Discover the Incredible Benefits of EMDR and How It is Done

Hey there, everybody, and welcome to this presentation on the overview of EMDR and bilateral stimulation. I'm your host, Dr. Donnellice Snipes. In this presentation, we're going to explore what EMDR and bilateral stimulation are and how they might work. Then we'll explore the research on the benefits of EMDR and bilateral stimulation and identify issues that might be treated with EMDR or bilateral stimulation. So let's back up. EMDR has been noted for its benefit in treating trauma. Why does that work? And why do we need a new treatment for trauma? Potentially, when traumatic events happen, the brain can't process stimuli normally or effectively integrate them into existing schema. When trauma happens, our fight or flight network is activated and it dumps cortisol and norepinephrine and adrenaline and dopamine and glutamate. And glutamate actually keeps our brain from being able to effectively solidify a lot of memories. So our memory formation system is sort of disrupted at that point because the brain is focused on five fight or flee. It's focused on noticing it's hyper vigilant to the threats that are going on. And the person is not taking time, is not able to take time to stop and think, okay, you know, what are the facts in this situation? So when this happens, think of it like having something that needs to be filed, but there's no existing place to put it. This trauma happens and people are stripped of their sense of safety and power, and they're like, this is not how the world's supposed to be. So they've got this memory that needs to be filed away somewhere, but there is no file for traumatic events, so they just kind of sit it right there. So it sits in your amygdala until your body can figure out what to do with it. Additionally, during this situation, your brain is flooded with automatic thoughts, like a crowd screaming at an event. You can't hear everyone, but all of their voices are contributing to your reaction. So when something bad happens, you have these automatic thoughts that may be telling you that you're in danger, that people can't be trusted, that the world is an unsafe place. There's lots of thoughts that go into this memory file that you've still got to figure out where to put. Eye movement desensitization and Reprocessing therapy, or emdr, has been found to be helpful for people who are needing to address traumatic memories. When a present situation triggers traumatic memories or negative core beliefs, it causes distress and triggers that stress response. So again, that HPA axis is kicked off Adrenaline, norepinephrine, cortisol, glutamate, all that stuff is dumped and the person is in that fight or flee, that adrenaline haze, they are not able to rationally think about what's going on. The brain is sort of on survival autopilot. When the stress response is active, it's extremely difficult to replace existing beliefs with new contradictory beliefs. Think about when somebody's upset or when you're upset and you tell them calm down, everything's fine. That doesn't really usually sit well with them because they're in fight or flee and you're introducing a contradictory belief that they, it doesn't compute. When we're in that situation, even if we try to tell ourselves to calm down, everything's fine. Sometimes our brain is so wound up in that memory and there's so much glutamate and so much adrenaline, we're so immersed in that fight or flee that we can't rationalize our way out of it. EMDR is designed to help people recreate memories in a safe space where they can explore them. Now, eye movement, that part is very self explanatory. Desensitization, let's talk about that for a second. Desensitization has been used for years in treating fears and phobias and those things. Typically when you engage in something called systematic desensitization, which is an old technique, the person would think about the situation. And let's take fear of flying for example. I usually use fear of spiders, but spiders get such a bad rap. So we'll go with fear of flying. When people think about flying, if they're afraid of it, their anxiety level rises to a high level. You know, we'll say to a 4. On a scale of 0 to 4, it goes up to a 4. It's just completely unmanageable. In desensitization, the goal is when they get there, think about it, they get their anxiety level up. We teach them down regulation strategies, distress tolerance strategies, coping strategies to help calm their HPA axis and get back back into their wise mind. As Linehan would say, we rehearse this and we do it over and over and over again until the person becomes very skilled with using those down regulation techniques. And they can get to the point where they can think about flying on an airplane and it doesn't really bother them. They're like, okay, you know, I've had that thought and I've been able to relax and then rationalize once I get into my wise mind, rationalize why it's not dangerous, done that. All right, cool. So that's step one. Now, systematic is the next step is instead of thinking about flying, it may be going to the airport and watching planes come in and out. You know, the next step that triggers anxiety and you repeat the process until the person can be in that situation and, and experience distress, down regulate it, get into their wise mind, rationalize what's going on, think more clearly about it in their wise mind. So