The Advantages of Combining EMDR with Schema Therapy and Polyvagal Therapy for Complex Posttraumatic Stress Disorder

By Jeff Dwarshuis LMSW ACSW

EMDR and Brain Functioning

EMDR is a treatment method used to eliminate the negative impacts of traumatic memory quickly and effectively. EMDR is a neurobiological intervention that makes use of eye movements to facilitate a physiological impact on brain functioning which creates permanent emotional and cognitive change in an individual when thinking about or visualizing a traumatic memory.

Recent studies on brain scans of individuals indicate that traumatic experience and traumatic recall negatively impact brain functioning and that EMDR corrects it. Specifically, during trauma a part of the brain called the amygdala, which controls many of our emotions and is responsible for autonomic responses associated with fear and fear conditioning, becomes over activated and this creates an impasse between itself and the hippocampus. The hippocampus plays an important role in the consolidation of information from short term memory to long term memory and spatial memory which is responsible for recording information about one’s environment and spatial orientation.

It is recognized that this impasse between the hippocampus and the amygdala creates symptoms found in generalized anxiety, panic attacks and posttraumatic stress disorder. During EMDR, this impasse is corrected as eye movements will both enlarge and activate the hippocampus so it can receive the overwhelming amount of information from the amygdala and then sort it. The hippocampus then completes the proper brain processing by sending information to the anterior cingulate cortex, which is involved in aspects such as attention, decision making, reward anticipation, ethics, morality, impulse control and emotion. The impact of opening this impasse and restoring proper brain functioning means that a negative memory, once too overwhelming to manage, is put into the proper context of time and space, has affective and cognitive aspects of the memory merged, is viewed with more rational thought, reason and control and exists in a clear distinction between the past and the present.

EMDR and the Two Primary Positive Treatment Reactions

During EMDR treatment, which is administered by a psychotherapist, a client responds to the neurobiological process described above and experiences two primary reactions to a traumatic memory. First, there is a distancing from the memory that includes an elimination of the negative emotional reactions related to the trauma. Second, the client experiences an increased level of rational perception related to the memory. This increased rational thinking is called Adaptive Information Processing (AIP). AIP is the result of successful EMDR reprocessing and allows the client to hold a more rational view of personal safety, personal responsibility and personal choice while visualizing or discussing a traumatic memory. AIP also allows the client to hold an accurate positive self-perception or cognition while visualizing the trauma. This assists the client in problem solving how he or she would react, or prefer to react, differently in a similar situation. Repeating the EMDR procedure over a series of planned interventions targeting traumatic memories relieves the person of the negative impacts the memories have created. Due to its neurobiological quality, the changes from successful EMDR reprocessing are permanent and generates dramatic symptom reduction across the spectrum of most all mental health diagnosis.

What Is Schema Therapy?

Schema Therapy is a branch of Cognitive Therapy that was developed by Jeffrey Young PhD and includes several different psychotherapeutic interventions including Behavioral, Gestalt, Psychoanalytic and Relational Therapies. Schema Therapy argues that if individuals are abused or neglected as children, they may develop “maladaptive schemas”. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. Maladaptive schemas (known as schemas) can be defined as self-defeating emotional and cognitive patterns that begin in early childhood and continue throughout life. The goal of Schema Therapy is to eliminate the schema(s) by recognizing and challenging it and replacing it with more effective behaviors.

Schema Recognition

The first step in Schema Therapy is schema recognition or evaluating if an individual has any schemas. This can be done in several ways. First, individuals can read “Reinventing Your Life” by Jeffrey Young PhD and complete a brief set of questions on each schema listed throughout the book. This will illustrate both the existence and intensity of the schema. Second, in a therapeutic setting, an individual can complete a questionnaire which will identify the presence of certain schemas as well as their intensity. After a schema is recognized, the person can read schema descriptions, provided in the book or by the therapist. These descriptions can bring clarity and definition to emotional and relational hardship.

