psychiatric and substance use disorders and the dearth of effective
treatment interventions leaves individuals in a state of suffering, accompanied
by impressive personal, familial, social, and economic consequences.
The correlation between trauma and other adverse experiences, especially when rst
experienced in childhood, and co-occurring mental health and substance abuse, is
strongly established in the literature (Felitti et al. 1998;Kessleretal.1995;Najavits
et al. 1999;NationalChildTraumaticStressNetwork(NCSTN)2008;Ouimetteand
Brown 2003). A strict denition of co-occurring disorders (COD) states that one or
more psychiatric or medical conditions co-exist with one or more addictive disorders.
CODs do not simply have overlapping symptoms, but are distinct, and can be inde-
pendently diagnosed from one another (American Psychiatric Association 2013).
Examples of diagnoses frequently co-occurring with addictive disorders include
posttraumatic stress disorder (PTSD) and other anxiety disorders, bipolar disorder,
borderline personality disorder (BPD), attention decit disorder (ADD/ADHD), and
major depression. The many possible permutations of addictions and co-existing
psychiatric conditions often lead to a complicated clinical picture that is challenging to
untangle and treat effectively, particularly when the contributing role of trauma is
70 S. Brown et al.
Co-occurring disorders are also associated with
Poorer motivation, retention, and treatment outcomes compared to individuals
with a single psychiatric disorder
Faster relapse and greater amounts of substances used
Less social support
Failure at work or school
Poorer overall health conditions
Impaired family relations
Abuse and violence
Legal difculties
(Brady et al. 1994; Brown et al. 1996; Felitti et al. 1998; Najavits et al. 1999).
Historically, these areas of mental health have separate treatment, education,
training, and funding avenues, creating signicant barriers to receiving integrated
treatment services. Currently, the development and implementation of effective,
integrated treatment services is a public health challenge worldwide.
The purpose of this chapter is to
Illustrate the relationships between trauma and other adverse life experiences,
mental disorders, and the development of substance abuse and behavioral, or
process, addictions (Felitti et al. 1998).
Describe the connections between substance and behavioral addictions (Grant
et al. 2006).
Describe the Adaptive Information Processing (AIP) model as the theoretical
framework for case conceptualization in EMDR therapy (Shapiro 1995,2001,
2007; Solomon and Shapiro 2008).
Provide a basic understanding of the principles, protocols, and procedures that
dene EMDR therapy (Shapiro 1995,2001).
Illustrate when and how to use EMDR therapy as an integrated treatment
approach for co-occurring mental health and addiction disorders.
The Relationship Between Trauma, Mental Health,
and Substance Abuse
Nothing is predestined: The obstacles of your past can become the gateways that lead to
new beginnings.Ralph Blum
Trauma is often the crucible from which psychiatric symptoms and addictions emerge.
With trauma, the past is present. The Adverse Childhood Experiences (ACE) Study
provides retrospective and prospective analysis of over 17,000 individuals, primarily
middle-class Americans from Kaiser PermanentesDepartmentofPreventiveMedicine
in San Diego, California (Felitti et al. 1998). The study examined the effect of traumatic
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 71
life experiences during the rst 18 years on later well-being, social function, health risks,
disease burden, healthcare costs, and life expectancy.
The ten reference categories experienced during childhood are listed in Table 5.1
below, with their prevalence in parentheses.
Scoring the ACE survey is simple: Exposure to any one category above is scored as
one point. Thus, an individual reporting sexual molest by one person would score the
same as someone who experienced multiple sexual assaults by several individuals. As a
result, these ndings tend to be under, rather than over, stated. Nevertheless, the study
revealed several surprising outcomes regarding the signicance of early trauma and
other adverse childhood experiences and the development of later substance addiction or
troubling behavioral patterns. The study found strong, proportionate relationships
between the number of categories of adverse childhood experiences (ACE score) and the
use of various psychoactive materials or behaviors including alcoholism and intravenous
drug abuse(op. cit.). The relationship is evident in the exponential increase in likeli-
hood of a person having a maladaptive response to his ACEs. For example, any person
with 4 or more childhood ACEs experienced a 500 % increase in potential that they will
become alcoholic, while males with ACE scores of 6 or more showed a step-wise
probability increase of 4600 % of becoming an intravenous drug user (Felitti 2004).
Not surprisingly, childhood trauma and neglect disrupts and can dysregulate the
brains information processing systems (Perry 1999; Schore 2002; Siegel 1999;
Table 5.1 Adverse Childhood Experiences Study (adapted from op. cit.)
Category Behavior Prevalence
1. Emotional Recurrent humiliation 11
2. Physical Beating, not spanking 28
3. Sexual
Contact sexual abuse
Women 28
Men 16
Overall 22
4. Mother Treated violently 13
5. Household
Alcoholic or drug user 27
6. Household
Imprisoned 6
7. Household
Chronically depressed, suicidal mentally ill,
in psychiatric hospital
8. Household
Not raised by both biological parents 23
9. Physical Lack of proper food, clothing, shelter 10
10. Emotional Isolation, lack of interaction 15
72 S. Brown et al.
Van der Kolk et al. 1996). Lesser-known risk factors in the development of a
childs brain and quest for mastery over emotional regulation are the signicant
roles played by the quality of parental attunement and attention (Siegel 1999).
Those who are unable to manage emotional responses to everyday stressors are
compelled to seek ways to control or numb their affect (Khantzian 1985).
Addictions and other compulsive behaviors temporarily change the experience
of painful emotions and body sensations, thereby providing a transitory sense of
relief. Often referred to as self-medication, this may be seen by the user as effec-
tively managing distress, thereby promoting a vicious cycle of addictive coping
strategies (Brown et al. 1996; Grant et al. 2006; Ouimette and Brown 2003; Volkow
2007). One study (Hien et al. 2010) found that reductions in the severity of PTSD
symptoms were likely to be associated with reduced substance use in those with
severe symptomotology. Results support the self-medication model and provide
empirical support for integrated interventions for PTSD and substance abuse. An
illustration of how this works is shown in Fig. 5.1.
Negative life Negative reinforcement
Expectation of relief
Lowered state
of anxiety and
Return of symptoms
Increased use of
substances (or
behavior) to
regulate distress
Substance Use
Other Behavioral
Frequent exposure
to alcohol and drugs
and/or compulsive
Increased exposure
to trauma
Alcohol and
other Drug Use
Gambling, etc.
Immediate but
short-term relief
PTSD & other MH
Intrusive thoughts
Sleep Disturbances
Fig. 5.1 Vicious cycle of mental health, substance abuse, and other compulsive behaviors for
emotional regulation. Illustration Copyright 2009 Brown, S. (Adapted from Steward & Conrad, 2002)
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 73
The Link Between Substance and Behavioral Addictions
Drunkennessthat erce rage for the slow, sure poison, that oversteps every other con-
sideration; that casts aside wife, children, friends, happiness, and station; and hurries its
victims madly on to degradation and death.Charles Dickens
Research suggests a strong neurobiological link between chemical and behavioral,
or process, addictions. Perhaps that is because the neurochemistry associated with
rewardor pleasure pathways(Grant et al. 2006; Pallanti 2006; Volkow 2007)
in the brain lead to the same loss of control and negative consequences, whether it is
a drug or a behavior to which the person becomes addicted. Therefore, it is not the
substance itself that is addictive, but rather, the individuals response to it. Not all
people who use substances become addicted, nor to common behaviors such as
gambling, yet they can both lead to similar patterns of misuse.
