Almost everyone who has been touched by addiction has a story about a turning point or revelation of new awareness. For those of us who are in recovery as well as being in the helping professions, it can be when the bottom dropped out, when we first sought help, or that first year of recovery. For those not in recovery, it might be the first time you ever considered becoming a mental health professional, or the first time you were faced with a person with addiction, or when you decided to make it a specialty.
Many of us are sharing a pivotal moment of awareness together in the second decade of the third millennium. We are all becoming aware, either a little or a lot, of the relationship between trauma, addiction, and recovery. In my trauma therapy trainings, I talk to my trainees a great deal about how we are writing the textbooks of twenty years from now by focusing on the role of trauma in mental health. Gabor Maté, Bessel van der Kolk, and countless others are all sounding the alarm regarding trauma and addiction, and many have followed that call to add trauma training and trauma informed practice to their toolkits. We now stand not at a crossroads, but at a jumping-off point. Now that we are in agreement about the relationship between trauma and addiction, how are we going to provide the treatment that points at the trauma, bringing trauma resolution, symptom relief, and renewed internal and external resources that will give our clients agency to continue forward into a life in recovery?
It is time to treat the trauma directly as it relates to addictive disorders. There has been a major obstacle to pursuing that goal: fear. There is fear—many times quite legitimate in the SUD counseling community and in the general mental health community—of approaching the trauma too quickly (or at all) during the course of treatment, fearing that it will retraumatize sufferers and lead to relapse. That is an important concern, but it is only one of many issues that needs to be put into the decision tree regarding treatment. In addition, perhaps the prism or lens we are looking through to make these determinations needs a bit of cleaning and in some cases a full changing out of outmoded parts. This is where trauma-focused therapy, and EMDR therapy in particular, enters our discussion.
What is EMDR?
Eye movement desensitization and reprocessing (EMDR) therapy, developed by Francine Shapiro, is an eight-phased, psychotherapy treatment consisting of standardized protocols and procedures to treat unprocessed memories of adverse life events by utilizing bilateral stimulation in the form of eye movements, taps, or tones. It is used to desensitize and reprocess these memories into a more adaptive and functional form, decreasing distress and dysregulation and lessening the intensity of negative emotions, beliefs, and physical sensations. The therapy also seeks to bolster clients’ resources and incorporate adaptive attitudes, skills, and behaviors, thereby boosting resiliency and lessening the impact of current triggers. So EMDR therapy is designed to not only clear out the muck of the past, but also to reduce the impact of current stressors and future fears and related negative beliefs (Shapiro, 2014).
According to the EMDR Research Foundation (2017), there are at least thirty-six randomized controlled trials that have demonstrated EMDR therapy as a treatment for trauma. The American Psychiatric Association, Department of Defense, and World Health Organization (WHO) all recognize EMDR as an effective therapy (Shapiro, 2014). From the beginning, Shapiro’s EMDR and Adaptive Information Processing (AIP) models theorized that the main cause of mental health disorders is maladaptively processed memories of earlier adverse life experiences. In other words, Shapiro already understood that trauma was the main cause of distress, and that EMDR trauma therapy has implications to effectively treat a plethora of clinical symptoms and even to be a standalone therapy. In my book with Dr. Jamie Marich, we state that EMDR therapy can help people with trauma-driven complaints other than PTSD, including problems of daily living and most of the diagnoses in the DSM-5, including SUD (Marich & Dansiger, 2018).
Markus and Hornsveld wrote a journal article reviewing the literature on addictions and EMDR, stating that “. . . both clinical and laboratory data suggest that EMDR can be useful to reduce intensity of substance-related imagery and craving and might be a valuable intervention in addiction treatment” (2017, p. 13). O’Brien and Abel, who wrote a book on the use of the stages of change along with EMDR therapy, determined that “EMDR is a very efficient addition to a clinician’s tool bag of interventions when dealing with addiction” (2011, p. 127). In line with Shapiro’s early thinking and the years of research that followed, we now see the treating of trauma as the main vehicle for healing for almost all psychological maladies, including SUDs. Therefore, we see EMDR therapy as more than just an addition to clinicians’ toolkits, but as a primary modality and even a theoretical orientation for clinicians treating SUDs.
Individuals who enter treatment programs seeking help for SUDs often leave treatment—either with or against clinical advice—without receiving the treatment they need to maintain recovery. Current treatment for SUDs, which varies in approach, can rely on cognitive behavioral therapy (CBT) and developing self-control, methods that have been proven inadequate (Markus & Hornsveld, 2017). Treatment relapse rates are sobering. Clinical treatment studies estimate that more than two thirds of individuals relapse within weeks to months of beginning treatment and that 85 percent of individuals relapse and return to drug use within one year of treatment (Sinha, 2011). While relapse rates and treatment retention may reflect how severe and chronic SUDs are, they also indicate a need for new interventions. If simply treating SUDs behaviorally was the solution to long term recovery, SUD-focused treatment centers would be much more successful. What is the missing link?