Polyvagal Theory and Psychotherapy

Polyvagal Theory was developed by Dr Stephen Porges PhD in 1994 as a method of understanding the relationship between individual heart rate variability and the Autonomic Nervous System. In recent years, the field of psychotherapy has had great interest in Polyvagal Theory as Polyvagal Theory has been able to provide neurophysiological explanations for several of the experiences described by individuals who have experienced trauma. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Disorder. This interest has led to numerous psychotherapeutic exercises assisting people with self-regulation, relational management and an articulation of the subjective experiences of danger and safety.

Polyvagal Theory and The Perception of Safety and Danger

Polyvagal Theory assumes, of course, that there are both dangerous and safe situations, but that people will have emotional, physical, cognitive and relational hardship if their perception of those safe or dangerous situations is inaccurate. It is important that people approach relationships and daily tasks with an accurate assessment of both the safety and the danger involved in those settings. In some cases, people who have a history of abuse, neglect or trauma will misread situations and inaccurately see a situation either as more dangerous than it is or safer than it is. Exaggerating danger might be shown by being easily offended, having difficulty accepting criticism or having irrational fears like phobias, generalized anxiety or panic. Also, people might misread situations as being safer than what they are. This happens when people stay in abusive relationships, voluntarily frequent threatening environments or allow verbal, physical or emotional boundary violations.

The Three States of the Autonomic Nervous System

Polyvagal Theory argues that people are regularly moving through three different autonomic states throughout their daily lives. This movement is caused by reactions to life events and the attempt to survive emotionally or physically, to restore oneself, or connect with others. These three states are the ventral vagal state (safe and social), the sympathetic state (mobilized for fight or flight) and the dorsal vagal state (immobilized and collapsed). Each state is managed by a specific set of nerves and each state serves a specific set of biological and social needs.

1.Ventral Vagal State – The ventral vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves in the upper part of the body connecting the brain to the heart, neck, face, mouth, eyes and ears. The ventral vagal state, also known as the “safe and social state”, is responsible for detecting, accepting, evaluating and reciprocating states of social safety. Also, it regulates the other two defensive autonomic states listed below. Being in a safe situation and then actively looking for and seeing safety will activate the ventral vagal state. The activation of the ventral vagal state facilitates self-regulation and eliminates unnecessary defensive thoughts, feelings and behaviors. In a relational sense, people in the ventral vagal state feel safe which leads to a sense of connection, trust, comfort, restoration and happiness. It is best that individuals solve relational problem(s) in the ventral vagal state. If they do not, they will switch involuntarily to the sympathetic state and attempt to solve their problem(s).

2.The Sympathetic State – The sympathetic state is a physical, emotional and cognitive experience facilitated by a set of nerves coming from the center of the spine and connecting to various organs. This set of nerves alerts and activates people when they detect danger and prepares the body to act. The sympathetic state, also known as “mobilized for fight or flight state”, moves through various levels of intensity measured by both the level of fear experienced and the related amount of physical and mental energy that is given to deal with the event. When someone is in this state, they are pulled out of the ventral vagal state, lose the benefits of feeling safe and begin to disconnect from people. Relationally it is a state of conflict and fear. Clinically the sympathetic state parallels anxiety, anger, posttraumatic stress, relational discord, obsessions and cognitive distortions leading to self-questioning. Physical symptoms include headaches, high blood pressure, heart disease and joint pain. If the problem or event is not solved in the sympathetic state, the person will then involuntarily activate the next state which is the dorsal vagal state.

3.The Dorsal Vagal State – The dorsal vagal state is a physical, emotional and cognitive experience facilitated by a set of nerves that extend from the Vegas Nerve to the organs located below the diaphragm. When the dorsal vagal state, also known as “the immobilized and collapsed state”, is activated an individual will shut down. Often this will follow the overwhelm of energy and fear caused by the sympathetic state. This overwhelm can be physical, emotional, or cognitive. The body will grow cold, weak, slow and lacking in energy. Socially the individual feels disconnected from others. Clinically this state triggers symptoms of depression, dissociation, performance anxiety, paranoia and cognitive distortions leading to challenged self-concept. Physical symptoms consist of low blood pressure, immune system disorders, stomach problems, obesity, fibromyalgia and irritable bowel syndrome.