Research over the past decade has stressed the substantial co-morbidity of
impulse control disorders with mood disorders, anxiety disorders, eating disorders,
substance disorders, personality disorders, and with other specic impulse control
disorders (Hucker 2004). Addictions and compulsions, despite the planning aspects
involved, are also associated with a lack of impulse control and often follow similar
symptomatic cycles (Grant et al. 2006) as shown in Table 5.2
The EMDR Therapy ApproachTreatment of PTSD
and Trauma
EMDR therapy is a comprehensive, integrative, A-rated and empirically validated
treatment for PTSD (American Psychiatric Association 2004; Department of
Veterans Affairs & Department of Defense 2004; National Institute for Clinical
Excellence 2005). Twenty-three clinical trials in peer-reviewed journals attest to
EMDRsefcacy with PTSD and trauma (see Shapiro, 2014 for a review).
The recent World Health Organization (WHO) practice guidelines (2013) state
that EMDR therapy and trauma-focused cognitive behavioral therapy are the only
psychotherapies recommended for children, adolescents, and adults with PTSD. As
noted in the WHO (2013) practice guidelines, [EMDR therapy] is based on the
idea that negative thoughts, feelings and behaviors are the result of unprocessed
memories. The treatment involves standardized procedures that include focusing
simultaneously on (a) spontaneous associations of traumatic images, thoughts,
emotions and bodily sensations and (b) bilateral stimulation that is most commonly
administered in the form of repeated eye movements. Like CBT with a trauma
focus, EMDR aims to reduce subjective distress and strengthen adaptive cognitions
related to the traumatic event. Unlike CBT with a trauma focus, EMDR therapy
74 S. Brown et al.
does not involve (a) detailed descriptions of the event, (b) direct challenging of
beliefs, (c) extended exposure, or (d) homework(p.1).
EMDR therapy has been found equivalent to prolonged exposure (PE) therapy
(Foa et al. 2007) and other cognitive behavioral therapies (CBT) in reducing PTSD
symptoms (e.g., Bisson and Andrew 2007). However, EMDR therapy has also been
found to be more efcient and more widely tolerated (has a lesser drop-out rate)
without the clients need for 1-2 hours of daily homework as in prolonged exposure
(e.g., de Roos and De Jongh 2008; Ironson et al. 2002; Jaberghaderi et al. 2004; Lee
et al. 2002; Power et al. 2002).
As is true for all psychotherapies, the mechanism of action responsible for
EMDR therapys effectiveness is still unknown. A recent meta-analysis by Lee and
Cuijpers (2013) examined 26 randomized controlled trials (RCTs) comparing the
eye movement component of EMDR therapy to an exposure condition while par-
ticipants concentrated on a disturbing memory. Pre/post-differences for both con-
ditions demonstrated signicant declines in standardized outcome measures,
negative emotions, and imagery vividness. Additional studies have examined the
effect of the eye movements in EMDR therapy and found that eye movements
enhance retrieval of episodic memories and increase recognition of true information
Table 5.2 Addictions, compulsions, and the similarities between them
Addictions and
Symptoms and cycles
Alcohol and other
substance abuses
Preoccupation (obsession), anticipation (craving), mood
modication (regulation), continued use despite adverse
consequences, relapse, and potentially life-threatening medical
Gambling Preoccupation, anticipation, mood modication, continued use
despite adverse consequences, and relapse
Shopping Preoccupation, anticipation, mood modication, continued use
despite adverse consequences, and relapse
Sex Preoccupation, anticipation, mood modication, continued use
despite adverse consequences, and relapse
Pornography Preoccupation, anticipation, mood modication, continued use
despite adverse consequences, and relapse
Binge-eating and food
Preoccupation, anticipation, mood modication, continued use
despite adverse consequences, relapse, and potentially
life-threatening medical complications
Compulsive exercising Preoccupation, anticipation, mood modication, continued use
despite adverse consequences, relapse, and potential medical
Cutting, Skin picking and
hair pulling
Preoccupation, anticipation, mood modication, continued use
despite adverse consequences, relapse, and potential serious
medical complications
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 75
(Christman et al. 2003; Ricci 2006). One hypothesis regarding the development of
PTSD is the failure to process episodic memory, thereby leaving upsetting mem-
ories stuckin the past instead of being integrated into semantic networks
(Bergmann 2000,2008; Stickgold 2002). For a more complete review of the
hypothesized mechanisms of action involved in EMDR therapy, see Solomon and
Shapiro (2008).
The EMDR model of psychotherapy includes an 8-phase structured protocol that
integrates elements of psychodynamic, cognitive behavioral, experiential, inter-
personal, and body-oriented therapies (Shapiro 2001). EMDR therapys theoretical
orientation is based on the Adaptive Information Processing model described below
(op. cit.).
Theoretical Basis of EMDR Therapy: The Adaptive
Information Processing Model (AIP; Shapiro 2001)
A long habit of not thinking a thing wrong, gives it a supercial appearance of being
right.Thomas Paine
The Adaptive Information Processing (AIP) model explains clinical phenomena,
predicts successful treatment effects, and guides the overall practice of EMDR
therapy across its wide range of therapeutic applications (Shapiro 2001). It asserts
that the brain possesses an intrinsic ability to process information in the moment,
interpreting and integrating current perceptions within the existing memory net-
works. The brain also processes distressing memories to an adaptive resolution.
However, high levels of disturbance can interfere with the brains natural infor-
mation processing capabilities not only in the moment but also later when cues or
triggers reactivate the disturbance.
According to the AIP, symptoms are a result of dysfunctional, physiologically
stored, unprocessed memories. Some, or all, parts of the memory (imagery, emo-
tions, body sensations, thoughts, beliefs, attitudes, and perceptions) remain frag-
mented in present time, distorted, and unassimilated into the more adaptive memory
networks. These distortions can negatively inuence an individuals thoughts,
feelings, and behaviors until reprocessed and integrated into a more adaptive state.
Current situations can trigger these memories causing the individual to experi-
ence the disturbing stored affects and perspectives. This in turn inuences their
perceptions of the present. Externally, a trigger can be a sight, sound, smell, person,
or event. Internally, a trigger can be an emotion, body sensation, mood, or dream.
The purpose of EMDR therapy is to access the traumatic material, activate the
information processing system, and allow the brain to move the dysfunctionally
stored material into a more adaptive, present-oriented state.
76 S. Brown et al.
EMDR therapy distinguishes between Big-Tand small-ttraumas. When
diagnosing PTSD, Big-T traumas are those designated as Criterion A events
(American Psychiatric Association 2013). Examples that might cause intense fear,
helplessness, or horror include: experiencing, witnessing, or hearing about some-
thing that is an immediate threat to ones own or a loved ones life or safety.
Physical and emotional abuse, or sexual assault or abuse, domestic violence,
vehicular accident, combat, terrorism, and natural disasters are commonly identied
Big-T events. However, a person can also be severely affected by more ubiquitous,
adverse life experiences (small-t life events) such as attachment or attunement
problems with parents, and/or siblings, bullying in school, peer problems, the death
of a pet, parents divorce, or the breakup of a romance. In EMDR therapy,
unprocessed memories of trauma and other adverse life experiences are viewed as
foundational to a wide range of pathology.
In support of this concept, 832 surveyed people (Mol et al. 2005) reported that
their PTSD symptoms were more related to common distressing life events than to
Criterion A events. The conclusion of the researchers was that the more everyday
disturbing life events can generate at least as many PTSD symptoms as events
designated as traumaticaccording to Criterion A (op. cit.). In EMDR therapy,
these adverse experiences may be referred to as small-t traumas not because they
are less traumatic, but because they are so common in our experience that they are
frequently overlooked as a cause of later problems (Shapiro 1995,2001,2007b).
