Trauma: Psychotherapy versus EMDR

Neuroscience, Memory & Trauma

You may think with all the latest research, MRI and CT scans, coloured 3-D images and videos that record real-time synoptic activity, we have a handle on how and what we remember.  But in truth these are just external phenomena. It is what we can see or rather what a highly expensive piece of equipment can detect. Behind the electrical impulse, the flashing lights, behind the scans, we simply do not know what or how or even if this electrical neurochemical process turns physical or visual stimuli into memory.

Let’s even take the simpler question of what we remember and why we remember what we remember. Do we all have total recall, like those with a photographic memory, but we just can’t access it until we have a visual or other sensory trigger and then it all comes back? Or do we just forget everything and what we think we remember is just some cognitive creation based on a memory? Part recall, part creation? Or maybe it’s all creation which explains why we often remember things different from how they actually happened.

Is there some other process that shifts memory between long-term and short-term and if so what is this process? What is deciding what memories to keep and what to delete and what is the basis for these decisions? It can’t be conscious desire as think of all the things, all those moments we are desperate to hold on to, that moment we embraced a loved one for the first or last time, the first time a child walks or smiles. Yet despite all our best effort these slip away as the months and years progress, and we’re left with something faded, hazy, a half memory.

Of course, when we come to trauma, it is the direct opposite: we don’t want it, yet we can’t forget it.  It won’t fade to the background, it stays there front and centre. It’s like there’s some sort of laboratory in your head, every night remaking the same experience, the same experiments, replaying the same experience. Keeping the memory alive, keeping it present. So everyday it’s like it just happened yesterday.

Brief History of Trauma

While the experience of trauma is nothing new, our reference points are historically centred around armed conflict such as World War 2 or the Korean war. However, it was the Vietnam war that started a broader cultural awareness of trauma and the condition of Post-Traumatic Stress Disorder. We started to see in the movies and in TV dramas, characters unable to escape the past horrors, unable to forget and move on.

Over time, however, the source of trauma broadened from war-time conflict to any graphically destructive or brutal act, whether that be witnessing a fatal car accident, victim of violent crime, experiences of emergency workers or individuals who were sexually or physically abused.

But not everyone who witnesses traumatic events are traumatised and why some events traumatise certain individuals is again something we don’t understand. Some combat veterans witness a variety of horrific events, unscathed, and will only be affected by a single incident. Sometimes with emergency workers, there is no single incident, just almost a montage of traumatic moments that the relive again and again.

Yet while there are a varied number of events that can cause a trauma reaction , the individual experience tends to be more uniform. There are the immediate physiological reactions, sweating, increased heart rate, numbness together with panic, blind fear, the need to shut down or escape.

And of course now this creates a secondary monster: not only do we have to fear the trauma, we have to fear our reaction to the trauma. So maybe we start to stop going out so much, stop seeing friends, maybe we struggle at work. Or we become hyper-vigilant or angry or more controlling or suspicious.  Which over time, can tip into severe anxiety, depression, paranoia, addiction or suicidal thinking.  Maybe you think you can handle it on your own, try to white knuckle it, but eventually you realise it’s getting on top of you. Eventually you realise you’re going to have to get some professional help.

Classical Psychotherapy & Trauma

The traditional approach used by psychotherapists is based on a controlled and cautious exploration of the events. Week by week, slowly starting to unpack the trauma and the effects of the trauma. The fear, shame, despair, frustration, anger, guilt are brought into the room, brought from the shadows into the light.  Equally, it is about placing the trauma as part of our history of experience: not trying to forget it or deny it but to ultimately accept it as another facet of the human experience. To see it for what it is: something that does not define us but has irrevocably shaped us.

However this approach is not without dangers, and in truth one of the principal sources of failure when dealing with trauma is not the theory, it is the therapist. Trauma is an immensely powerful psychic force: however while it has to be respected, it can not intimidate and that is a very delicate balance. 

Therapists who under-estimate this power can do more damage by retraumatising or overwhelming a client who is not yet sufficiently prepared or able to process the often intense thoughts and feelings associated with the trauma.. They recklessly open Pandora’s box but then leave a client damaged and vulnerable particularly in the space between sessions.

The challenge with a too cautious approach, which is often a characteristic of multi-year trauma-focussed approaches, is that in a sense this caution unconsciously reinforces the clients fear. This caution rather than dismantling the status and power of the trauma, entrenches it. And of course, it is disingenuous, not to point out specialist trauma treatment can be a lucrative business model. Once a week, maybe twice a week, for one year maybe two is a steady source of income.

And finally, there is no guarantee of success. Indeed one of the key drivers of the next approach considered, EMDR, was the poor outcomes of psychotherapy with PTSD.

EMDR

This article will not go into the detailed mechanics of how EMDR (Eye Movement Desensitization and Reprocessing) works, but broadly it involves between 6 and 12 60 minute sessions in which the client verbally recalls the traumatic event while the clinician taps you rhythmically on either side of your body. Hence why EMDR is also referred to as the tapping therapy.

Reading this your first response might be that this sounds, well a bit crazy. Or that it’s a bit like an act from one of those stage or TV hypnotists or mentalists. Well in truth, psychotherapy has a tangled history with hypnosis, and indeed many of the founding fathers were all trained hypnotherapists, including Freud and Charcot. There is a vocal community of psychotherapists who are hostile to EMDR for the same reason they are hostile to hypnosis:they don’t like things that work without them knowing why it works.

The current scientific thinking around EMDR is that, as we discussed previously, trauma is linked to the processing of memory. EMDR argues that the traumatic incident was too extreme to be processed, so it’s not processed. It is stored as a sort of raw data, a continually live experience. Recollecting and verbally describing the trauma combined with physical touch somehow allows these unprocessed memories to become processed and then categorised like any other memory.

An alternative theory is that it is not the physical tapping that works, it is the process of continually revisiting and recollecting the traumatic event. In this sense, EMDR is a variation on a traditional psychotherapeutic technique used commonly with anxiety known as ‘flooding’, it which a client is forced to sit with an extremely anxious thought until the fear of that thought gradually subsides.

But equally, does it matter how it works if it works?  That’s back to the opening paragraph and the truth is we don’t really know why any of this works. The bottom line is the EMDR has numerous positive personal testimonies from combat veterans and emergency response workers around the world whose lives have been transformed after treatment.

Selecting Treatment for Trauma

That was a brief overview of the two main approaches, the next question is which approach is right for you? Obviously there are no hard and fast answers but generally, in my view, which course of action you select depends on whether the trauma is a single event or a pattern of events.

For more random events, such as in combat or emergency response trauma, there is minimal relevance to your sense of identity. It was a brutal, horrific moment and for most the objective is really just to forget about it in which case EMDR is probably a good fit.

For trauma that comes from repeated or sustained actions, such as childhood or domestic abuse, the connection between events and identity is often more complicated.No matter how much you want, you can’t just simply forget about it. It has shaped who you are and the process of therapy is about understanding and accepting,  exploring and reflecting.  It is not about escaping the pain or the shame or the anger, it is about not being a hostage to these events and emotions. It is about damage control, it is a statement that you are not going to be the victim, that these past horrors do not dictate your story. And this of course is the terrain of psychotherapy.

As said at the outset, however, this is just a guide and as with all therapy it’s about finding the combination that works for you. So if you’ve tried it and it hasn’t worked, in truth, you’ve probably picked the wrong therapist for you. With trauma you really need to pick the right fit, the balance of formal and informal, push and softness, catharsis and analysis. In my view, what has been programmed can be reprogrammed and there is no pain that can define us.