SUD treatment needs to catch up with more current understanding of the profound influence of trauma on the development of addictive issues. As with most psychological issues, it should come as no surprise that trauma commonly co-occurs with SUDs. The Substance Abuse and Mental Health Services Administration (SAMHSA), reports that 90 percent of clients in public behavioral health care settings have experienced trauma (Mueser & Rosenberg, 2001). Additionally, trauma survivors are found in several studies to represent the majority of clients in human service systems (Browne & Finkelhor, 1986; Najavits, Weiss, & Shaw, 1997; Polusny & Follette, 1995, as cited in Elliot, Bjelajac, Fallot, Markoff, & Reed, 2005). Another study states that “Approximately half of individuals seeking treatment for SUD meet current criteria for PTSD” (Berenz & Coffey, 2012, p. 469). It is also evident that adverse childhood experiences are associated with substance dependence. Douglas et al. found the following:
Individuals who experienced sexual abuse or physical abuse, or who witnessed a violent crime were significantly more likely to be diagnosed with substance dependence, consistent with prior studies showing that ACEs increase the likelihood of substance dependence later in life (2010, p. 12–3).
A study that recruited 402 people from residential treatment programs with comorbid SUDs and mental health problems found that nearly all of their study sample (95 percent) compared to about half (52 percent) in the primary care health maintenance organization study, reported having experienced one or more childhood traumatic events (Wu, Schairer, Dellor, & Grella, 2010).
For people with SUDs, trauma symptoms also serve as both direct triggers for relapse and barriers to developing stronger resourcing and resiliency skills against future stressors. Some individuals are simply unable to enter recovery until their underlying trauma is treated (O’Brien & Abel, 2011).
There have been many studies showing that using EMDR therapy within a SUD treatment center benefits clients greatly. Marich (2009) illustrated the impact that EMDR therapy has had on the recovery process of a cross-addicted female diagnosed with substance dependence and PTSD through a case study. Prior to receiving EMDR therapy, the longest period of continued sobriety that the participant achieved was four months after being treated twelve different times. The participant received treatment in a Twelve Step facilitation program and then received fifteen sessions of EMDR therapy over a nine-month period. Following the EMDR therapy, the individual reported having achieved eighteen months of sobriety. Marich (2010) presented a case series on ten women who had received EMDR therapy as part of their continuing care treatment. All ten women credited EMDR therapy with serving as a vital element of their recovery continuing-care processes. Several other studies exhibited the benefits of using trauma-focused EMDR (TF-EMDR) to treat SUD and other addictive disorders (Brown, Gilman, Goodman, Adler-Tapia, & Freng, 2015; Cox & Howard, 2007; Henry, 1996; Rougemont-Bücking & Zimmerman, 2012).
Using the standard EMDR therapy protocol, Perez-Dandieu and Tapia (2014) targeted a specific traumatic memory, hypothesizing that this would lead to significant reductions of addiction symptoms. Over a six-month period, participants who were diagnosed with substance dependence and PTSD were randomly assigned to treatment as usual (TAU) or to TAU plus eight sessions of EMDR therapy. Despite the results that the TAU+EMDR therapy group did not show a significant improvement in addiction symptoms, EMDR therapy was correlated with a significant decrease in PTSD, depression, and anxiety symptoms, in addition to a significant increase in self-esteem (Perez-Dandieu & Tapia, 2014). Although the reprocessing of traumatic memories did not alleviate addiction symptoms, this study implies that EMDR therapy increases adaptive behavior in the form of increasing self-esteem and decreasing depression and anxiety.
In addition to using standard TF-EMDR to treat SUDs, other studies have demonstrated the application of adapted EMDR therapy to treat SUDs and other addictive disorders. Markus and Hornsveld) describe addiction-focused EMDR (AF-EMDR) as “the use of adapted EMDR therapy to target nontrauma memory representations of addiction” (2017, p. 6). The tenets of AF-EMDR include desensitizing triggers and decreasing the emotions and/or cognitions that prevent addicted people from reducing the charge of cravings and urges to use substances. Additionally, the AF-EMDR protocols target the associated euphoria of addictive behavior through highlighting positive nonuse memories as well as “increasing the stability of treatment effects” (Markus & Hornsveld, 2017, p. 15).