Small-t traumas include some of the adverse childhood experiences previously
described by Felitti et al. (1998). EMDR therapy entails identifying, accessing, and
reprocessing Big-T and small-t memories that are identied as the foundation of the
Mental Health and Substance Abuse Through the Lens
of the AIP
Case Conceptualization
Most of the current randomized controlled research on EMDR therapy focuses on
the treatment of PTSD (Lee et al. 2002). However, a growing body of case studies
using EMDR therapy for other mental disorders and addictions reveals a history of
trauma and other adverse life experiences as contributing factors.
Examples of diagnoses and disorders other than PTSD that were treated with
EMDR therapy include:
Body dysmorphic disorder (Brown et al. 1997)
Borderline personality disorder (Brown and Shapiro 2006)
Choking phobia (de Roos and de Jongh 2008; Schurmans 2007)
Deliberate self-harm (McLaughlin et al. 2008)
Domestic violence perpetration and victimization (Stowasser 2007)
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 77
Eating disorders (Beer 2005; Bloomgarden and Calogero 2008)
Obsessive compulsive disorder (Whisman 1997; Whisman and Keller 1999)
Phobias (de Jongh 2003; de Jongh and ten Broeke 2007)
Panic disorder (Fernandez and Faretta 2007; Feske and Goldstein 1997;
Whisman 1997)
Pathological gambling (Henry 1996)
Phantom limb pain (Russell 2008; Schneider et al. 2007; Tinker and Wilson
2005; Wilensky 2006)
Sex offender treatment (Ricci 2006; Ricci et al. 2006).
Social phobia (Sun and Chiu 2006)
Substance use disorder (Brown et al. 2015; Hase et al. 2008; Marich 2009,
2010; Popky 2005; Shapiro et al. 1994; Vogelmann-Sinn et al. 1998; Zweben
and Yeary 2006)
Controlled research is needed in all these areas to further determine the efcacy
of EMDR therapy with these diagnoses that are implicated as causal or related to
substance abuse and compulsive behaviors. However, based on this emerging lit-
erature, it does not seem to be a question of whether to consider using
EMDR therapy to treat complex disorders with a basis in trauma and other adverse
life experiences, but rather when, how, and with whom.
Eye Movement Desensitization and Reprocessing (EMDR):
Principles, Protocols, and Procedures
Man is made by his belief. As he believes, so he is.Goethe
EMDR therapy is taught worldwide to licensed clinicians through, for example, Eye
Movement Desensitization and Reprocessing International Association (EMDRIA),
EMDR Ibero-America, and EMDR-Europe approved Basic Training providers.
These trainings tend to be a minimum of 6 full days of instruction and practicum
with an additional 10 hours of consultation.
EMDR therapy uses a 3-prong approach within an 8-phase model to sequentially
(1) past experiential contributors that laid the groundwork for the current
(2) present triggers that activate current cognitive, affective, and/or somatic
symptoms; and
(3) future desired states and behaviors. (see Table 5.3).
Following the principles of the AIP, EMDR therapy is a treatment that recog-
nizes that false negative beliefs or Negative Cognitions (NCs) about oneself result
from dysfunctionally stored, unprocessed memories and the attendant emotions,
78 S. Brown et al.
Table 5.3 Overview of EMDR therapy phases (Shapiro 2005)
Phase Purpose Procedures
1. Client history Collect background information
Assess suitability for EMDR
Identify-specic treatment targets
from history
Standard history taking keeping
the AIP in mind
Review EMDR
Elicit: (1) past events related to
symptoms, (2) present-day
triggers, and (3) future desired
2. Preparation Prepare clients for EMDR
Stabilize and increase access to
positive affects
Educate about symptom
Teach stabilization techniques
such as a safe/calm place
3. Assessment Activate the chosen targets for
Elicit the following:
Distressing image
Negative belief currently held
(assess SUD 010)
Desired positive belief (assess
VOC 17)
Current emotions
Current physical sensations
4. Desensitization Process past experiences and
current triggers to an adaptive
resolution (SUD of 0)
Fully desensitize all channels
Incorporate positive future
Process past, present, future
Standardized EMDR protocols,
including sets of bilateral
stimulation, allow for spontaneous
emergence of insights, emotions,
sensations, and other memories
If processing becomes blocked,
use Cognitive Interweave to
activate more adaptive information
Stay out of the wayof clients
natural processing
5. Installation Increase connections to positive
cognitive networks
Increase generalization effects
within associated memories
Have client identify the best
positive cognition (initial or
Continue processing until positive
cognition is a 7 on the VOC scale
6. Body scan Complete processing of any
residual distress associated with
Concentration on physical
sensations and processing any
residual distress
7. Closure Ensure client stability at the end
of an EMDR session whether
completely reprocessed or not
Use relaxation or guided imagery
to leave client in comfortable state
to leave ofce
Ask client to monitor what
happens between sessions
8. Reassessment Evaluation of treatment effects to
ensure comprehensive
Explore what has emerged since
last session by re-accessing the
previous target
Evaluate integration after all
targets processed
Reprinted with the permission (c) EMDR Institute, Watsonville, CA
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 79
body sensations, and behavioral patterns they can generate. NCs are clustered under
the headings of Responsibility, Safety, and Choices. These negative beliefs are not
the cause of the dysfunction; they are a symptom of the unprocessed memories at
the root of pathology. Rather than directly challenging the beliefs, as in cognitive
behavioral therapy (CBT) for example, EMDR therapy identies these core, irra-
tional, negative beliefs along with the memories that give rise to them. The desired
Positive Cognitions (PCs) that the client would prefer to believe and feel are true
are also identied and are measured at a gut levelby the Validity of Cognition
(VOC) scale. For genuine change to occur, the memories generating for example,
the incorrect belief, I am not good enoughmust be fully reprocessed at cognitive,
affective, and somatic levels such that the correct belief, I am ne the way I amor
I am good enoughis integrated into the nervous system until experienced as true
at a felt-senselevel.
The Use of Bilateral Stimulation in EMDR Therapy
EMDR therapys Standard Protocol incorporates alternating bilateral stimulation
(BLS) of the senses using preferably eye movements, or tactile taps or audio tones.
BLS is used during the preparation Phase 2 to install and/or strengthen and enhance
any needed client resources and positive affective states, such as in the Safe/Calm
Place exercise. Short and slow sets of BLS are used to strengthen and enhance
positive resources, rather than access and activate potentially associated negative
material, which may occur naturally when faster and longer sets BLS are
EMDR therapy is organized around the principles of a client-centered model,
meaning the clients internal pathways for healing override the interpretations and
directives of the therapist. In EMDR therapy, clinicians do not assume they know
the precise way the client needs to heal because the clients memories are linked in
ways that are not always evident to the clinician or the client. Within the desen-
sitization and reprocessing Phases 46, the clinician utilizes standardized protocols
that encourage and support the clients internal associations regarding their targeted
During desensitization and reprocessing (phases 46), longer and faster sets of
BLS are used to access, activate, desensitize, and reprocess the distressing elements
of the target. This type of purposeful activating, accessing, and moving of material
liberates a persons previously painful or disturbing reactions and behaviors.
Reprocessing continues until the material is integrated and a coherent narra-
tive emerges in present time. This resolution allows the persons own intrinsic
drives toward mental, physical, and spiritual health to emerge and take the place of
addictive patterns.
