Trauma derives from the Greek word traumatikos, meaning wound. In a broad sense, trauma simply refers to human wounding, be it physical, emotional, verbal, sexual, spiritual, or in any other domain of human existence. When professionals discuss issues of trauma, it is rare to hear the same definition offered twice. The helping professions have done so much over the years to make the definition technical and clinical, yet many find it useful to keep the conceptualization of trauma as simple as possible: trauma refers to human wounding that has not yet been healed or otherwise addressed.

This meaning, although useful as a technical operations definition, comes with limitations. First, for many survivors, trauma is not just a one-time event, it is a series of experiences, like growing up in poverty or as part of an oppressed group, with too many "events" to even name. Second, trauma manifests in different ways for different people contingent upon a variety of contextual factors. Thus, attempting to condense it into a single definition often seems forced and sterile. Bessel van der Kolk, MD, refrains from giving a standardized, set definition of trauma in his book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. He does offer that [2]:

Trauma, by definition, is unbearable and intolerable. Most rape victims, combat soldiers, and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, trying to act as if nothing happened, and move on. It takes a tremendous amount of energy to keep functioning while carrying the memory of terror and the shame of utter weakness and vulnerability.

There is a clear link between unhealed trauma and symptoms manifesting in the body. Dr. Shapiro began her work with mind-body medicine connections as far back as the late 1970s, as a result of her own experiences with cancer recovery. As Dr. Shapiro explains in her story of how her serendipitous discovery in a park one day led her to develop what would become EMDR, she was always experimenting on herself. In a 2011 documentary, Shapiro explained that as she was walking, she noticed that some distressing thoughts, the types of thoughts that you would normally have to bring up and consciously engage, began to disappear. Shapiro, in the spirit of mindfulness, kept paying attention, and when a type of disturbing thought came up she noticed that her eyes started moving back and forth. After her series of spontaneous eye movements, she recalled the thought and noticed that it did not have the same charge as before. This ushered in a process of experimenting on herself, her colleagues, and willing volunteers; what emerged were the initial procedures of eye movement desensitization, or EMD [3,4].

Shapiro's initial working hypothesis was that she stumbled into a simple desensitization technique, something that essentially tapped into rapid eye movement (REM) sleep in an awakened state. The Journal of Traumatic Stress Studies published her first formal research, a randomized controlled study, in 1989 [5]. Shortly after that publication, she added the concept of reprocessing to create EMDR. As she continued to develop her work, she noticed that the procedures elicited free associations that allowed people to process memories or other remnants of painful experiences that were not processed at the time of the memory. Hence the use of the term reprocessing instead of just processing. In 1990, a visually impaired individual presented for treatment and thus could not easily track eye movements. At that point, many in the field had already begun referring to EMDR as the "finger-waving technique" (usually in a pejorative sense) to reference the procedure used to guide clients to move their eyes back and forth. Although the eye movements happened spontaneously in her initial walk of discovery, she induced them purposefully in others by moving her hand across a person's plane of vision. This blind individual could not easily track eye movements, so Shapiro and those close to her began experimenting with alternative forms of creating bilateral stimulation. A device was created to generate audio tones that alternated back and forth, and they also discovered that tapping alternately on the individual's legs could produce similar effects. Although eye movements remain the most researched mode for creating the bilateral stimulation, actual eye movements are not required to do EMDR. Indeed, many individuals who present for treatment prefer the audio tones or the various forms of tactile stimulation to fully engage in the process. This will be discussed in detail later in this course.