The Vagal Brake and The Window of Tolerance

The vagal brake is a term created by Stephen Porges PhD to describe the process of stopping physiological reactivity to life events that lead either to the sympathetic or dorsal vagal defensive state. It is important that individuals accurately read the level of both safety and danger in life events to not overuse a defensive state position. People who have a history of trauma and nonacute trauma found in PTSD and Complex PTDS have histories where it was necessary to maintain states of high defense. However, in different life settings, or in adulthood, the level of threat generally is less and the need for a defensive state is less. An unnecessary overactivation of a defense state will create emotional, physical and cognitive overwhelm and a relational management style that is ineffective. The activation of the vagal brake, at the right time, will ease a defense reaction and leave the individual in a position to self-regulate and return to a ventral vagal state of safety. The development of an accurate vagal brake response can be done by polyvagal exercises as well as by the reprocessing of traumatic memory through the EMDR protocol. These interventions are central to the treatment of Complex PTDS.

The window of tolerance is a clinical term used to describe the parameters of one’s state of non-defense. It is necessary to recognize one’s own window of tolerance since it will determine what are manageable tasks, thoughts, memories, relationships and topics in and out of therapy. Thus, the awareness of one’s window of tolerance will assist in self-regulation and with creating the most likely positive results from the use of internal resources and therapeutic suggestions. A goal of treatment is for the client’s window of tolerance to increase over time so one can actively problem solve needed topics of change while maintaining a ventral vagal state position. As this relates to the vagal brake, the window of tolerance will expand as one can more quickly use their vagal brake to inhibit defense response, maintain a state of safety and “tolerate” life events. The window of tolerance is expanded by Polyvagal exercises and EMDR since both will decrease the automatic activations of unnecessary defensive states.

What is Coregulation?

Coregulation is the moment to moment act of managing a relationship to self-regulate. Coregulation is based on attachment theory which argues that the regulation of a child doesn’t simply come from the “good enough” behavior of the parent but is a process by which the child feels calm in reaction to the parent’s self-regulation which is in response to the child’s initial signs of self-soothing. In relationships, coregulation is the processes of keeping a relationship safe in an effort of bring oneself to state of regulation. In Polyvagal terms, the individual has an awareness of both their window of tolerance and sensitivity to their vagal brake and will use methods to manage the relationship to remain in or return to a ventral vagal state. This often requires the need to defuse the defensive states of sympathetic defense and dorsal vagal defense that occur both in oneself, but also in others. Often individuals with a history of abuse or neglect leading to PTSD or Complex PTSD have a history of strained and conflictual relationships and do not have a background of guided experience leading to self-regulation through relational management.

The Polyvagal Hybrid States

Polyvagal Theory argues that the three states of the autonomic nervous system listed above, the ventral vagal, sympathetic, and dorsal vagal states, are not mutually exclusive nor antagonistic but rather comingle and coexist to create a full spectrum of cognitive, relational, behavioral and emotional experiences. These coactivated states are called “hybrid states” states. There are two hybrid states which are the combined ventral vagal and sympathetic state and the combined ventral vagal and dorsal vagal state. Polyvagal hybrid states represent how polyvagal awareness and creative application can facilitate the process of using internal client resources for self-regulation and solving problems. For more information on this topic and useful exercises see “Polyvagal Hybrid States and Complex Posttraumatic Stress Disorder” by author.

The Advantages of Combining EMDR and Schema Therapy

As stated, EMDR is a powerful and effective intervention for eliminating the negative impacts of traumatic memory. Clients with a history of multiple traumas leading to complex Posttraumatic Stress Disorder often exhibit complications beyond PTSD symptoms which require added interventions to the EMDR Protocol. Schema Therapy assessments allow a client and therapist to categorize the effects of trauma into various schemas. This categorization facilitates memory identification needed in EMDR treatment as it directs the client and therapist to specific causal events. Also, Schema Therapy has several exercises which are like the EMDR Protocol. These similarities allow for daily exercises which strengthen progress made through EMDR work. See specific advantages listed below.