80 S. Brown et al.
The Treatment of Co-occurring Disorders with EMDR
The concept of a tri-stage model for treating complex trauma was rst introduced
by Pierre Janet in 1907 and then again by Judith Herman in 1992. The tasks of this
type of model are (1) safety and stabilization; (2) trauma processing and mourning;
and (3) reconnection and reintegration (Herman 1992; Janet 1907). Relapse pre-
vention for addiction is an essential part of Janets and Hermans 3rd stage, and
EMDR therapys 2nd and 6th phases, primarily. Please note that with complex
treatment populations, neither the phases of EMDR therapys 8-phase Standard
Protocol nor the stages of the 3-stage complex trauma model are rigid or discrete,
but continually intertwine and overlap as needed throughout treatment.
EMDR therapy is highly effective and efcient. However, it is also emotionally
evocative in the initial phases and potentially poses an additional, though tempo-
rary, risk of relapse with addiction. Therefore, initial and concurrent attention to
safety, support, and resources is paramount. Clients and family members need
thorough education about the relationship between trauma and addiction. The
therapist explains that EMDR therapy conceptualizes cravings and the use of
substances or other behaviors as symptoms resulting from unresolved trauma.
Nightmares, ashbacks, and hyper-arousal, for example, can trigger the desire to
medicate with drugs and/or alcohol (National Child Traumatic Stress Network
(NCSTN) 2008; Steward and Conrod 2003). It is proposed that once EMDR
therapy reprocesses disturbing traumatic memories they will no longer hold any
physical, emotional, or cognitive distress, and there will be less interest in and need
for self-medication, thereby ultimately reducing the risk of relapse. Not all psy-
chiatric disorders are life threatening, but because substance use and abuse can be, it
is recommended that EMDR therapy is conceptualized and administered as a
tri-stage model within its established 8-phase Standard Protocol.
Tasks of a Phased, Integrated Model of EMDR Therapy
STAGE ONE (Phases 1 and 2 in EMDR Therapy)
History, assessment, motivation, safety, and stabilization
Safety and stabilization skills (Najavits 2002; Shapiro 2001)
Motivation (Miller and Rollnick 1991; Prochaska and DiClemente 1983)
History gathering and diagnostic assessment
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 81
Phase 1 of EMDR Therapy: History
Client history is gathered with the AIP in mind, using the designated 3-prong
approach to identify (i) the past experiences causing the dysfunction, (ii) the current
situations triggering disturbance, and (iii) skills needed for adaptive future func-
tioning. It is just as important to identify, strengthen, and enhance internal and
external resources to which the client has access, as it is to uncover adverse
experiences. This ensures that the client will be prepared for the reprocessing
phases of memory work. Reprocessing is dened as unlinking maladaptive con-
nections and forging positive neurophysiological connections between the targeted
memory and more adaptive networks. If the client does not have access to positive
memory networks, there may be little to connect their dysfunctionally stored
material to and reprocessing would not be expected to go smoothly or
speedily (Shapiro 2001).
Clinicians are cautioned to gather history slowly when presented with lifelong,
complex trauma cases in order to minimizethepotentialtriggeringofhighly
charged emotional material. Gradual, paced history taking is preferred, as too much
too sooncan increase the risk of relapse. The following guidelines are recommended:
Assess for and provide any needed self-control or affect management techniques
Gather the clients bio/psycho/social history including mental status, strengths,
chronological trauma history, PTSD, anxiety, and depressive symptoms
Assess for the presence of co-occurring disorders
Initially screen for dissociative disorders using the Dissociative Experiences
Scale (DES; Bernstein and Putnam 1986) and if indicated, seek a more formal
diagnostic assessment for dissociation such as the Structured Clinical Interview
for Dissociative Disorders (SCID-D; Steinberg et al. 1990). It is important to
note that the presence of a dissociative disorder is contraindicated for treatment
using EMDR therapy without both the specialized expertise of the clinician and
readiness of the client (Forgash and Copeley 2008; Shapiro 2001)
Elicit a detailed history of substance use/abuse/dependency/addiction and
behavioral compulsion
Note all substances used and pattern of use, e.g., binge, regular use,
increasing amounts, and maintenance
First use: What was happening at the time client rst started using?
Assess current triggers and urges to use substances or other addictive
Assess relapse patterns
Evaluate past treatment attempts and outcomes
Assess level of readiness for treatment: precontemplation, contemplation,
preparation, and action (Miller and Rollnick 1991; Prochaska and DiClemente
82 S. Brown et al.
Educate the family about the nature of addiction as a brain disorder and
untreated traumas contributing rolethis is considered a key to successful
Assess level of support from family, friends, and co-workerseach family
members role in either supporting or undermining the treatment process should
be assessed, addressed, and treated, whenever possible (Shapiro 2007)
Case Example: PTSD, Bipolar Disorder, Marijuana and Alcohol Abuse,
and Compulsive Use of Pornography
Sheila referred her 33-year-old husband John (not their real names) for EMDR
therapy because she had become fearful about his rapidly deteriorating emotional
state.She reported that during the last 6 months he had become increasingly more
depressed, anxious, withdrawn, physically and emotionally abusive, and expressed
occasional suicidal ideation and intent. His marriage was at risk of failure.
John reported that 1 year ago he had attended a family gathering where he
unexpectedly saw an older cousin who had molested him between the ages of 11
and 13. He had not seen that cousin in 10 years and thought he had already dealt
with the molestation.He was upset to nd he was still powerless over his reac-
tions. His parents dismissed his distress by asking him why something from such a
long time agowould bother him now. Admittedly attempting to deal withthe
symptoms listed below, John self-medicated with alcohol and marijuana and
pornography on and off since the sexual offenses made against him during his early
adolescence. These behaviors and moods again escalated after encountering his
cousin and were now threatening his job and marriage.
Johns History
Presenting Symptoms
Sleep disturbances
Severe marital discord with emotional and physical rage outbursts
Mood swings
Self-injurious impulses
Compulsive use of pornography
Marijuana and alcohol abuse
Past: To be reprocessed during initial stage of the 3-prong protocol
Family history of alcoholism, depression, and suicide.
Extreme parental mis-attunement and emotional neglect, e.g. Johns isolated,
unsafe conditions at home frightened and overwhelmed him. When he tried to
communicate his fear to his parents, they minimized him and told him how
easy he had it compared to them.
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 83
This ongoing invalidation was later revealed as the earliest contributor for the
present-day over-reactivity to wifes communications with him.
Extended periods of isolation and loneliness.
Sexual assault from age 11 to 13 by his 18-year-old male cousin.
John reported that his preoccupation with pornography and substance abuse
emerged in his early teens, shortly after the molestation began. This is the most
commonly reported temporal relationship between trauma and substance abuse
(Steward and Conrod 2003).
Early relational mis-attunement, poor attachment, parental neglect, and extended
periods of isolation would be expected to decrease Johns developing ability to
manage affect in childhood and into adulthood (Perry 1999; Schore 2002; Siegel
1999; Van der Kolk et al. 1996). The Adaptive Information Processing (AIP) model
would see Johns symptoms as being an expression of his genetic, environmental,
and experiential factors that fostered the later development of his mood disorders
and substance abuse (Felitti et al. 1998; Shapiro 1995,2001).
The negative, irrational beliefs or Negative Cognitions (NCs) that often emerge
from a history such as Johns are a focus of treatment in EMDR therapy. Both the
SUD level and the VOC rating are re-assessed and re-measured after the repro-
cessing and installation phases 46 of EMDR therapy. A decrease in the SUD rating
to 0or ecological validity associated with the memory, along with an increased,
felt-sense rating of the VOC to a 7, indicates a positive treatment effect as a result of
reprocessing traumatic material in EMDR therapy.