Shapiro's initial working hypothesis was that she stumbled into a simple desensitization technique, something that essentially tapped into rapid eye movement (REM) sleep in an awakened state. The Journal of Traumatic Stress Studies published her first formal research, a randomized controlled study, in 1989 [5]. Shortly after that publication, she added the concept of reprocessing to create EMDR. As she continued to develop her work, she noticed that the procedures elicited free associations that allowed people to process memories or other remnants of painful experiences that were not processed at the time of the memory. Hence the use of the term reprocessing instead of just processing. In 1990, a visually impaired individual presented for treatment and thus could not easily track eye movements. At that point, many in the field had already begun referring to EMDR as the "finger-waving technique" (usually in a pejorative sense) to reference the procedure used to guide clients to move their eyes back and forth. Although the eye movements happened spontaneously in her initial walk of discovery, she induced them purposefully in others by moving her hand across a person's plane of vision. This blind individual could not easily track eye movements, so Shapiro and those close to her began experimenting with alternative forms of creating bilateral stimulation. A device was created to generate audio tones that alternated back and forth, and they also discovered that tapping alternately on the individual's legs could produce similar effects. Although eye movements remain the most researched mode for creating the bilateral stimulation, actual eye movements are not required to do EMDR. Indeed, many individuals who present for treatment prefer the audio tones or the various forms of tactile stimulation to fully engage in the process. This will be discussed in detail later in this course.

EMD, and later EMDR, was initially met with a great deal of skepticism by the psychotherapeutic professions in general. Shapiro hypothesizes that many academics criticized what she was doing because clinicians were so enthusiastic about it. As clinicians, and later those with academic credibility, began to discover how the approach seemed to offer an answer to healing traumas where traditional talk methods had been failing, EMDR began to attract more believers. Although skepticism about EMDR remains to this day, it is becoming increasingly more mainstream within the helping professions due to the growing body of research supporting its efficacy. In discussing preferred treatments for post-traumatic stress disorder (PTSD) in the modern era, EMDR is typically listed alongside the more traditional approaches, such as cognitive-behavioral therapy (CBT) and prolonged exposure. In 2013, the World Health Organization (WHO) guidelines for trauma care identified trauma-focused CBT and EMDR therapy as the only psychotherapies recommended for children, adolescents, and adults with PTSD [6]. Before 2016, EMDR appeared on the National Registry of Evidence-Based Programs and Practices (NREPP), a list published by the Substance Abuse and Mental Health Services Administration (SAMHSA) following rigorous research and review. The NREPP was discontinued in 2018 and was replaced by the Evidence-Based Practices Resource Center [7,8,9]. A plethora of clinical bodies worldwide, including the American Psychiatric Association, the American Psychological Association, and the International Society for Traumatic Stress Studies, have listed EMDR on their best practices or highly efficacious lists in the treatment of PTSD since the early 2000s [10].

The existence of a model that distinguishes EMDR from other forms of psychotherapy is one of the reasons that EMDR merits distinction as a type of therapy. The model Shapiro developed was originally called the accelerated information processing model, now referred to as the adaptive information processing (AIP) model. In a 2014 communication to the members of the EMDR International Association (EMDRIA), Shapiro made the correlation that CBT, psychodynamic therapy, and EMDR therapy have unique foundations of pathology and approaches to treatment (Table 1) [11].

The AIP is a model, not a theory, although upon reviewing earlier information processing models published in the 1950s and 1960s, one can see clear roots in behaviorist theory. Originally published in the second edition of Shapiro's textbook Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures, the AIP model has gone through various permutations in semantics and points of emphases. The basic hypotheses of the AIP model, as published by the EMDRIA, are [12]:

The AIP is a model, not a theory, although upon reviewing earlier information processing models published in the 1950s and 1960s, one can see clear roots in behaviorist theory. Originally published in the second edition of Shapiro's textbook Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures, the AIP model has gone through various permutations in semantics and points of emphases. The basic hypotheses of the AIP model, as published by the EMDRIA, are [12]:

The AIP model recognizes that humans learn things, either about themselves or their surrounding world, as a result of traumatic experience. When trauma remains unprocessed, so do these trauma-charged pieces of information, and there is an evitable effect on output (e.g., how we feel, how we think, how we act). For example, if the traumatic experience(s) leaves a cognitive imprint of "I'm not good enough," this is likely to manifest in other areas of human experience. Consider how the belief "I'm not good enough" might play out emotionally, somatically, or even spiritually. A solid course of reprocessing (such as with EMDR therapy) allows the maladaptively stored belief ("I'm not good enough") to shift to a more positive, natural opposite ("I am good enough"). It is not enough for the belief to be confronted. Many patients who have had therapy before know what their negative beliefs are and may even know what they should believe, but the shift has not internalized [14].

