EMDR and Medication: and the Future of EMDR Therapy

With Dr Millia Begum: and Dr Michael Hase

A Summary of the day by Ushma Patel

EMDR regional Networking Day 26th November 2022

Saturday November 26 2022

Millia Begum

More than 230 delegates signed up for the day, on the day including colleagues from East Anglia and much wider Trauma Aid network from as far afield as Iraq, Egypt and Bosnia.

Dr Millia Begum, Consultant Psychiatrist and EMDR Consultant and Training facilitator, started the day with a deep dive into EMDR and medication.

Three key areas we focused on during the morning were:

  1. Psychological influences of medications on therapies, specifically EMDR
  2. PTSD specific medications and a video from Dr Ruth Lanius on Dissociation medications
  3. EMDR with Psychedelics

Millia walked us through the key medications; antidepressants, anxiolytics, antipsychotics and mood stabilisers as used in services, as well as the effects on the client and their trauma symptoms.

Interestingly, NICE guidelines from 2018 say that medication should not be a first line treatment for PTSD, highlighting the importance of therapeutic input.  Millia offered examples of the difference between a nocebo, where a patient might anticipate and therefore experience negative side-effects to what they believe is a medication but is actually inert, and the more familiar placebo that also uses an inert substance but has a positive impact on a patient thinking they’re being medicated.

Read more: EMDR and Medication: and the Future of EMDR Therapy

Millia explored the familiar dilemma of clients dependent on Diazepam and fearful that if they don’t take it before their EMDR session they will have a panic attack and not be able to attend. Diazepam can of course interfere with processing, and Millia reminded us how important psychoeducation can be, as well as the EMDR installation of resources to maintain a window of tolerance where emotions are appropriately regulated.

Jim Knipe’s very useful suggestions around targeting what he calls the Levels of Positive Affect (LOPA) where clients are reluctant to let go of the upsides of medication that’s now actually dysfunctional.

We then moved on to PTSD-specific medications and the evidence base for the use of alpha-blockers, a group of blood-pressure-lowering drugs.

Millia explored the case of  Don, a military veteran with severe nightmares and how alpha-blockers stopped his nightmares completely after two weeks. Prazosin in particular is found to have a positive effect on hyperarousal, nightmares, concentration and irritability.

Interestingly, the higher the blood pressure before application of Prazosin, said Millia, the better the effect – suggesting that in PTSD, raised blood pressure might be a marker of hyperarousal.

Much appreciated by our group, Millia had secured two recorded interviews to run as part of her presentation, the first of them with Dr Ruth Lanius who discussed targeting dissociation with opioid blockers.

We were introduced to the Defence Cascade Model: from hyper- to hypo-arousal with a delineation between defence reactions and dissociative states, with their reflections in the sympathetic or parasympathetic nervous system response.

It was fascinating to hear how chronic developmental trauma can influence the fight-or-flight, and/or the unresponsive immobility responses, the former being an active defence and the latter a passive defence. This is where Dr Lanius suggested opioid blockers can be helpful in reducing trauma and dissociative symptoms.

After a break, we moved to the thoroughly topical issue of EMDR and psychedelics, with studies of ketamine, MDMA or psilocybin (the ingredient in magic mushrooms) being used to lower defences blocking access to trauma memories in the treatment of PTSD and depression.

Ketamine use, we heard, is licensed in the UK for treatment-resistant depression, with MDMA likely to be licensed next year for Complex PTSD.

Randomised Control Trials on Ketamine on its own have shown promising results in the mainly short term, but with a high relapse rate. However, when paired with EMDR, the temporary enhancement of neural plasticity can be used to address deep-seated trauma very effectively, with much longer-lasting effect.  

Attendees were thrilled with Millia’s second special recorded interview, with US-based specialist Sunny Strasburg talking us through how she uses ketamine with EMDR and also an Internal Family Systems model.

Sunny also works with the legendary Bessel van der Kolk in Boston, another enthusiast for psychedelics in trauma treatment, and stressed that building therapeutic alliance is exceptionally important in psychedelic therapy, because the ketamine will disable a client’s protector parts.

Interestingly, in psychedelic-assisted therapy the Negative Cognition has to be tweaked, Sunny said, towards a positive affirmation.