Johns negative belief clusters related to the sexual assault are listed below. Each
belief was targeted through the complete 3-prong approach of past contributors,
present triggers, and desired future states and behaviors (Table 5.4).
Present triggers: To be processed during the second phase of the 3-prong
1. Feeling criticized
2. Feeling misunderstoodand not able to be heard
3. Feeling unimportantto his wife
Table 5.4 Johns negative and positive cognitions and cluster types
Negative cognitions (NC) Positive cognitions (PC) Cluster types
I am permanently damaged”“I am ne as I amResponsibility
Theres something really wrong with me”“I am ne as I amResponsibility
Im not safe”“I can keep myself safe nowSafety
I cant trust”“I can learn to trustSafety
I am powerless”“I have choices nowChoices
I cant stand it”“I can handle itChoices
84 S. Brown et al.
Phase 2 of EMDR Therapy: Preparation
Safety, stabilization, and resource development
Readiness for EMDR therapy reprocessing (Phases 46) includes:
The ability to access and use safe coping skills (Najavits 2002; Shapiro 1995,
2001) to soothe high levels of distress
The ability to have a dual awareness of the past traumatic material while still
maintaining present-moment orientation
The willingness to engage available resources such as a 12-step program, sober
living, family, and/or other personal support systemsthis is crucial when
clients are still using substances
Sobriety of at least 30 days or until symptoms of withdrawal are minimized,
whenever possiblethis recommendation has exceptions, see the section Early
Trauma and Other Adverse Life Experiences Treatment in Addictions:
Guidelines and Exceptionslater in this chapter
Safety and stabilization with any population comes rst in treatment, but because of
the potentially evocative nature of EMDR therapy, and the risk for relapse with
co-occurring disorders, the timing of the reprocessing (phases 46) is carefully
assessed. When EMDR therapy is used to treat single incident traumas, such as a
motor vehicle accident, dog-bite, or a one-time assault, reprocessing with EMDR
therapy can be an exceedingly brief, effective intervention consisting of 13
(90-min) sessions (Marcus et al. 1997; Rothbaum 1997; Shapiro 2001). There are
also clients who have strong personal strengths and resources who may not need a
lengthy preparation phase. Sobriety and self-soothing are often enough to move
forward into trauma processing when clients have less complex histories.
For clients with complex trauma histories
For those who have confounding variables of long-term, complex childhood
trauma, and exhibit a more severe and chronic course of symptoms, extensive
preparation is strongly recommended to promote the safest trauma reprocessing
experience. Here, reprocessing with EMDR therapy may have both a longer
preparation phase and longer reprocessing phases.
Additional resource development is needed when clients are missing resources
that may interfere with their ability to tolerate reprocessing. Resource Development
and Installation (RDI; Korn and Leeds 2002), for example, which accesses and
incorporates a variety of positive affective and somatic states, can accomplish this.
Other grounding and self-soothing exercises may include visualizations in which
people are able to imagine themselves behaving in a more positive, adaptive way.
This manner of preparation for trauma treatment is a variation of the 3rd-prong, or
Future Template, of EMDR therapy.
More structured interventions may be integrated with EMDR therapy in envi-
ronments where group work or more intensive individualized preparatory experi-
ence is needed prior to individual trauma processing, for example: Seeking Safety
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 85
(Najavits 2002), Motivational Interviewing (M.I.; Miller and Rollnick 1991),
Desensitization of Triggers and Urge Reprocessing (DeTUR; Popky 1998), and
Dialectical Behavior Therapy (DBT; Linehan 1993).
Johns Preparation
Personal strengths and resources
Creative and artistic
Sensitive and warm
Long-term friendships from high school
Supportive wife
Resources needed
Ability to self-soothe (Safe Place)
Willingness to commit to sobriety
When John initially sought treatment, he was not sober and had suicidal thoughts.
Substance abuse can confound assessments and trigger or prolong symptoms;
therefore, a psychiatrist conducted a medical evaluation and concluded, in collab-
oration with the treating therapist, that John required medically managed stabi-
lization prior to initiating any trauma processing with EMDR therapy. John agreed
to take medication and enter into a course of sobriety to allow the clinical picture to
clear. He was able to remain clean for 30 days and the co-occurring Bipolar, PTSD,
and Substance Use Disorders were conrmed.
John was now able to demonstrate, along with other self-soothing techniques, his
use of the Safe/Calm Place exercise and an ability to shift from a state of high
distress to a state of calm. This, along with his sobriety and medical stabilization,
allowed the client and clinician to move forward and reprocess his rst EMDR
therapy target.
STAGE TWO (Phases 36 in EMDR Therapy)
Phases 36 in EMDR Therapy (assessment, desensitization, installation, body scan)
use the 3 prongs of past, present, and future
Assess, desensitize, and reprocess all past adverse life experiences and present
symptoms and triggers until they no longer cause cognitive, affective, or somatic
Teach necessary skills and imaginally rehearse future reactions and behaviors
with BLS in order to develop future templates for more adaptive choices
86 S. Brown et al.
Phase 3 of EMDR Therapy: Assessment
John collaborated in his treatment planning, and with the clinical agreement of his
therapist, chose the rst of the sexual assaults against him as his rst target for
memory reprocessing.
Setting up and activating the target
Identify the most disturbing image associated with the event:
The rst time he was held captive in a closet and sexually assaulted by his older
Identify the irrational negative belief (NC) related to the event:
Theres something really wrong with me
Identify the desired positive, more accurate belief (PC):
Imne the way I am
Assess the Validity of Cognition (VOC) with the image held in mind, on a scale
of 17, where 1 feels totally gut-level false and 7 feels completely gut-level true
John reported a VOC of 2
Assess the Subjective Units of Distress (SUD) on a scale of 010, where 0 is no
disturbance and 10 is the highest disturbance imaginable:
John reported a SUD of 9
Identify where in the body the distress is noticed:
John reported tightness in chest, nausea, stomach cramping, and head
Phase 4 of EMDR Therapy: Desensitization
The desensitization and reprocessing phasesuseaninitialsetof18-24eye-movement
passes while asking theclienttomindfullyjust noticewhat is emerging during and
between sets. The length of subsequent sets of eye-movements is based upon the
cliniciansassessmentsoftheclientsaffectiveandcognitiveresponses. A deep breath
is taken when BLS is stopped, and the client then reports what is being experienced.
The clinician then helps guide the client to thefocusofattentionforthenextset.After
approximately 20 sets, John stated with clear conviction that he was only 11 years old,
that his cousin was almost an adultat 18, and that he could not imagine an
11-year-old child causing or being responsible for their own molest.He also noted
that the absence of his parentssupervisionduring much of his childhood left him at
greater risk for exploitation. Clearing those networks revealed JohnsadditionalNCs
such as Imunimportantand Icanttrustand the insight that he inappropri-
ately managed feeling misunderstood or unduly criticizedby becoming explosive
and abusive toward his wife.
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 87
The Treatment of Present Triggers and Urges to Use
Johns present triggers and urges to use alcohol, marijuana, pornography, and
verbally abuse his wife were reprocessed. It should be emphasized that in order to
prevent relapse, it is also necessary to reprocess any other early memories and their
triggers that might contribute to setting the groundwork for pathology (Table 5.5).
When exploring Johns triggers, they were revealed to be directly associated
with the experiences and emotions he had rst felt as a child in response to his
parentsbehavior. His parentsinsensitive responses to him frequently left him
feeling misunderstood, unheard, unimportant, and extremely frustrated.