1.Decreased Dissociation – Combining EMDR and Schema Therapy creates a solution to the problem of seeing and experiencing dissociation as an uncontrolled state of psychological dysfunction by reframing dissociation as a reasonable movable state created by triggers which can be controlled through EMDR reprocessing. Following the identification of individual schema reactions, clients can identify the triggers to these reactions and use EMDR to reprocess triggers.

2.Decreased Self-Abuse – Combining EMDR and Schema Therapy creates a solution to the problem of self-abuse by recognizing self-abusive behavior a reaction to a dysfunctional schema “Punitive Parent Mode”. After a client recognizes the existence of this mode, they can track its development and triggers and reprocess them using the standard EMDR protocol.

3.Managed Addiction – Combining EMDR and Schema Therapy creates a solution to the problem of addiction by recognizing addiction as a schema coping mechanism of avoidance. Clients can identify schemas that trigger the desire to avoid and EMDR can be used to both reprocess the negative memories contributing to the schema and to reprocesses the “pleasure state” using the EMDR Addiction Protocol.

4.Increased Personal Narrative – Combining EMDR and Schema Therapy creates a solution to the problem of flashbacks by decreasing negative emotional trigger arousal while assisting the client to use the descriptive language of schema identification rather than visualizations to deal with trauma. After a client identifies their individual schema reactions, they can use EMDR on the traumatic memories that created PTSD symptoms and schemas. Following, the client can use schema descriptions to accurately verbalize the schema’s development.

5.Productive Imagery – Combining EMDR and Schema Therapy creates a solution to the problem of daily of self-management struggles by providing effective visualizations to use during EMDR reprocessing as well as outside of therapy sessions. The cognitive exercises of Schema Therapy are like those used in EMDR protocols. Following successful EMDR sessions, clients can continue to apply their positive changes to daily events through Schema exercises.

6.Effective Memory Targets – Combining EMDR and Schema Therapy creates a solution to the problem of memory avoidance by quickly and accurately providing EMDR target memories for reprocessing that will bring the greatest amount of change. Following the recognition of individual schemas, clients can use this information to explain their development. These developmental topics can be used as EMDR memory targets for effective change.

7.Ending Self-Blame – Combining EMDR and Schema Therapy creates a solution to the problem of self-blame by creating workable reframes of personal responsibility and self-forgiveness through recognition of the schema’s necessary and reasonable beginnings. EMDR reprocessing will eliminate the cognitive hardship of irrational self-blame. Schema Therapy exercises can assist clients in using these changes in daily struggles with self-blame.

8.Decreeased Overwhelm – Combining EMDR and Schema Therapy creates a solution to the problem of emotional overwhelm caused by triggers. Solutions are facilitated by EMDR reprocessing which decreases emotional reactivity and with Schema Therapy which provides daily exercises to elicit strength and solution.

The Advantages of Combining EMDR and Polyvagal Therapy

Polyvagal Therapy is based on neurobiological theory and allows for a unique and powerful articulation of the impacts of safety and danger. This is of importance for someone who has a history of repeated trauma since dangerous or threatening situations may cause over or under reactivity in these clients. Increased recognition of states of defense and safety facilities one’s ability to self-regulate both when alone and when in contact with another. EMDR reprocessing of traumatic memory makes this process easier and more feasible since the reprocessing of memory decreases emotional reactivity and cognitive decline. See specific advantages listed below.

1.Decreased Dissociation – Combining EMDR and Polyvagal Therapy creates a solution to the problem of dissociation by reframing and treating dissociation as an expected, involuntary reaction to traumatic triggers that can be changed through decreasing defense through EMDR reprocessing. After a client identifies the subjective feelings of the various Polyvagal defensive states, they can use this awareness to identify triggers leading to defense and dissociation. EMDR can then be used to decrease those triggers.

