By Jeff Dwarshuis LMSW ACSW
What is Eye Movement Desensitization and Reprocessing?
Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1989 as a method of treatment for Posttraumatic Stress Disorder (PTSD).
Over time, researchers and therapists expanded the use of EMDR to include several other mental health diagnoses besides PTSD. It was discovered that not only did EMDR eliminate the impacts of acute memories leading to PTSD, but it also eliminated the negative impacts and irrational self-perceptions caused by nonacute memories and bad experiences in general. This is particularity true with individuals who have a history of repeated abuse or repeated traumatic incidences causing Complex Posttraumatic Stress Disorder (Complex PTSD).
Due to the many complexities found in the assessment and treatment of Complex PTSD, EMDR treatment required added interventions and assessment tools. These tools can be found in Schema Therapy. This article explains how EMDR and Schema Therapy can be combined for increased speed and effectiveness for treatment of individuals suffering from Complex PTSD.
EMDR and Neurobiology
EMDR is a treatment method used to quickly and effectively eliminate the negative impacts of traumatic memory. 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 PTSD. 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, challenging and replacing it with more effective behaviors through a series of exercises as listed below.
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.
Testing Schema Validity
After an individual knows about their schemas and understands the description of the schema, they can begin to challenge the schema by testing its validity. Schemas, in general, are inaccurate negative representations of the person and can reasonably be disproven through evidence. However, people often will identify with their schemas and see a schema as a representation of who they are. Therefore, creating a list describing how the individual sees themselves relating to the negative qualities of the schema can easily be done. However, creating a list of evidence about how the person is different from the schema, can be difficult.
Testing the validity of the schema can be done by first listing all evidence from the past and present to support the reality of the schema. There should be a general consideration of these questions. How does this description of the schema apply to me? How do I act it out? How might others see me as acting out this schema? Following this, the person should make a list of all the evidence that refutes the schema. The person can do this by evaluating their realistic accomplishments, intentions and capacity shown throughout their life that are different from the schema.
After testing the schema’s validity, the individual should challenge the reality of the schema by reframing it. This can be done by taking each piece of evidence that supports the schema and attributing it to another more rational cause. For example, instead of thinking “I am unlovable” the person might instead say “I was not given enough attention and was taught to think I was unlovable” or instead of thinking “I am a failure” the person might list or say “I was not given enough opportunity to recognize my potential.” Typically, these causes have to do with the person’s childhood family, especially the parents who had control over the person’s life and events that may have contributed to the schema development. To complete this exercise, it is important to not personalize the schema but to rationally consider the influences of its development.
Identifying the Advantages and Disadvantages of the Coping Behaviors
Schemas are themselves emotional and cognitive patterns and each person has a set of behaviors that are used to deal with, display, represent or ignore the schema(s). These behaviors are called “coping responses”. Coping responses generally fall into the behavioral categories of avoiding, surrendering or overcompensating for the schema. One can think about and then list these coping responses then evaluate both the pros and cons of what the coping responses do or don’t do. It is important to recognize that these behaviors may have been adaptive as a child and as an adult might help to decrease emotional reactivity. However, the behavior generally does not create effective solutions for adult problems.
Schema Problem Solving
With the initial exercises completed, one is a better position to coordinate and use the learning on a day to day basis through Schema Problem Solving. The goal is to use some of the understandings and growing awareness from the previous exercises and apply them to daily relational and emotional challenges perpetuated by the schema(s).
Completing the framework sentence below will allow for gradual change and the elimination of schemas. The goal is to get to the point of being able to do the exercise automatically in real life settings.
I feel (emotion) because of (causal event). This event has triggered my (schema) and has caused me to want to do (coping behavior). Although my schema causes me to believe that I am (negative self-belief) I am (rational positive self-belief) as evidenced by (supporting evidence). Although I would like to do (negative behavior) instead I will do (positive behavior).
Combining EMDR and Schema Therapy for Complex Posttraumatic Stress Disorder
Both EMDR and Schema Therapy are highly effective treatment methods for the treatment of Complex PTSD. Combining these methods leads to a faster and more effective level of change by using their relative strengths. EMDR is fast and highly effective in eliminating the negative impacts of negative memories. Additionally, the changes are permanent. However, individuals with Complex PTSD present with complicated histories and a set of symptoms that do not allow the therapist using the EMDR Protocol to accurately assess negative contributing memories leading to Complex PTSD symptoms. Schema Therapy provides a plausible explanation for the development of Complex PTSD since it is based on understanding the impacts of unmet childhood needs and its related negative experience and memory. The EMDR therapist can use this relationship of events to create a list of treatment target memories that are the most effective for client change.
Below is a list of the five treatment steps that are needed to combine EMDR and Schema Therapy safely and effectively.
1.Create a safe environment for the client – Creating a safe environment for the client involves using practical steps at the beginning of treatment to protect the client from unpredictability, overwhelm and danger.
First, EMDR can be difficult to understand and most clients entering treatment do not know about it. Because of this, the therapist should decrease the sense of unpredictability one might experience during EMDR by explaining its preparation stage, procedure, successes and structure. Also, clients should understand the possibility of increased recall of negative memories that often come during EMDR reprocessing. The therapist should explain ways to successfully manage these possible reactions. As the therapist better understands the client’s schemas, he or she will be able to better predict possible negative responses during EMDR reprocessing.