In EMDR therapys Standard Protocol, triggers are identied and reprocessed as
an individual EMDR target. For example, the feeling of being misunderstoodwas
set up as follows:
Target image Arguing with his wife
NC Im not important
PC I am important and deserve to be heard
Emotions Extreme frustration, anger, sadness, fear
Location Tightness in chest and stomach
The target was reprocessed to SUD of 0 and VOC of 7 with clear body scan.
As a result, John saw that his parents were good peoplewho often commu-
nicated with criticism due to their own anxiety, not his shortcomings. They also left
him alone for long periods of time because both worked long hours to support the
child they loved, not because he was unimportant. These clarications sponta-
neously emerged during reprocessing and were keys to Johns establishing positive,
loving connections within and for himself and for his wife.
Additional outgrowths of reprocessing included desensitization of his triggers.
They no longer activated his urge to use substances or pornography and his nervous
system was cleared of the old feelings associated with the belief that he didnt
matter. As expected, he also no longer incorrectly perceived his wifes intentions as
critical, demeaning, or mistrustful. John was then able to respond more appropri-
ately and non-defensively to her communications and her needs and their marriage
Table 5.5 Triggers and addictions of choice
Triggers Addiction of choice
Perception of being criticized Marijuana (calming)
Feeling misunderstood Marijuana, alcohol (calming, and to relieve tension)
Social events Marijuana and alcohol (felt more social)
Loneliness and isolation Pornography (felt more connected)
88 S. Brown et al.
Phase 5 of EMDR Therapy: Installation
Once a SUD of 0 (or with some ecological exceptions, a 1) is reported, installation
of the PC is continued until a VOC of 7 is reached. Johns original NC was, Its
my fault.Johns PC evolved into, I was just a child; it wasnt my faultand was
reported to be felt at a VOC of 7.
Phase 6 of EMDR Therapy: Body Scan
During the body scan the client brings up the original target, their positive belief, and
scans their body for any remaining distressorsensation.Ifanythingevenslightis
reported, reprocessing continues until no remaining discomfort orbodysensationscan
be identied. John reported he was clear and had no remaining bodily distress.
Future Template: At this point, if possible, a futureimaginalrehearsalcanbecon-
ducted. In Johnscase,hewasaskedtothinkaboutafuturetimethathemightruninto
his cousin and notice whether he sensed any distress connected with that possibility.
John was able to imagine the scene without much problem, until the therapist tested his
Future Template by suggesting that he visualize his cousin chatting with another young
male family member. This triggered some distress and feelings of protectiveness toward
the younger male family member. John stated that, as an adult, he would do whatever
might be necessary to keep a child safe from his cousin. The visualization was continued
until John could imagine himself thinking, feeling, and behaving as he wished: calmly
and assertively with no physical, emotional, or cognitive disturbance.
Phase 7 of EMDR Therapy: Closure
Close down complete or incomplete sessions by using the Safe/Calm Place and
positive resources developed and strengthened by the client in the preparation phase
of EMDR therapy. Johns session, having arrived at a SUD of 0 and VOC of 7 with
a clear body scan, was closed down safely. The desensitization and reprocessing of
his triggers and Future Templates would come at later sessions. John left the session
condent in the truth of his words, I was just a child; it wasnt my fault.
Phase 8 of EMDR Therapy: Re-evaluation
Treatment targets are re-evaluated at the following session to see whether any
change has occurred. The client is asked to bring up the memorythat was worked
on and notice what comes up for you today.If the client reports any distressing
imagery, thoughts, feelings, or body sensations, they are reprocessed until complete
(SUD of 0, VOC of 7) using the same procedures noted during assessment and
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 89
desensitization. When no further disturbance is reported, Phase 3 is revisited and
the next target in the treatment plan is selected.
At Johns follow-up visit, the target was reassessed and remained at a SUD of 0,
a VOC of 7, with a clear body scan. He also reported he experienced a sense of
lightnessbetween sessions when he would think of the molestation, as if the
weight of a boulder had been lifted from his chest.
STAGE THREE All Phases of EMDR Therapys 8-phases
and 3-prongs
Reconnection, Integration, and Relapse Prevention
Reconnection and reintegration takes place in all phases of EMDR therapy. When
traumatic memories are successfully reprocessed and ones personal strengths and
resources are fully accessible, this then allows for the freedom to be a more honest,
open, and authentic self.
Stage 3 involves and may result in:
A felt-sense of integration with oneself, along with an enhanced ability to
connect or reconnect with others which is believed to be a natural result of
reprocessing and integrating distressing material
Preparation of the neural networks for future adaptive actionwithout the use
of substances or other self-destructive behaviors
Future Template: 3rd-prong of the 3-prong Protocol
Use of the Future Template (imaginal rehearsal) gives clients an opportunity to
systematically imagine the future, as if running a movie, focusing on potentially
relapse-triggering situations, people, places, rituals, and/or internal states. These
targets are reprocessed with bilateral stimulation until they can be imagined without
distress and the positive, self-referencing statement (e.g., I am deserving) feels
true at a felt-senselevel.
The therapist asks: With respect to these issues, how would you like to see
yourself thinking, feeling, and behaving in the future?
Calm and rational communications with wife
Able to hear and receive feedback without interpreting it all as critical
Clean and sober from substances and pornography
Able to be alone or connect with others and be comfortable either way
Johns Future Template Target: Remaining calm when in disagreement with his
90 S. Brown et al.
John was asked to imagine a movie scene of he and his wife disagreeing about
the social plans she made without rst consulting him. This triggered his belief, I
dont matteralong with anger and tension in his chest. The image, emotion, and
body sensation were reprocessed until he reported they were neutral and no longer
disturbing. Asked if there was any level of urge to use substances at the thought of
arguing with his wife, John said, No.It is expected that successful use of the
Future Template will lower the risk of relapse because it reduces or eliminates
identied motivators to self-medicate.
Early Trauma and Other Adverse Life Experiences
Treatment in Addictions: Guidelines and Exceptions
Treating clinicians must be experienced as both chemical addiction and behavioral
compulsion specialists in addition to EMDR therapy, or be under close supervision of
someone with those qualications. The common guideline in addiction treatment has
been to wait for a period of stabilization and sobriety, generally 30 days, before
working through disturbing memories. However, although there clearly are risks in
treating trauma prior to sobriety or early in recovery, there are also cases where
reprocessing a traumatic memory can reduce the risk that unresolved trauma will
interfere with attempts to sustain sobriety (Zweben and Yeary 2006).
Case Example: EMDR Therapy Before the Client Has
Attained Sobriety
Jeannie (not her real name) had a rocky childhood with adoptive parents who had
decided, They really didnt want a child after all.She was physically cared for but
was emotionally neglected and verbally berated. An alcoholic, sex, and cocaine
addict since her teens, she was now 41, married, with a teenage son.
At 15 years of age, Jeanniesparents,whooftenfoughtviolently with one another,
went through a bitter divorce. She blamed herself for their marital failure since she was
often the subject of their ghts. Jeannie lived with her mother who made it clear that
she was not to open the door to her father if she was not present. Her father, who
suffered from severe emphysema, came by one day hauling his oxygen tank behind
him. He became angry and escalated into a rage when Jeannie refused to open the door.
The angrier he got the more impaired his breathing became. Terried of her mother,
Jeannie did not let him in. Later that week, her father was hospitalized and died shortly
thereafter. She blamed herself for his death and her mother blamed her as well. Jeannie
soon began to use substances to cope with her perception of these childhood events,
and her addictions quickly spiraled out of control. She found herself unable to manage
without the use of substances.
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 91
Jeannie had numerous previous attempts at counseling and sobriety, but when
sober, the ashbacks and anxieties stemming from her childhood overwhelmed her.