they're basically reprogramming their thoughts and feel comfortable with it. And they'll get to the point where being in the airport and watching the planes come and go, and then maybe the next step is not flying, but, but getting on the airplane, you know, so you take it step by step and gradually increase people's level of exposure to the scary stimulus and help them learn how to down regulate their stress response and get into their wise mind. Okay, so that is what traditional desensitization and systematic desensitization would look like. In emdr, the therapist is also doing that type of desensitization and helping the person get into a place where they can think about that memory, think about that thought without having that flood of cortisol and glutamate, which impairs their ability to replace those thoughts. So, so we're doing something very similar here. But the grounding techniques are the bilateral stimulation. Emdr, as I said, is designed to help people recreate those memories, think about those memories in a safe space where they can explore them. Another unique thing about EMDR is they identify other associated beliefs and feelings. So they start out with the loudest voice in the crowd, what you remember about that event. And then as the person processes it and starts to get into their wise mind, they will hear other voices or other thoughts, and then they process those thoughts. So they are gradually attending to every voice in the crowd. As they do this, they desensitize to the event, and they also start gaining a greater understanding of why it might have been stressful because they start hearing all these other voices and they're like, okay, where did that belief come from? What does that mean? Is it accurate? Once the person is desensitized, once they are in a place where they're in their wise mind, they are not flooded with adrenaline. They are encouraged to replace the unhelpful beliefs while they're in a receptive instead of a reactive state. So the first part is helping the person be able to think about the memory and without getting completely distressed where they can think about the memory. And instead of being a four on Distress, they're at a zero or maybe even a one. In that situation, the person is more receptive instead of reactive. Once they process their thoughts and they can think about that memory without getting completely distressed, then the reprogramming or installation of new beliefs begins. They're not exactly sure how eye movement desensitization or bilateral stimulation work. Reading through the research, there are a lot of hypotheses, but they don't know for certain. Eye movement works by stimulating rapid eye movement or REM sleep, which is when our brains process recent memories. So the eye movement part of EMDR may, may be simulating that REM sleep and getting our brain into a more receptive state. Bilateral stimulation can use tactile or auditory stimulation, where the person either hears sounds on the right and the left and the right and the left, or they're holding something that vibrates on the right and the left and the right and the left. Excuse me. Bilateral stimulation is important because emotions are processed throughout the brain in most people, not just on the right side or the left side. It is important to get both sides of the brain into a receptive state. Bilateral stimulation is thought to produce what's called a distancing effect. So the problem seems less hooked to you, more distant, like you're watching a movie or a television show, less problematic than as part of you. One thing that's interesting is habituation does not occur with bilateral stimulation as a result of your attention being held captive. You can think of the problem and you start to feel relaxed, which leads to changes in the way the memory is stored. Now let's process this a little bit. Think about if you've ever been around a little kid who wanted something and they were tapping on your shoulder. Mommy. Mommy. Mommy. Now, that's generally not bilateral, but most of the time you're not going to habituate to that. You're not going to get to the point where you can just ignore it. And they're continuing to tap on you. And a lot of times if you start to ignore it, what do they do? They go around to the other side and they start tapping on you or pulling on your shirt or something. And so kids kind of understand this. When that's happening, your attention, even if you're trying to focus on a conversation you're having with another adult, your attention is pulled, distracted to whatever that child is doing. And we know this happens if you're a parent, if you've been around kids, you know this is for true. So what we're talking about with bilateral stimulation is intentionally doing that. So our attention is pulled to either the eye movement, to what we're following with our eyes, or to the sounds or to the tactile sensations. Because when we're thinking about that, then while we may be getting irritated about that, the emotional reaction, not as potent toward whatever that memory is, because that memory is floating around out there. And you're like, okay, yeah, that's out there, but this is really attracting my attention, or this is really annoying me right now. And your brain is like, oh, well, maybe I don't need to be as worried about that. So it's kind of an interesting paradox that happens with the bilateral stimulation. If you've ever used a TENS