Second, therapists need to watch for patterns of client dissociation and substance abuse. Dissociative reactions can intensify if the client is flooded with too much negative memory during EMDR reprocessing. This can have a negative impact on client safety if the client is having difficulty grounding themselves during treatment. Also, substance abuse will confuse the process of treatment causing both the therapist and client to be unsure of the impacts of treatment. Additionally, the use of substances can increase the likelihood of high-risk behavior outside of sessions. The recognition of client schemas can assist the therapist in understanding the reasons the client abuses substances and therapy can prioritize to target those reasons. Additionally, schema recognition can assist the therapist in measuring the possible intensity of memory reactions as well as triggers leading to dissociation. This recognition can assist the client and therapist in creating a self-monitoring plan to decrease risk.
Third, it is important to maintain a focus on established EMDR safety procedures. The therapist should generously use “the safe place” procedure to assist clients in recognizing their capacity to both see and maintain safety. Also, therapists and clients should consistently consider the client’s “window of tolerance” by keeping EMDR eye sets brief if necessary and allowing the client to have some control over the order of the memories reprocessed. Completing the schema exercise of “identifying the advantages and disadvantages of coping behaviors” should assist the client and therapist in assessing the client’s window of tolerance since it illustrates patterns of client defense behaviors.
2. Use EMDR to reprocesses the memories creating PTSD symptoms first – Complex PTSD can consist of both major traumatic memories as well as memories of repetitive nonacute occurrences. Following the initial assessment, it should be determined if the client has symptoms of PTSD. If it is the case, those memories leading to PTDS should be reprocessed first using EMDR. This is done for two reasons. First, eliminating the negative impacts of traumatic memory leading to PTDS will bring the most amount of relief to the client in the fastest way. This relief will then allow for better functioning in and out of sessions as well as more ego strength to manage the treatment process. Second, PTSD generates a specific set of symptoms that are debilitating and will interfere with reprocessing memories that are nonacute. Eliminating these symptoms will assist the client in better listing and reprocessing nonacute memories found in Complex PTSD.
3. Use the schema assessment to develop a list of nonacute memories leading to Complex PTSD – The impacts of repetitive abuse in a relationship or in childhood will have a profound negative and confusing impact on a person’s cognitive, social, and emotional life. Schema Therapy is based on the idea that people will react in specific ways if their childhood needs are not met. Therefore, after a schema assessment is completed, the client and therapist can evaluate the origins of the schema(s). As this is done, an EMDR target memory list can be created which represents the negative, nonacute events of repetitive trauma and loss leading to schema development. Completing this process will decrease or eliminate the schema as well as the symptoms of Complex PTSD.
4. Determine if a schema is unconditional or conditional when planning the order of EMDR memory completion. – According to schema theory, an unconditional schema is a direct result of not getting one’s needs met in childhood. A conditional schema is often (but not always) the result of an individual reacting to or attempting to manage an unconditional schema. Thus, EMDR target memories should first be applied to the events leading to the development of an unconditional schema since the reprocessing of these memories could also lessen or eliminate the conditional schema reinforcing it. See the list of unconditional and conditional schemas below and use them in EMDR treatment planning.
Unconditional Schemas –The list of unconditional schemas is – abandonment/instability, mistrust/abuse, emotional deprivation, defectiveness, social isolation, dependence/incompetence, vulnerability to harm or illness, enmeshment/undeveloped self, failure, negativity/pessimism, punitiveness, entitlement/grandiosity, insufficient self-control/self-discipline.
Conditional Schemas – The list of conditional schemas is – subjugation, self-sacrifice, approval-seeking/recognition- seeking, emotional inhibition, unrelenting standards/hypercriticalness.
5. Reframe “too much of a good thing” schemas to highlight loss and hardship. – Most all schemas are caused by not getting one’s childhood needs met through loss, abuse or negligence. However, in some situations a schema is developed by a child having “too much of a good thing”. This is shown, for example, in the dependence/incompetence schema where a child is rescued from the normal expectations of life. Another example is the entitlement/grandiosity schema which comes from not receiving appropriate limitations. For the effective use of EMDR, the schema causes in both cases should be reframed to illustrate childhood loss or hardship from the events creating the schema. For example, with the dependency/incompetence schema, instead of focusing on the “ease” of being rescued, EMDR target memories might be based on recollections of childhood fear when having to confront typical challenges, Also, they could be recent memories of resentment for being rescued as an adult or child. Concerning the entitlement/grandiosity schema, instead of focusing on the “joy” of not having limitations, the schema could be reframed to highlight memories of social hardship resulting from the negative actions of entitlement or it could highlight feelings of defectiveness leading to the overcompensation seen in the entitlement/grandiosity schema.
6. Complete EMDR reprocessing before schema exercises – Focusing first on the reprocessing in EMDR should be done for several reasons. First, EMDR changes negative cognitions, physical reactions, emotions and related behaviors leading to PTSD and Complex PTSD quickly and effectively. Because the client will be less triggered and more emotionally regulated, this change should assist the client in more effectively being able to do the schema exercises. Also, PTDS and Complex PTSD have a neurobiological impact on the brain that impairs the client’s ability to understand, describe and hold a personal narrative. EMDR Therapy should bring relief, symptom reduction and personal focus. However, successful EMDR does not have a structural process designed specifically to assist with individual narrative. Schema Therapy allows for an understanding of the personal impacts of unmet childhood needs, the impacts on mood, identity, thinking, feeling, relationships and behavior. These are necessary understandings for personal narrative. Additionally, schema exercises assist the client in distancing themselves from the schema’s power and its impacts, thus allowing them to understand and discuss the reality of their past and hope for their future more freely.
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)