After several months of phased preparation: teaching safe coping skills, strength-
ening inner resources, and developing emotional management skills, she was still
unable to establish sobriety for more than a few days and could not maintain a
serious recovery program. While sobriety is preferable before beginning EMDR
therapy reprocessing phases, in Jeannies case the therapist and client collabora-
tively decided to proceed and target her belief that she was responsible for her
father dying, in the hope that lessening the distress of that memory would promote
her efforts at sobriety.
The reprocessing was successful within two sessions and freed Jeannie from her
26-year belief that she caused her fathers death. She also came to know that the
way her parents treated her in childhood was not because something was wrong
with her, but was a consequence of her parentsown issues which were not her
fault. With these deeply felt perceptual changes, Jeannie was nally able to enter
into and sustain recovery. She said that resolving that experience had given her
hope that the remainder of her traumatic past could be reprocessed as well. It took
over a year to target her remaining issues with one relapse early in recovery. Jeannie
is now in her tenth year of uninterrupted sobriety.
An Integrated Trauma Treatment Program (ITTP) Using
EMDR Therapy and Seeking Safety in an American Drug
Court Program
An Integrated Trauma Treatment Program (ITTP; Brown et al. 2015) combining
two evidence-based, empirically validated treatments: EMDR therapy (Shapiro
2001) and Seeking Safey (Najavits 2002), was implemented as an enhancement to
the Thurston County Drug Court Program in Olympia, Washington, which previ-
ously had no trauma-focused component. The ITTP included 3 phases (early,
middle, and later recovery) over a period of 1218 months and offered treatment in
lieu of incarceration to nonviolent individuals arrested for drug-related offenses.
Data was collected from 220 participants from 20042009. Since unresolved
trauma is believed to underlie addiction, the objective of the ITTP was to determine
if adding a trauma-specic treatment component to the program as usual
(PAU) would improve program outcomes such as graduation and recidivism. Drug
court program completion and graduation are the strongest predictors of lower
post-program recidivism rates (National Institute of Justice 2006).
Seeking Safety (SS) is a manualized, CBT-based treatment program for PTSD and
substance abuse that focuses on the present rather than delving into past trauma. SS can
be conducted as a group intervention or individually by trained, non-licensed support
staff. SS has demonstrated signcant treatment effects (Hien et al. 2010;Najavitsand
Hien 2013). See for a comprehensive list of SS studies. SS is
92 S. Brown et al.
listed as a Best Practice through the Substance Abuse and Mental Health Services
Administration (SAMHSA 2005)andiscomposedof25topicsthatprovideeducation,
safety skills-building, and stabilizationtechniques.Same-gendergroupswerea
mandatory addition to the PAU for those endorsing a trauma history. Fifteen
pre-selected topics were used in the ITTP as a more formal part of Phase 2 in EMDR
therapy (Preparation, Safety, and Stabilization) to prepare participants for individual
trauma treatment with EMDR therapy, including exploration and reprocessing of past
trauma. Completion of all SS groups was required prior to receiving voluntary EMDR
therapy. Participantssobriety was assessed via random urine drug screens throughout
the entirety of the drug court program.
Out of the 220 participants assessed with either the Clinican Administered
Posttraumatic Stress Scale (CAPS; Blake et al. 1995) or the Detailed Assessment of
Posttraumatic Stress (DAPS; Briere 2001), 68 % endorsed a criterion A trauma
sometime in their life. Program graduation outcomes revealed that participants in
the PAU who did not endorse any trauma history graduated at a rate of 60 %. Those
who endorsed trauma and completed the Seeking Safety portion of the ITTP but
declined EMDR therapy, graduated at a rate of 57 %. Those who went on to
complete EMDR therapy, graduated at a rate of 91 %. Post-program recidivism
rates were 10 % for PAU graduates, 12 % for those receiving EMDR therapy and
33 % for those completing SS groups but declining individual EMDR therapy.
Case Example of Drug Court Participant
One Drug Court participant, Tom, (not his real name) had been arrested 14 times for
felony drug possession. He was in his third, and nal, Drug Court Program
opportunity when EMDR therapy was introduced. His history revealed two alco-
holic parents, and other adverse childhood experiences, including his fathers early
death from cancer. Toms substance abuse began in adolescence and included
alcohol, marijuana, and his primary drug of choice: methamphetamine. At the age
of 31, Tom and his brother were cross-country tractor-trailer truck driving partners.
They engaged in a bitter argument while driving drunk. In a t of rage, Toms
brother unbuckled his seat belt and stepped out of the truck as it was going 65 miles
(105 km) per hour. He died in Toms arms at the side of the road.
Tom blamed himself for his brothers death. His addictions increased and led to
the loss of his family, business, and freedom. Tom never had treatment for his
traumatic past, nor did he know that unprocessed adverse experiences fueled his
addictions. Successfully targeting and reprocessing the death of his brother with
EMDR therapy was the beginning of a long-lasting recovery for Tom, now 12 years
sober. One of the rst successful participants of the ITTP, Tom has been an avid
spokesperson and role model for the program and often speaks publically to inspire
other Drug Court participants.
5 EMDR Therapy and the Treatment of Substance Abuse and Addiction 93
The following case example illustrates the importance of considering small-t
traumas, or adverse life experiences, as well as the Big-T traumas when treating this
Case Example: Co-occurring Panic and Substance Use
Disorder Rooted in a Small-T Trauma
Karen (not her real name) was 47 years old when she was referred for EMDR
therapy. She was nine months sober from poly-substance abuse, but was still
sexually compulsive and continued to have panic attacks, that despite several trials
of psychotropic medication, caused her to use again. She thought choosing her own
drugs was more effective than medication, even though using only deepened her
sense of guilt, shame, and isolation.
She had more than 10 years of unsuccessful treatment for her panic attacks
before her earliest memories of them were targeted and reprocessed with EMDR
therapy. She focused on the fear in her bodyas the target and within a few
moments connected with a memory from age four of being dropped off at a park
with instructions to care for her 2-year-old sister. It seemed to Karen that her
parents left her there the entire day. By the time they returned, Karen was in a panic,
vomiting, sobbing, and unable to catch her breath. Her father screamed at her to
knock it off and quit acting like a baby.Her panic shifted to shame and humil-
iation when his rage changed to laughter about how wimpyshe was.
The developing brain of a child requires a certain level of attunement and safety
in order to develop its emotional regulation capacities (Schore 2002; Siegel 1999)
without which a child is more vulnerable to later substance use (Linehan 1993).
Thus, 4-year-old Karen tried to regulate her emotions in the absence of supportive
parenting. In less than a year, at age 5, Karen took her rst sip of beer at an
unsupervised party of her parents and from that point, continued to drink as
opportunities at home presented themselves. At age 12, she began smoking mari-
juana. She entered treatment for alcohol and marijuana abuse at age 46.
More serious traumatic and adverse experiences occurred throughout her childhood,
including multiple molestations by her brothersfriendssuchassexuallyinappropriate
touching. However, Karen states she experienced the park incident as the rst and most
overwhelming experience that set the tone for the rest of my life.That memory felt
just like the panic attacks she continued to experience in adulthood and attempted to
medicate with drugs, alcohol, and compulsive sex; by all clinical standards the adverse
childhood experience at the park was a small-t trauma.
The intensity and frequency of Karens panic attacks diminished after repro-
cessing of this pivotal memory easing her urges to use marijuana and alcohol to
medicate them. This case underscores the importance of reprocessing memories
responsible for not only the faulty cognitive beliefs one holds about ones self, but
94 S. Brown et al.
also the body sensations that are reported, such as in panic attacks, that may or may
not have a specic negative cognition associated with them. This example illumi-
nates the importance of not only reprocessing Big-T traumas, but also all of the
relevant adverse life experiences we consider to be small-t traumas.
