Untangling EMDR: What are the EMDR, EMD, EMD(r) AND R-TEP protocols? (MAY 2022)
Marilyn and Richard discuss the apparent confusion in the EMDR world about these four protocols.
People appear seem to know about how the protocols relate to one another but unclear about the exact differences in how the protocols are applied in practice. We are going to use this blog to highlight some of the confusion and see if we can tease out some practical ways of working that will be followed by videos on emdrgateway that demonstrate the protocols in action. Video 038 on EMD is the start.
The thing there is agreement on is that the reason for these four protocols is to do with client complexity and levels of dysregulation. If a client has a good degree of affect regulation and can access their window of tolerance, then there is no problem in using the standard EMDR model with its eight phases, and three prongs (Shapiro, 1999). In using the standard protocol, the therapist stays out of the process and encourages the client to make their own connections, to follow whatever comes up and to trust the natural tendency for more adaptive meaning-making.
If, however, the client is easily dysregulated and can’t regain their window of tolerance, other measures are put into place. In this situation, the therapist has a repertoire of responses. There is the possibility of increasing the stabilization and resourcing phase of the work. You can also alternate stabilization work with processing sessions. Similarly, there are many strategies that can be employed to contain abreactions during processing (see Video 024). When these are not enough, that’s the time to bring into play either EMDr or EMD.
EMDr is, as implied by the name a protocol that focussed on the desensitization but limits the reprocessing as we will explain in greater depth further on in this blog. EMD is a protocol that eliminates any possibility of reprocessing and keeps the client narrowly focussed on one particular target image with a view to desensitizing that image. The theory is that if the client can be less triggered by images, they will be able to access their window of tolerance more easily and so become stable enough to move on to EMDr and then EMDR.
So let’s look at these protocols one at a time and see if we can understand the differences. That way we’ll have a much better grasp on when each of them in appropriate in our work.
Let’s begin with the most commonly used i.e. EMDR. This protocol is the one originally developed by Francine Shapiro and is the one familiar to all EMDR trained therapists. For the vast majority of clients, this is the most appropriate protocol and is largely very successful. It is used when clients have good access to memory networks and an ability to regain affect control in their window of tolerance and maintain dual awareness. They can access the difficult memory and also notice safety with the therapist in the here and now.
The analogy we could use if of a car on a motorway. If the driver of the car (the client) is competent he or she can use any speed in any lane on the motorway and can choose which is lane is the more appropriate for this particular journey.
In the reprocessing phase of EMDR, after each set of bilateral stimulation we ask the client a very open-ended question: ‘What do you notice?’ or ‘What’s coming up now?’ This gives the client complete freedom to access body sensation, emotions, thoughts, beliefs, images, sounds, urges and related memories either past or present. The client is left to make the connections and his or her brain is trusted to find more adaptive ways of processing past and present experiences. Once a channel is cleared, or in our analogy, one leg of the journey is over, the therapist returns to the target to see if there are any other channels for this particular memory. Once all channels are cleared, the VoC is strong and the body scan clear, the therapist might then encourage the client to think forward using a Future Template so that the new, adaptive ways of being can be applied in future scenarios.
EDMr finds its use with some clients, particularly those with more complex trauma histories or severe recent trauma, whose ability to tolerate affect or retain dual focus is compromised. Free-ranging reprocessing is unwise because of the possibility of triggering overwhelming affect and abreactions where the client is reliving the trauma in the now. In the motorway analogy, the client isn’t safe to drive in any lane and needs some intervention to keep them in the most appropriate lane for their ability to drive. The therapist puts in the equivalent of traffic cones to narrow the lanes and keep the driver in a safer, and slower driving space.
EMDr is a small narrowing of the driving lanes. It still involves reprocessing and is still about desensitization. It is used when the client finds it very hard to stay focussed on the target memory and tends to make connections to many other memories that produce a feeling of overwhelm and emotional flooding. EMDr still requires an ability to tolerate affect, to work within the window of tolerance and maintain dual attention but the focus is kept more narrowly on the selected memory and on the channels that are clearly connected to that target. The client is not encouraged to free-range but to stay within the slightly narrowed traffic lanes.
The therapist does this by directing the client’s attention back to the target memory after each set of bilateral stimulation. Only when the target memory is in mind does the therapist ask ‘What do you notice?’ or ‘What do you get?’