For people who continue to manifest distress at an emotional, somatic, and/or spiritual level, the processing work should incorporate these other channels. As explained in the AIP model, unprocessed components or manifestations of memory can be stored in a variety of states—visual, cognitive, sonic, emotional, somatic, existential, or a combination [15]. These states can transform during processing to an adaptive resolution. Information processing transmutes information through all accessed channels of memory. For Shapiro, the modality of choice is EMDR therapy, but there are many other ways to process "stuck" information. The key is determining where a person is still "stuck" and accessing that channel. For many clients, the cognitive work has been done, but the emotional, somatic, or existential work still needs to be completed [14].

Shapiro's introduction of the small-t concept (now adverse life experiences not meeting the criteria for PTSD) was a revolutionary step forward in how trauma is conceptualized. It is now accepted that trauma does not have to qualify for PTSD or fit DSM Criterion A for it to be life-changing or even clinically significant. Shapiro defined these adverse life experiences as upsetting life events that may prove difficult to heal and integrate into one's larger experience [15]. This can include a variety of experiences, including racial or ethnic discrimination, verbal abuse, bullying, divorce, a medical crisis, spiritual abuse, mind control, emotional blackmail, or loss of a pet. While these traumas may not have the life-threatening connotation of Criterion A, they can be life-altering. If a person is not able to process or make sense of an experience due to a variety of reasons, these traumas can be just as damaging [14].

Several mental health conditions may be explained or exacerbated by unresolved adverse life experiences that do not meet the criteria for PTSD diagnosis. The links between major depressive disorders, persistent depressive disorder, and various anxiety disorders and earlier, unprocessed life experiences are apparent. Even personality disorders, long regarded as difficult to treat, may be better conceptualized in light of the pervasive impact of unresolved trauma on childhood development. In the book The Angry Heart: Overcoming Borderline and Addictive Disorders, Joseph Santoro suggests that borderline personality disorder is a manifestation of complex PTSD [17]. Many of the Cluster B personality disorders develop in individuals who experienced profound trauma in childhood, usually a combination of Criterion A traumas and adverse life experiences not meeting this standard [14].

Before exploring how EMDR is believed to work, it is important to examine how bilateral stimulation, in general, can provide healing to the brain. There are countless examples of how bilateral stimulation is accessed in nature for healing or other positive mechanisms of action. Cultures around the globe have used bilateral processes, specifically drumming and dancing, for millennia. Bilateral stimulation refers to any alternating, back-and-forth movement. As discussed, Shapiro initially developed EMDR with bilateral eye movements following her serendipitous discovery, although she soon discovered that alternating taps on the legs, hands, or with the feet, or bilateral audio tones could produce a similar effect. Many believe that EMDR accesses a natural healing mechanism (i.e., bilateral stimulation) that exists within the brain.

There is evidence in world literature, history, and anthropology indicating that others before Shapiro noticed the effects of bilateral stimulation, especially in cultures where dancing and drumming have been used for centuries as a way to release distress [18]. The books and poems of Native American author Sherman Alexie document how tribes have utilized dance, an activity of tactile bilateral stimulation, to cope with distress and heighten performance for centuries [19,20]. Kyra Gaunt documented how generations of African American girls have used clapping games, double-dutch jump rope, and other bilateral rhythmic activities to transition into adulthood [21]. Massage therapists also use bilateral stimulation quite a bit. For instance, a massage therapist will often alternate pressure from shoulder to shoulder or from hip to hip.