unit, a transcutaneous electronic nerve stimulation, a lot of times it's used for pain. And one of the things that you'll notice is a lot of the programs in a TENS unit involve, guess what? Bilateral stimulation. And the thought there again is that by using that alternating stimulation, it is helping the person relax, and it's distracting the brain from the pain stimuli. What happens in an EMDR session? Well, according to what I read, standard, EMDR begins by asking the participant about their current cognitions, their current thoughts, emotions, or sensations, holding all of these elements together in awareness. The therapist then directs the person to think back to times in life when these elements were experienced together, finding implicit past associations with the presenting problem. If the person presents in your office and they are feeling unlovable and worthless and depressed, okay, you know, so let's talk about what the thoughts you're having, what those emotions are like, and what that feels like in your body now, thinking about that. Think back to times in your life when you felt the same way and what was going on then, you know, it basically is this triggering a past memory when you were unsafe or when there was a trauma. Alternatively, patients may be asked to provide experiences that have proven their core beliefs, such as I am unlovable. The targeted memory is desensitized and then paired with a positive or more helpful core belief. Once the past experience is processed, present reminders and future fears of a similar experience may happen, are found in a similar fashion and then again processed. I had a client that I referred for EMDR and his therapist. Therapist had him identify 10 examples of when he had experienced rejection and abandonment, and those were the similar situations to what he was dealing with. And they processed each one of those things. They replaced his unhelpful thoughts with more functional thoughts in session. And then once they finished processing those past experiences, she asked him to Think about future relationships and fears, about future abandonment. And again, they went through that same process and identified the loudest voice first and processed that. And then once that loud voice was silenced, what was the next voice you heard? What was the next thing? Let's go with that. EMDR therapy uses a structured eight phase approach that includes phase one, which is history taking. And we're going to go through each of these phases. Phase two, preparing the client and developing grounding and distress tolerance skills. When the person is recreating this memory and even in a safe space, it is extremely intense. And it's important that you don't just throw them into the deep end. We need to make sure that they have the confidence that they have the skills and tools in order to be able to down regulate their emotional response. Otherwise it may be very terrifying. Phase three, assessing the target memory and components. The image. What do they see when they think about that memory? What pictures do they see in their mind? Cognition. When they see that picture in their mind, when they think about that memory, what thoughts do they have? What's their inner critic saying? What are they telling themselves? What are they hearing other people saying when they see that image? When they hold that memory in their mind? What is their feeling? And a lot of times we have multiple feelings. We've talked about dirty discomfort before. It's not just anxiety. It may be anxiety and anger or anxiety and guilt. So what feelings are coming up for them and how do they feel it in their body and where do they feel it in their body? Is it localized in their stomach? Do they feel it all over? Is it in their heart? Is it in their chest where they feel like they can't breathe? You know, where does, where are they feeling those sensations? Phases four through seven, processing the memory to an adaptive resolution. And this is when the EMDR therapist helps the person work through all of those voices until they can think about that situation and, and not experience extreme distress. When they are ready to start reprogramming. And then phase eight is evaluating the treatment results. Two measures are used to evaluate changes in feelings and thoughts in emdr. The subjective units of disturbance. Now, a lot of times people will use a 1 to 10 scale, but from a statistical point of view, it's actually a lot more accurate to give people a four point scale or a five point scale because you can anchor those with words. If you have too many increments, it can be hard for them to differentiate, for example, between a 7 and an 8. So they may say something like on a scale of 0 to 4, where 0 is no distress at all and 4 is the most distress you can imagine. How distressful does it feel to think about that memory or that trauma right now? Again, the goal is to get it so the person can think about that situation and their distress is at a zero or maybe a one. The second measure that is used is called the validity of cognition. When you think about the incident, how true does your new belief? So this is used when you're instilling the new, more empowering beliefs. How true does your new belief feel to you on a scale of 0 to 4, where 0 feels completely false and 4 feels totally true. Now, the official validity of cognition scale, again, it goes on a 0 to 7. However, I think there is