In this way, the client keeps in narrower lanes and reports what they notice about the target. They don’t have the opportunity to associate to other memories. Often the phrase used in this narrower focus is, ‘When you focus on this original experience, as it appears to you now, what do you notice? As long as the client’s response is related to the target memory, then the therapist says ‘Go with that’ or ‘Notice that’ and continues with bilateral stimulation. If the client still makes connections to other memories, the therapist gently refocuses them on the target being worked on.
Now, let’s look at EMD. This has two distinct uses - as an early EMDR intervention protocol (EEI) for clients whose trauma experience is recent (within the last three months) and before memory consolidation has occurred. It’s also useful for clients with particularly complex trauma histories and who are easily overwhelmed and flooded, so that there is a risk of extreme abreactions and even of re-traumatization. These clients find it very hard to stay in their window of tolerance so that they can maintain dual attention and access their thinking brain. Therapists need a range of approaches for holding these clients if they have an abreaction, but using EMD can also reduce any risk of harm and increase probability of desensitization.
As the name suggests, this protocol is not about reprocessing. It is purely about desensitizing memories that bring severe dysregulation so that the client can manage their affect more effectively. It is about lowering or even eliminating the level of disturbance associated with a particular memory. EMD work often leads on to EMDr or EMDR depending on the client’s ability to focus on targets, hold dual attention and work within their window of tolerance.
In the EMD protocol, the target memory is important, as is the SUDS. The negative cognition can be useful, though it’s not essential; the positive cognition is not relevant to EMD, but a body location of the disturbance could be helpful in tracking somatic reactions to the target. In this work, after each set of bilateral stimulation, the therapist directs the client’s attention back to the target memory. The question asked is not ‘What do you notice?’ but ‘How disturbing is it now?’, using a phrase such as, ‘When you bring your attention back to this original experience, as it appears to you now, how disturbing does it feel to you, on a scale of 0 to 10, where 0 is neutral or no disturbance, and 10 is the highest level of disturbance you can imagine feeling?’
The aim is to get the SUDS down to 1 or 0. If the SUDS are higher than 1, the therapist asks the client ‘What’s the worst part of the target or the image now?’ When the client responds, the therapist says ‘Focus on that, and notice what happens next’ followed by BLS.
In our motorway analogy, EMD is when the lanes have been reduced to one lane only. The client is kept on a very narrow focus by asking how disturbing it feels to them after each set of bilateral stimulation. This way, the client is unlikely to make associations with other memories and is less likely to become overwhelmed or flooded. They might be some abreaction but the therapist is more likely to be able to hold it and to help keep the client safe in the presence of the therapist and his or her office. If, despite this, abreactions do become worrying, then seek to contain them – see Video 024 for help.
Lastly, what about EMDR R-TEP, because this protocol can be a combination of all of the above[1]. This protocol is a comprehensive current focussed protocol for EEI (Early EMDR Intervention) that incorporates and extends the existing EMD and/or EMDr protocols. As an EEI intervention, the assumption is that the traumatic experiences have not yet been adaptively processed. EMDR R-TEP usually requires 2-4 sessions, and unlike EMD and EMDr, is specifically designed to address a traumatic Episode, not a single traumatic event. The episode will include an original traumatic event and its aftermath and will therefore comprise multiple targets of disturbance. These target fragments are referred to as Points of Disturbance (PoDs), and will have been identified by asking the client to do a ‘Google search’ (see Video 038), with or without BLS depending on the client’s ability to stay in their widow of tolerance. Each one of these points of disturbance (PoDs) will need desensitization (with EMD) or desensitization and reprocessing (with EMDr but without a body scan). The Episode itself will have been checked for a SUD level at the beginning of the process, and when all PoDs have been dealt with, the Episode SUD is checked again and if ‘ecological’ a PC is chosen and installed, followed by a body scan. It’s important to get trained in this protocol as well as in its adaption for working with groups (G-TEP) before embarking on using them with clients.
We hope this short explanation of the four protocols helps to bring more clarity to your practice.
[1] Recent-Traumatic Episode Protocol (R-TEP) and Group-Traumatic Episode Protocol (G-TEP) training has been developed by Elan Shapiro, and is available in the UK.