For survivors of trauma, the twists and tangles in the neuronetworks of the brain exist within the lower levels: the limbic brain and the brain stem. In working with trauma, the most basic concept to grasp, based on MacLean's triune brain model, is that the human brain is composed of three separate brains, each with its own separate functions and senses of time (e.g., the R-complex brain or brainstem, the limbic brain, and the cerebral brain or neocortex) [23]. While this model's use in terms of neuroanatomic evolution is considered by some to be outdated or oversimplified, it is useful as a purely explanatory tool. It describes the brain structure in a manner that is easy to understand and use as a conceptualization for treatment planning [23]:

The goal of successful trauma processing is to move or to connect the charged material from the limbic brain into a part of the brain that is more efficient in its long-term storage capacities. Most persons working in the psychologic professions have cared for a person in crisis at one point or another, often encouraging the person to "leave the past in the past" and "focus on the now." These interventions are often a default because so much of the training in the helping professions is cognitively focused, making it natural for those with traditional training to confront a person's negative thinking or attempt to persuade a person to see the positive spin in any negative situation. This approach is often unsuccessful, perhaps because it only engages the neocortex, not the entire brain. It is the limbic region of the brain, activated during the original trauma to help the person survive (through flight, fight, or freeze to submission), where the unprocessed material remains. Because the left frontal lobe is "turned off" (i.e., no blood flow) and the right frontal lobe is "abandoned" (i.e., awareness but lack of ability to process) during trauma, the individual is unable to link the limbic activation with frontal lobe functions during the experience. For a person in crisis or intense emotional distress, this process is playing out in real time and/or triggers from earlier, unprocessed experiences fuel the distress.

The bilateral processes involved with EMDR, whether they are eye movements, audio tones, or tactile motions, stimulate all three brains. In 2014, Pagani, Hogberg, Fernandez, and Siracusano published a comprehensive summary on all of the imaging and other biologic monitoring studies conducted on EMDR therapy to date [24]. EMDR-related neurobiologic changes were monitored by electroencephalogram (EEG) during therapy sessions and showed a shift of the maximal activation from emotional limbic to cortical cognitive brain regions—the first documented finding of its kind. Neuroimaging investigations of the effects of psychotherapies treating PTSD, including EMDR therapy, have reported findings consistent with modifications in cerebral blood flow on single photon emission computed tomography, in neuronal volume and density (on magnetic resonance imaging), and in brain electric signal on EEG. This validates the belief that the mechanisms of EMDR therapy promote positive shifts in where traumatic memories are stored in the brain. Some hypothesize that long-term positron emission tomography scan studies will reveal how EMDR works to heal the traumatized brain [24].

As discussed, Shapiro clearly views the present state of her discovery as a separate and distinct form of psychotherapy with a theoretical model as a guide and distinct phases. The EMDRIA maintains a standing definition of what constitutes EMDR that is very closely aligned with Shapiro's ideas. There are several different types of protocols required for therapy to be considered EMDR [15]. In the broadest sense, the protocol refers to Shapiro's eight-phase model of EMDR treatment: client history, preparation, assessment, desensitization, installation, body scan, closure, and re-evaluation.

The second phase, preparation, continues the development of the therapeutic alliance and integration of exercises designed for client stabilization. These can include, but are not limited to, guided visualizations like the "safe place" exercise. Generally, the more complex the client, the more preparation will be needed. The essential goal of this phase is to ready the client for deeper work on the traumatic memories/issues in phases three through six.

Desensitization consists of the application of bilateral stimulation sets after establishing the targeting sequence, designed to shift the traumatically stored material into more adaptive states. The time that one spends in desensitization (i.e., the number and length of bilateral stimulation sets) varies from client to client. Some clients can work through desensitization of a targeting sequence in one session, and others need several sessions. If desensitization is not completed within an allotted session, phase seven should be done before ending the appointment; the next session may be reopened with phase three.

The final phase, referred to as re-evaluation, involves continuing to monitor client progress after a successful processing through of a targeting sequence. Together, the client and clinician determine the other targets that may need to be addressed in order for the client to achieve his or her goals (in which case the EMDR therapy cycles back through phases three through seven). The re-evaluation process can also include the target of future templates or scenarios connected to the work done in previous phases. Re-evaluation, in theory, can continue indefinitely.