some latitude in your Likert scale based on the person that you're working with and how effectively they can granulate the intensity of their emotions. The first phase. I told you we'd go through each of the phases. History taking. This is when the therapist meets the client and explores with them their presenting symptoms. Depression, anxiety, grief, what's going on and associated memories and core beliefs in general. And I mentioned I had a client that I referred who was dealing with abandonment trauma. So the therapist asked him. They processed what that felt like in the present. And the therapist asked him to think back to 10 times in the past when he had had similar feelings and sensations and thoughts. It's important to recognize that the therapist can look at things like emotional dysregulation. If that's a presenting symptom, you know what thoughts, what images are going through your mind, depression, anxiety, you know, those are symptoms the person has had. And typically the EMDR is used to process trauma that is triggering a feeling. So the person will go and talk to the EMDR therapist and say, I had this traumatic event or these traumatic events or these adverse childhood experiences. And the therapist will help the person process those traumas and the associated feelings of depression, anxiety, guilt, shame, etc. During this meeting, the therapist also does a mental status exam. It's important to make sure that a person is emotionally, cognitively and physically able to to engage in this activity, even though we're not going there yet. There are certain caveats. Obviously, someone who is actively under the influence of substances, for example, may not be a good candidate because there may be a higher level of impulsivity and more difficulty with down regulation. The therapist also assesses the person's safety. Not only in session can they tolerate feeling those feelings or thinking those thoughts, but also when they leave the session. When the person leaves the session, they may have residual memories that come up. They are going to be exhausted. This is hard work. This is not something that's just like a day at the spa. And it's important that the person has resources that they can tap into during the other 23 hours of the day when they're not in the EMDR session to help them stay safe, to help them meet their basic needs if they start to have flashbacks or decompensate, that they have a plan to deal with that. And so the therapist will also assess the person's support systems. The next session is preparation and grounding. The therapist explains to the client what's going to happen in the EMDR session. But then they start working on making sure that the client has these grounding skills that they can use not only in session when they're actively processing the memories, but between sessions if they start to have a flashback or a strong emotional reaction. Remember I said this is exhausting. So what normally might not irritate somebody or overwhelm somebody may be irritating or overwhelming. And it's important to prepare them for that and, and help them feel safe and in control of themselves, even though their emotions may feel a little bit more powerful, even between sessions. Activities. The butterfly hug is crossing your fingers over and alternately tapping yourself on the shoulder or doing it just with your fingers very, very lightly. This is that bilateral stimulation. It can also. There's something about crossing over your chest that also has been shown to trigger oxytocin. You know, it's almost like giving yourself a hug. It triggers that bonding hormone. And oxytocin can also help people feel safer and more grounded. Slow breathing. And we talk about this one all the time. We. When you slow your breathing, you trigger the rest and digest response. So teaching people how to inhale slowly for a count of four, maybe six, hold for a count of four, slowly exhale for a count of four. And then if they can, hold on, the exhale for a count of four. So it's inhale four, hold four, exhale four, hold four. And sometimes that's called square breathing, because you're going around in a square. 5, 4, 3, 2, 1 is another really common grounding technique. When people start to feel distressed, their mind starts going to stressful memories, and it may be hard for them to think clearly because of all of that adrenaline. So five, four, three, two, one forces them to start thinking, okay, what are five things that I see right now? And they look around. What are four things that I hear? Three things that I Smell two things that I can feel and one thing that I can taste and that can help people get back into the moment. By doing that, they're intentionally turning their attention to something other than whatever it is that that's causing them distress. Going for a walk or engaging in another physical activity can also be something that is very helpful for people when they're experiencing anxiety or anger, any of those fight or flee emotions, because their body is dumping cortisol and adrenaline and blood glucose and so dumping all kinds of energy to help the person fight or flee. So, all right, well, it's given me the energy, let's use it. So if you give your body a way to use that energy, it gets things synced back up a little bit. Guided imagery can also be helpful. A safe space visualization is a great thing if they are able to do that, if they can envision themselves in