2.Increased Personal Narrative – Combining EMDR and Polyvagal Therapy creates a solution to the problem of flashback imagery by helping clients use language and trigger identification instead of visualizations to deal with traumatic memory. After a client increases their awareness of shifting through Polyvagal states of defense, they can verbally explain this reaction as well as its development.

3.Ending Hyperarousal – Combining EMDR and Polyvagal Therapy creates a solution to the problem of hyperarousal found in Posttraumatic Stress Disorder by assisting the client in recognizing triggers that activate defensive states leading to hyperarousal. Clients can increase awareness of hyperarousal by doing “Polyvagal Mapping” and identifying triggers of arousal and the activation of safety states. EMDR can be used to reprocess triggers as well as initial memories associated with triggers.

4.Increased Self-Awareness – Combining EMDR and Polyvagal Therapy creates a solution to the problem of trigger vulnerability by allowing the client to track states of defense and safety and provides the capacity to shift the state of defense at will. After a client identifies their movement between Polyvagal defense states they can notice environmental triggers causing the shifts and reprocesses triggers using EMDR.

5.Danger Management – Combining EMDR and Polyvagal Therapy creates a solution to the problem of psychological numbing by recognizing and problem solving social and situational times of danger. This can be done by actively noticing and tracking subjective experiences of safe and dangerous situations through Polyvagal exercises. Clients can use this awareness to problem solve change and use EMDR to eliminate triggers which might cause an irrational perception of danger.

6.Relational Management – Combining EMDR and Polyvagal Therapy creates a solution to the problem of behavioral reactivity to relational conflict by maintaining self-regulation through the management of conflict levels in relationships. This can be done by using state defense awareness to plan necessary times of relational change and management. Change can be facilitated by relational management strategies such as boundary management, the use of validation and demands for reciprocity.

7.Proper Physical and Emotional Activation – Combining EMDR and Polyvagal Therapy creates a solution to the relational problem of over and under activation of defensive states by assisting clients in learning manageable levels of safety and energy. This change can be facilitated by tracking the subjective experience of defensive state shifts, tracking the levels of safety and energy in each state and problem solving ways to decrease danger and energy levels through rules, cooperation, game metaphors and using EMDR positive interjection imagery.

Resources

The Pocket Guide to Polyvagal Theory: The Transformative Power of Feeling Safe by Stephen Porges (2017)

The Polyvagal Theory in Therapy by Deb Dana (2018)

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment Communication and Self-Regulation by Stephen Porges PhD (2011)

Traumatic Stress: The Effects of Overwhelming Experience on The Mind, Body and Societ y by Bessel Vander Klok, Alexander Mc Farlane, and Lars Weisaeth (2007)

Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience for Self-Regulation and Resilience by Sullivan, Erb, Schmalzi, Moonaz, Tylor, and Porges from Frontiers in Human Neuroscience February 2018.

Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures by Francine Shapiro PhD (2001)

EMDR as an Integrative Psychotherapy Approach: Experts from Diverse Orientations Explore the Paradigm Prism Edited by Francine Shapiro PhD (2002)

Getting Past Your Past: Take Control of Your Life with Self Help Techniques from EMDR Therapy by Francine Shapiro PhD (2012)  

Schema Therapy – A Practitioner’s Guide by Jeffrey Young PhD, Janet Klosko PhD and Marjorie Weishaar PhD (2003)

Reinventing Your Life by Jeffrey Young PhD and Janet Klosko PhD (1993)

Schema Therapy by Eshkol Rafaeli, David Bernstein and Jeffrey Young (2011)

Negative Thinking Patterns: A Schema Therapy Self – Help and Support Book by Gitta Jacob, Hannie Van Genderen and Laura Seebauer

Cognitive Therapy – Basic and Beyond by Judith Beck (1995)

Cognitive Therapy for Personality Disorders – A Schema Focused Approach by Jeffry Young (1999)

Cognitive Therapy of Personality Disorders by Aaron Beck, Arthur Freeman and Denise Davis (2004)