In evaluating the question of how EMDR works, it is a blend of model, methodology, and mechanism. There is a clear model associated with EMDR therapy (i.e., the AIP model), the methodology is the eight-phase protocol, and the mechanism is the impact of EMDR in the brain. There are clinicians who have taken deviations from the founder's word-for-word presentation, and for many, using these variations has been vital to using EMDR with clients.

Face 2 EMDR therapists, in addition to naturally making combinations with other theories and approaches to psychotherapy, are more likely to make modifications in the strict 11-step set up for phases three through six. These modifications can be made while still adhering to Shapiro's eight essential phases. For example, in her modified protocol, Parnell streamlined the set-up to be less clunky and significantly less numeric [18]. Table 3 is a hypothetical example of how EMDR phase three assessment may be set up using Parnell's classic modification.

Face 2 (and 3) EMDR therapists are more likely than Face 1 EMDR therapists to use other approaches to bilateral stimulation aside from eye movements. Although many Face 1 EMDR therapists will use the alternative forms of stimulation, many adhere to an "eye movements first" policy, because those are the most researched. Face 2 EMDR therapists often give clients the choice of what stimulation modality they prefer.

EMDR-informed interventions, Face 4, exist as separate and distinct modalities or approaches developed by clinicians who were originally trained in EMDR and have used EMDR-informed interventions or evolutions of original EMDR elements to create a new technique or approach to therapy. Perhaps the most popular new modality that has grown from experimentation within EMDR is brainspotting. In 2013, David Grand published his first book on the phenomenon, a technique derived from EMDR but with greater simplicity in implementation [30]. Other evolutions include the developmental needs meeting strategy (DNMS), developed by Shirley Jean Schmidt; induced after-death communication, by Alan Botkin; and progressive counting, developed by Ricky Greenwald [31,32]. Of these modalities, progressive counting has some empirical evidence suggesting it is at least as effective as EMDR. As Greenwald promotes, it is easier to learn and to teach than standard EMDR [32]. Although delving into a full exploration of each therapy is beyond the scope of this course, research on these therapies may help therapists determine if they may be useful in their practice, especially if traditional EMDR does not totally resonate.

A variety of clients can benefit from EMDR therapy or EMDR-related techniques, presuming that the clients are open to exploring the possibilities. EMDR has, to date, been officially validated for clients with PTSD. However, there are a plethora of case studies, field reports, and other research articles demonstrating the efficacy of EMDR for a variety of diagnoses. If one can appreciate the role of adverse life experiences in causing or exacerbating other diagnoses, using EMDR with other diagnoses is not a stretch. However, official empirical research is lagging, so clinical practice recommendations do not generally recommend it as an approach yet. Another issue is that PTSD and other trauma-related diagnoses exist comorbid with other major diagnoses, like substance use disorders and eating disorders. Although EMDR has not been officially validated as a treatment for addiction, many clinicians have incorporated EMDR into their work with addicts because of the high comorbidity between substance use disorders and trauma- and stressor-related disorders. As long as the client is sufficiently stabilized, using EMDR phase two approaches or stabilization approaches from other traditions, the trauma reprocessing phases of EMDR can be used with most willing clients.

In many cases, clients who have tried standard "talk therapy" approaches and have not met their goals are generally willing to attempt EMDR because it offers a different avenue. Each client can go through phases one and two, as long as the treating clinician is sensitive to the dynamics of trauma-sensitivity. For instance, in doing phase one work, the issue of taking a detailed trauma history should not be forced if clinical judgment suggests that relaying the entire history verbally would worsen the client's condition. Some general recommendations for determining whether a client is a candidate for EMDR include [29]:

In many cases, clients who have tried standard "talk therapy" approaches and have not met their goals are generally willing to attempt EMDR because it offers a different avenue. Each client can go through phases one and two, as long as the treating clinician is sensitive to the dynamics of trauma-sensitivity. For instance, in doing phase one work, the issue of taking a detailed trauma history should not be forced if clinical judgment suggests that relaying the entire history verbally would worsen the client's condition. Some general recommendations for determining whether a client is a candidate for EMDR include [29]:

Shapiro has also recommended that clinicians should not do EMDR with a client they would not normally feel comfortable treating [4,15]. For instance, if a clinician is very comfortable working with addiction, using EMDR therapy with addicted clients would likely be appropriate. However, if one does not usually work with young children or couples, EMDR should not be done with those types of clients because he or she may not competent in the modifications that may need to be made. In general, if a client who is often defined as a part of a "special population" (e.g., children, military, gender and sexual minorities) seeks out EMDR, the likelihood of their success is greater if they are working with a clinician who understands that population.

After observing how well Client J responds to the preparation exercises, the counselor explains that stimulation could be used in a different way to help process some of her traumatic memories, and the client is willing to try this approach. The first several sessions of trauma processing with EMDR are all over the place, and the counselor uses a significant amount of interweave, or open-ended questions/statements typically used to assist complex clients work through blocks within the EMDR processing. However, after these first several sessions, Client J is able to quickly process a series of traumatic memories that are both recent (e.g., an accident) and deep-seated (e.g., past abuse). EMDR is used off and on over a nine-month period. (Breaks in formal EMDR bilateral reprocessing occur because, during some sessions, Client J states a need to just talk, which could be viewed as part of re-evaluation.) Significant improvements in Client J's overall self-image and decision-making begin. In the counselor's last contact with Client J by phone, she reports that she is remaining on her bipolar medications and realizes that she will probably need to do so for the rest of her life. However, her mood swings are no longer as violent and her lifestyle choices have improved because much of the underlying traumatic material has been processed.

In nature, primates cross their arms over their chest and tap their shoulders in an alternating pattern to self-soothe. This natural phenomenon of bilateral stimulation may be duplicated to practice self-soothing. EMDR therapists refer to this exercise as Butterfly Hug or Monkey Tap. It is taught with the following steps:

Asking a person to identify the beliefs about self that have been acquired throughout life is a powerful gateway through which to assess for trauma, or in AIP terms, to ascertain negative cognitions and their origins. Having a patient rehash the whole trauma narrative is generally counterproductive and can potentially cause more harm than good. Instead, ask the client to identify two or three significantly negative, driving beliefs about the self that seem to be causing problems. Tracing the origins of these beliefs will likely provide most, if not all, of the information needed to begin working with the client in a trauma-sensitive manner in whatever modality is selected.

Some individuals come into professional services with a clear sense of their blocking negative beliefs; "I'm not good enough," "I'm to blame," or "The world is out to get me" are very common. People may have a sense of some but may not recognize others.

As an assessment strategy, begin by having a client identify core driving beliefs. A general list of negative schema or self-defeating beliefs may be used as a guide. After identifying the core negative beliefs, consider asking any one of the following questions (based on clinical judgment) to trace the origin of that belief:

Completing a basic training does not confer the title of Certified EMDR Therapist in the eyes of EMDRIA; only the descriptor of "trained in EMDR" may be used. Clinicians can practice with partial training (i.e., completed the first part of a full training program), although the full basic training is recommended. In order to obtain EMDR's official credential, one must also complete an additional 12 hours of continuing education training every two years, 20 hours of additional consultation with an EMDRIA-approved consultant, and documentation of practicing EMDR in a minimum of 50 sessions with at least 25 clients are required. To be clear, EMDRIA certification is not mandatory to be able to practice EMDR. Some insurance companies may require official certification to list a provider on their panels as specializing in EMDR, but this is the only possible financial benefit (other than the marketing of using the credential).

When clients are referred to an EMDR provider, the first step will be classic phase one history-taking: an evaluation about the presenting problem, assessment of how unresolved trauma/adverse life experiences may be complicating that problem, and determination of the client's appropriateness for EMDR. A significant proportion of referred clients will not be candidates for EMDR, typically because of overmedication with central nervous system depressants (particularly benzodiazepines, generally a strong inhibitor of trauma processing work) and/or poor motivations for wanting to do the EMDR work.