a safe space. But that requires that they also feel like they're in a safe space, because you can't easily use guided imagery, for example, when you're on the bus or the subway or somewhere where you don't feel like you can relax. But a safe space space visualization that they can use when they're in their safe space, like at home, can be very helpful. Unhooking, that is a concept from acceptance and commitment therapy. But it can be very helpful where the person envisions taking that feeling and unhooking from it. It's not attached to their heart or their gut anymore. They're taking it and they're holding it and then they can see that feeling, they can see that image, that memory, whatever it is, and they can decide what to do with it. It's not attached to them anymore. I've had other clients, when working on developing distress tolerance skills, visualize themselves as the loving, caring parent or the defender of the child. If the memory, especially if the memory involves a trauma, when somebody was younger, they envision themselves as adults being powerful and pushing that little child self that they have, pushing that inner child behind them, letting that child know, I'm an adult, I'm going to protect you, you're safe now. Sensory stimulation is another distress tolerance technique. Now, it doesn't solve the problem. None of these solve the problem. The goal of distress tolerance is to help people guess what, tolerate distress until they can down regulate and get in their wise mind and figure out how to cope. Sensory stimulation, the easiest one, and I think we've all done it at a time or another, go into the bathroom and splash cold water on your face or submerge your hands in ice water or hold an ice cube, especially if you hold it in both hands bilateral, that can really help distract your attention so you can downregulate. Aromatherapy is also very helpful if you use positive smells, things that trigger positive memories or even aromas that are known to have terpenes that trigger relaxation, like lavender. That can be helpful for some people. Other people I've talked to actually go the other direction and prefer for their aromatherapy or for their aromatic sensation, they use something putrid because they smell it like the smell of a skunk or the smell of a rotten egg. And that just jolts them out of whatever they're in. They're like oh my gosh, that's awful. And they're focused on that awful smell now. Ambient noise with guided imagery can be another. It's a combination of guided imagery and sensory stimulation. A lot of the white noise machines will have the babbling brook or the ocean turning that on so you can hear it and focusing on that sound and, and then creating pictures in your mind of what that must look like. That beach can be another way to get grounded. And finally music. Just like aromatherapy, you can use something that's pleasant and relaxing or you can use something that is putrid. Some people will use music that they can really connect with the words and it's very cathartic. Other people will use music that is more calming and relaxing like Gregorian chants or Brahms symphonies or something. It's up to you. And I skipped over thoughts. Distress tolerant thoughts are also important for people to make a list of and keep on their mobile device. Keep somewhere handy so when they're in distress they don't have to think alright, what, what was I supposed to tell myself? Distress tolerant thoughts emphasize safety and empowerment. They emphasize to the person. They encourage the person to say this sucks and I can get through it or this too shall pass. Distress tolerant thoughts encourage people to acknowledge the distress and recognize that they can tolerate it, it will not destroy them. And this can be very empowering when emotions to date have felt very overwhelming. The mnemonic for this, as you've seen in other videos that I've done on distress tolerance skills is tags thoughts, distress tolerant thoughts, activities, guided imagery and sensory stimulation. All of which can help the person get get regrounded, turn their attention from the anxiety provoking thoughts until their brain can get down regulated, until their HPA axis can get down regulated and they can get into their wise mind. The next phase is the assessment of the target memory Describe the image that represents the worst part of that memory. So that's the loudest voice. When you hold that image, are there any negative beliefs? And generally there are. And the therapist has the person just list those beliefs or explain those beliefs. What beliefs would you prefer to hold and encourages the person to think about? What would they rather tell themselves when they have that, when they have that memory? When you hold that image and your preferred belief, how true does it feel? So if you're holding a memory of abandonment and you're telling yourself you're a high value person and you are lovable, you're holding those two almost contradictory things. How true does that feel? When you hold the image in your mind of that abandonment and you tell yourself that preferred belief that you are lovable and high value, what feelings do you have? And a lot of times the person may have feelings of discomfort because of the dissonance, because of the disconnect. The goal in that part is to identify the beliefs that are associated with the memory, then the unhelpful beliefs or the painful beliefs, as well as