Sunny walked us through how she switches to EMDR’s phases 4-7, actually targeting trauma memories only once the client is coming out of the immediate intensity of the psychedelic experience, only using hand tappers rather than eye movements, since EMs are compromised by the effect of the ketamine on the eyes.

Sunny stressed that specific training in psychedelic-assisted therapy is vital before offering this approach to clients. Also, Sunny was very clear that as a therapist one absolutely must have one’s own first-hand experience of taking ketamine in a therapeutic context, to be able to understand a client’s somatic response when it is administered.

Sunny was so inspiring that there’s a strong chance in the near future of a group field trip of delegates going to one of the retreats she so effortlessly sold to us…

A delegate informed us that there is a documentary on Netflix by Michael Pollan exploring the history and uses of psychedelics, including LSD, psilocybin, MDMA and mescaline, titled,’ How to Change Your Mind’.

Another delegate recommended the docudrama Nine Perfect Strangers starring Nicole Kidman, about psychedelics with veterans and including the use of Ayahuasca.

Millia provided a truly fascinating and thought-provoking morning.

Michael Hase

In the afternoon, we were joined by Dr Michael Hase, Consultant Psychiatrist, Psychotherapist and EMDR trainer from Germany who took us on a tour of EMDR in the wider Europe, current developments in defining the future of the EMDR protocols, EMDR supervision and research.

We learned from Michael that EMDR Europe now brings together 36 countries, with a total of 33,645 members in national associations.

Europe is a hotspot for EMDR research, focusing particularly the Netherlands, Italy, Spain, Turkey and the UK, trailblazing with some high-profile publications. Currently, said Michael, there appears to be less research happening in the US.

It was reassuring to hear that after Francine Shapiro died in 2019, the EMDR International Association set up a Future of EMDR Therapy (FOET) project with a Steering Committee and Council of Scholars, and  active work groups looking into the future of EMDR, research, clinical practice and training and accreditation.

The goal is to preserve the integrity of Shapiro’s vision of EMDR as a comprehensive psychotherapeutic approach, and stay faithful to the application of the Adaptive Information Processing model. The hope is that this will inform robust and best practice, research as well as training, practice and future innovations.

Michael walked us through core elements identified in this process, including a glossary of terms and an understanding of EMDR under three headings: EMDR-derived Techniques, EMDR protocols and full EMDR Psychotherapy.

Moving to the latest scientific research, Michael talked us through the findings of a computational neural network model which accurately predicts which brain centres respond to Bilateral Stimulation (BLS) when compared to real-life brain scanning data.

This study brings us a step closer to understanding  the mechanisms of PTSD and EMDR, particularly of how EMDR achieves trauma remission and how EMDR exerts its therapeutic action.

Michael considered the neurobiology of BLS compared to Prolonged Exposure and the role of the ventromedial prefrontal cortex and the dorsolateral prefrontal cortex.

It is suggested that ventromedial prefrontal cortex activation during exposure and the resulting downregulation of the amygdala are key factors in prolonged exposure therapy.

Interestingly the dorsolateral prefrontal cortex is activated following BLS, a key finding being that EMDR–recruited regions of the brain have a higher capacity to inhibit the amygdala compared to the regions activated during prolonged exposure.

Discussion of the AIP model and resources centred fundamentally on the need for balance between the two; positive memory networks need to be present in order for processing to occur. We also need to understand that the therapeutic relationship is a positive memory network in itself – a dimension to EMDR not often explicitly recognised.

The take-home message from Michael? EMDR is a sensitive therapy strongly dependent on the therapeutic relationship, especially when working with attachment-deficit clients. Resourcing can be as powerful as adhering to protocols.

After Michael’s fascinating presentation, we had a quick break and returned to group discussions in groups of 5-6 delegates to discuss our thoughts on the morning or afternoon’s presentation.

The feedback was that there were many thought-provoking discussions and plenty of reflection and assimilation of the two presentations. It was lovely to be in groups with delegates from all over the world and have stimulating conversations that would not have been possible if the event today were in person.

To end the day, we finished off in our traditional Zoom plenary with questions and appreciation for our two presenters, a perfect way to finish a truly informative day.