Conclusion and Summary: Why Use EMDR Therapy
to Treat Co-occurring Disorders?
Although the world is full of suffering, it is also full of overcoming it.Helen Keller
As research and clinical experience suggest, the incidence of co-occurring disorders
within the criminal justice system (Substance Abuse and Mental Health Services
Administration (SAMHSA) 2005) and substance abuse treatment centers across the
nation indicates the need for specialized treatment programs designed specically
for this challenging population. The personal, family, social, health, and economic
consequences as a result of failing to treat these individuals have been staggering
and seems remediable.
Co-occurring disorders are a unique treatment challenge and EMDR therapy is a
unique response to that challenge. EMDR therapys 8-phases and 3-prongs, along
with the informing AIP model, predicts that early trauma and other adverse life
experiences are primary contributors to the emergence of clinical symptoms and
disorders, and are often the leading causes for the use of substances designed to
regulate distress. The 3-prong approach of EMDR therapy is ideally suited to the
treatment of co-occurring disorders and targets: (1) the past experiential contribu-
tors to present-day symptoms, (2) present-day triggers that activate distress, and
(3) future templates of desired states and behavior.
The third prong (Future Template) in EMDR therapy gives clients an opportunity
to imagine encountering many possible relapse-triggering situations (people, places,
and things) as well as internally triggering negative emotions in the future. These
future targets are then reprocessed with BLS until the future can be visualized
without distress and the clients positive self-referencing statements feel true at that
felt-senselevel. It is believed that the treatment effects observed with EMDR
therapy offer co-occurring disordered clients an extra measure of protection against
future relapse with drugs, alcohol, or other self-destructive behaviors originally
intended to help the client feel better.The temporary solution of addiction
eventually displaces a persons true self with a sense of powerlessness and
self-loathing that impacts the not only the individual, but their family and the next
generation in the vicious cycle introduced at the beginning of this chapter. Therefore,
we call to attention the hypothesis that societys number one problem is not sub-
stance abuse and other harmful behaviors, but rather, unresolved trauma, neglect,
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In reaction to the impact drug abuse has on society, professionals in a range of fields are working toward developing more effective methods to reduce the substance abuse. This chapter provides a brief overview of drug treatment. First, a broad definition is provided and some of the general frameworks utilized in the field are described. Then a number of the most commonly used approaches are examined in more detail. The various types of drug treatment programs include: detoxification, psychotherapy and behavioral approaches, anonymous groups, pharmacotherapy, therapeutic communities, and treatment centers. This is followed by a discussion of drug treatment's place in the criminal justice system, by focusing on treatment programs and including specific instances of success and failure. Subsequently, some comparisons on international drug treatment efforts are made, and the chapter concludes with a comment on the future of drug treatment.
This therapist guide of prolonged exposure (PE) treatment is accompanied by the patient workbook, Reclaiming Your Life from a Traumatic Experience. The treatment and manuals are designed for use by a therapist who is familiar with cognitive behavioral therapy (CBT) and who has undergone an intensive training workshop for prolonged exposure by experts in this therapy. The therapist guide instructs therapists to implement this brief CBT program that targets individuals who are diagnosed with posttraumatic stress disorder (PTSD) or who manifest PTSD symptoms that cause distress and/or dysfunction following various types of trauma. The overall aim of the treatment is to help trauma survivors emotionally process their traumatic experiences to diminish or eliminate PTSD and other trauma-related symptoms. The term prolonged exposure (PE) reflects the fact that the treatment program emerged from the long tradition of exposure therapy for anxiety disorders in which patients are helped to confront safe but anxiety-evoking situations to overcome their unrealistic, excessive fear and anxiety. At the same time, PE has emerged from the adaption and extension of Emotional Processing Theory (EPT) to PTSD, which emphasizes the central role of successfully processing the traumatic memory in the amelioration of PTSD symptoms. Throughout this guide, the authors highlight that emotional processing is the mechanism underlying successful reduction of PTSD symptoms.
The reduction procedures for fear and anxiety described in the previous chapter are now applied as treatments to specific anxiety disorders. As is most often the case in clinical practice, several procedures are used with the same individual in order to capitalize on the most effective elements of each and to adapt the treatment to the specific characteristics and needs of the individual client. The cases that follow were selected to illustrate how the various procedures can be adapted effectively and combined into comprehensive individualized treatment programs.
Starting with the Foreword by Daniel Siegel, MD, the Handbook demonstrates in superb detail how you can combine EMDR's information processing approach with family systems perspectives and therapy techniques. An impressive and needed piece of work, Handbook of EMDR and Family Therapy Processes provides a clear and comprehensive bridge between individual and family therapies.
This article reports on the first 3 randomly allocated cases treated by the author in an ongoing trial comparing eye movement desensitization and reprocessing (EMDR) with cognitive behavioral therapy (exposure and response prevention) in the treatment of obsessive-compulsive disorder in a U.K. primary care setting. This article describes the treatment and data collection procedures, followed by a summary of each of the 3 cases supported by quantitative and qualitative data. The Adapted EMDR Phobia Protocol (Marr, 2012) was provided, following the trial protocol of 1-hour, 16-session treatment. The Yale-Brown Obsessive Compulsive Scale was administered at every 4th session. At posttreatment, 2 of the 3 cases showed more than a 50% reduction on validated psychometric measures, with symptoms below diagnostic cutoff. The final case started treatment below the diagnostic cutoff on the primary outcome measure and showed a slight improvement. Six-month follow-up data showed maintenance of treatment effects. Transcripts from a semistructured telephone interview carried out by an independent researcher following treatment were analyzed using a 6-stage thematic analysis method, which identified 3 themes: the role of traumatic experiences, role of shame, and importance of therapeutic alliance. This article concludes with a discussion of implications for EMDR practice and theory.
Behavioral addictions, such as pathological gambling, kleptomania, pyromania, compulsive buying, and compulsive sexual behavior, represent significant public health concerns and are associated with high rates of psychiatric comorbidity and mortality. Although research into the biology of these behaviors is still in the early stages, recent advances in the understanding of motivation, reward, and addiction have provided insight into the possible pathophysiology of these disorders. Biochemical, functional neuroimaging, genetic studies, and treatment research have suggested a strong neurobiological link between behavioral addictions and substance use disorders. Given the substantial co-occurrence of these groups of disorders, improved understanding of their relationship has important implications not only for further understanding the neurobiology of both categories of disorders but also for improving prevention and treatment strategies.
In the last 20 years, research on substance addictions has changed its focus from the social foundations to the neurobiological foundations. Hence, some behaviors have begun to be considered as equivalent to addiction based on proposed criteria: salience, withdrawal symptoms, tolerance, conflicts, relapse, and mood modifications. New knowledge about the brain's reward system suggests that “as far as the brain is concerned a reward is a reward, regardless of whether it comes from a chemical stimulus or an experience.” Pathological gambling was the prototypical addiction disorder, sharing some hallmarks with substance addictions: a high rate of comorbidity and treatment response to pharmacotherapies, such as opioid antagonist. However, compulsive sexual behavior, compulsive exercise, food starving, binge eating, and, most recently, Internet addiction have been gradually conceptualized as non-substance addictions with overlapping features with substance dependence. Several definitions” have been adopted regarding these behaviors: natural addiction, non-chemical addiction, and negative dependence are only some examples. This issue of CNS Spectrums focuses on behavioral addictions.