identify the thoughts that we want to instill in the person or reprogram. So we're kind of laying the groundwork. Then they move into desensitization. The person focuses on the memory, thinking of the worst part of that memory while engaging in some form of bilateral stimulation. Either the eye movement, tapping, sounds, they do that for about 30 seconds. And then the therapist stops and they say, okay, while you were doing that. Now remember, during the bilateral stimulation, it's hard to think about that memory because the stimulation is pulling their attention so other thoughts can emerge. And they say, while you were doing the bilateral stimulation, what thoughts emerged for you? The associated material becomes the focus of the next set of brief bilateral stimulation. They process one memory and then they say, okay, what was the next memory that came up for you? All right, now hold that. Or the next thought that came up for you, hold that thought. And they do the bilateral stimulation. The theory is that all of our experiences in life are kind of connected in this memory web in our mind. And each thought that comes up helps us trace the web or the connections. It's not linear. A lot of times, a lot of times there are offshoots. And by doing this, it helps us figure out what offshoots are being called in when this memory is present in our minds. The process continues until the client reports that the memory is no longer distressing. Now how does that work? Well, if they are thinking about the worst memory and then they go on to thinking about another part of that memory, another one of those voices, another one of those thoughts. And then they hold that and they come down and they think about another thought. They continue to hold that memory. They continue to experience the bilateral stimulation which has. Helps calm the body down. So they're having this memory, but their HPA axis is not ramping up like it normally does. So they're reprogramming to a certain extent. They're desensitizing themselves to this memory. The therapist may say something about. Think about when this started today, when you realized that you were in pain or depressed, or when you got angry or when you started having a craving, for example. And if we're dealing with a presenting symptom, describe your physical sensations and feelings. When you think about this, what is your level of emotional and physical distress and what negative beliefs are associated with this experience? So again, we're looking at the memory. We're having the person become very mindful not only of their thoughts, but also of their feelings and their physical sensations. Research has shown that trauma impacts people on a cellular level. We know that trauma impacts the HPA axis. And continued trauma, or holding on for a long time to unprocessed trauma, actually causes changes the person's nervous system. So we need to recognize that there are physiological, emotional, and cognitive responses. Then the therapist asked the person to engage in eye movement or bilateral stimulation and continue to think about the situation or memory and their negative belief for 30 seconds. Stop and recall what other thoughts you had, what came up during that period. Okay, now hold that thought and those feelings in your. In your mind. And then they repeat the eye movement or the bilateral stimulation, tracing the web. This can go on for up to about 20 minutes. They recommend that after 20 minutes you need to call it because it is exhausting. And after the person has gone through this, now think they're doing the bilateral stimulation for 30 seconds. They're identifying a thought, and then they're doing another 30 seconds. So you can go through this probably eight times in 20 minutes, maybe six times in 20 minutes, and process six different memories. You can hold on to that for that memory, that trauma, the thoughts of that trauma for up to 20 minutes. Now, that's exhausting because that trauma is heavy. After doing this, the person is asked to think about the original memory, the original situation, not just a particular thought, and rank their emotional and physical distress. Most of the time, people report that they have experienced a fair amount of desensitization. They've been able to think about it and hold that thought without getting distressed. So now when they think about it, it doesn't trigger the same distress response. The next step is installation and body scan installation, or this is the reprocessing or restructuring part, strengthens the preferred positive connection. The person has already gone through and desensitized some. Now they can think about that memory without triggering that flood of adrenaline and glutamate and the HPA axis. Okay, now they think about it. People are asked to observe their physical response while thinking about that memory or that incident. And the positive cognition identify any physical distress. If the person reports any disturbance, then they engage in the bilateral stimulation again and are encouraged to process that. Now we're trying to encourage the person to pair the positive thought with that memory. They can think of that memory and they can think, I am safe now, or that wasn't my fault. And we want to create a unity in their, in their thoughts and their feelings, their head, heart and gut honesty. We want them to be able to think that. And on a emotional level, but also on a mind, on a wise mind level, prefrontal cortex wise. We want them to actually believe what they're telling themselves, identify the preferred beliefs and associate with that situation or memory. How congruent does that thought feel with the situation? Again, they engage in eye movement or bilateral stimulation and continue to think about the situation or memory and the new beliefs for 30 seconds. When they stop, they're asked to recall what other thoughts they had during that period. And they may have a lot of very resistant thoughts like you're lying to yourself or this is never going to work, or whatever thoughts they have. But it's important to process those as they come up. Repeat the EMDR bilateral stimulation with any of those new thoughts that come up while they're trying to pair the memory with the new positive thought and again, repeat this up for up to 20 minutes. The entire session is going to last about 50 minutes. You know, your introduction and niceties. 20 minutes of desensitization and 20 minutes of installation. People are then asked to observe their physical response while thinking of the incident and the positive thought and identify the stress. Closure is used to end the session. If the targeted memory was not fully processed in the session, specific instructions and techniques are used to provide containment and ensure safety until the next session. So if the person thinks about the distressful situation and it still triggers a level 3 on a scale of 0 to 4, it still triggers a level 3 distress, then it's not fully processed. Or if they're still having a lot of other memories come up, it's still not fully processed. Or if they still have a lot of incongruence when they think of the memory and they think of their positive thought. If it doesn't feel like it fits, if it feels disingenuous, then the memory is not fully reprogrammed and the therapist will need to ensure this person is able to close that Pandora's box, so to speak, until the next session and has a plan to stay safe in case they do have other residual thoughts or memories come up. This will include revisiting that plan to make sure they have a safe space at home. If you start feeling unsafe or dysregulated or having flashbacks at home, what can you do to stay safe? And creating an emergency plan that includes distress tolerance and grounding skills. Now, ideally, this would have been done in phase two when they were learning the distress tolerance skill skills. But it's always important to review these things. The next session starts with an evaluation of the person's current psychological state, whether the treatment effects have been maintained, and what memories may have emerged since the last session. Then the therapist and client identify targets for the current session and repeat. EMDR has been found to be very helpful in the research with trauma oriented feelings, memories and cognitions. So trauma, PTSD and complex PTSD all have been found to respond quite well to emdr. Mood disorders and addictions that are related to or triggered by trauma can also be very helpful. The key is, with emdr, there has to be a target that the person can focus on. A memory, an event, a sensation, or multiple memories, events and sensations that they can focus on and identify where those core beliefs came from and then reprogram those core beliefs. Interestingly, you know, I said that EMDR may not be appropriate for everybody, and a lot of therapies are not very appropriate for people who are actively in a psychotic state. But patients with psychosis who are hallucinating or having delusions. Patients with psychosis and PTSD also may experience a positive effect on auditory verbal hallucinations, delusions, anxiety symptoms, depression symptoms, and self esteem. Obviously this would need to be done with a lot of care. If you're working with somebody who is in an overt psychotic episode, and there are only certain situations, somebody who is a danger to themselves or others, somebody who is feeling extremely threatened, extremely paranoid, may not be receptive to the emdr. But people who are having mild to moderate hallucinations and delusions, this research indicates that it might possibly be helpful. EMDR has shown very robust effects in the research. Bilateral stimulation paired with distress tolerant thoughts or guided imagery may be a very effective distress tolerance technique to teach people. So even separate from emdr, the bilateral stimulation like the butterfly hug or the sounds alternating when paired with the stress tolerance skills may actually enhance the stress tolerance and relaxation capabilities of those techniques. While virtual or self guided EMDR does exist, its utility and safety are still under investigation. It's important to think about this because in EMDR people are thinking about a traumatic memory and they are really thinking very deeply about that traumatic memory and it's very easy to decompensate. It's very easy to get into a place where they are not safe and if they're doing that by themselves it could be very dangerous. So it really is important to be aware of what you're doing. And for those people who use self guided emdr, it can be helpful for things like the occasional anxiety feeling that they're having. It can be helpful for moderate symptoms. But processing intense trauma really needs to be reserved for being done with a in the presence of a professional who can ensure your safety, it.