The American Psychological Association (APA) considers EMDR therapy to be a structured, individual therapy (2017). Francine Shapiro, the founder of EMDR, and others have also consistently touted EMDR as a complete system of psychotherapy rather than a technique. It is currently best practice to recognize EMDR therapy as “. . . a complete system of psychotherapy with a model (AIP), a method (the various protocols for how EMDR therapy is delivered), and distinct mechanism of action” (Marich & Dansiger, 2018, p. 3). There are many studies which use EMDR therapy as one of the primary treatments for various disorders such as addiction (Marich, 2009; Kullack & Laugharne, 2016), PTSD (Zepeda Méndez, Nijdam, ter Heide, van der Aa, & Olff, 2018), complex PTSD (Bongaerts, van Minnen, & de Jongh, 2017), generalized anxiety disorder (Gauvreau & Bouchard, 2008), acute stress disorder (Buydens, Wilenksy, & Hensley, 2014), and depression (van der Kolk et al., 2007).
EMDR for PTSD and SUDs
With the implementation of trauma-focused treatment, and by reviewing the aforementioned research, we can see that a reduction in PTSD symptoms is associated with SUD improvement (Hien et al., 2010). Considering the evidence, it is no longer effective to ask whether or not to treat PTSD in SUD treatment, but how best to treat PTSD in an effective way with people who have SUDs (Ford, Russo, & Mallon, 2007). Instead of wondering why substance-use-specific treatment is so ineffective over the long term, the question becomes this: How do we provide trauma treatment in a way that promotes healing from SUDs? From this jumping-off point, I see a clear case for using EMDR trauma therapy infused with mindfulness and resourcing support as a primary modality of treatment.
EMDR therapy has been compared to other treatments for PTSD (Chen, Zhang, Hu, & Liang, 2015; Graca, Palmer, & Occhietti, 2014). Chen, Zhang, Hu, and Liang (2015) found that EMDR therapy was superior to CBT in the treatment of PTSD. Graca and colleagues (2014) discovered that EMDR therapy and cognitive processing therapy are clinically effective and complementary treatments in treating PTSD in a residential setting. In a meta-analysis of randomized controlled trials (RCTs), Chen et al. concluded that not only does EMDR therapy reduce symptoms of PTSD and subjective distress, but that “. . . EMDR therapy can improve self-awareness in patients, change their beliefs and behaviors, reduce anxiety and depression, and lead to positive emotions” (2014, p. 15). This evidence is reflective of EMDR therapy serving as a comprehensive psychotherapy. However, EMDR therapy has not yet been studied as a complete, standalone treatment system. In my recent work with different treatment centers across the country, I am making the case that EMDR therapy has the potential, when imbedded with mindfulness techniques, to be used as the comprehensive primary clinical operating protocol within a treatment center.
EMDR therapy can support all of the phases of SUD treatment through its ability to promote the visualization of a healthier future lifestyle, its resourcing capabilities, and trauma resolution. Its three-prong approach allows individuals to process past experiences that are contributing to present-day symptoms, to cope with present day triggers that cause distress, and to create a future for themselves that is worth living (Brown, Shapiro, & Stowasser, 2016). The resource development and installation component assists individuals in developing and strengthening internal and external positive resources to assist in coping with distress that might otherwise lead to relapse. EMDR therapy provides resolution from the incapacitating effects of trauma, so that they no longer serve as a reason to self-medicate.
EMDR for Addiction
So what would it look like to use EMDR therapy as the primary treatment protocol? Possibly, this would mean taking addiction-specific EMDR protocols one step further to base the entire treatment planning system on the eight phase EMDR protocol. According to Wise and Marich (2016), the premise behind addiction-specific EMDR protocols is to promote stabilization and decrease the risk of relapse without requiring the direct targeting of traumatic memories. Addiction-specific EMDR protocols “show promise in promoting recovery from addictions according to practice knowledge in the EMDR therapy community and the limited research that exists” (Wise & Marich, 2016, p. 232).
Markus and Hornsveld (2017) identify four different addiction-specific EMDR therapy protocols in their compelling “EMDR Interventions in Addictions” article:
Stemming from these protocols, Markus and Hornsveld (2017) created a collection of all resourcing, trauma, and AF-EMDR therapy interventions that can be used to treat addiction. Markus and Hornsveld (2017) termed this set of fifteen interventions “The Palette of EMDR Interventions in Addiction” (PEIA), which derive from current protocols, theoretical considerations, and clinical experience. The PEIA offers clinicians a toolkit of options to choose from when treating addiction with EMDR therapy, while of course taking into consideration clients’ histories and individual case conceptualizations. The PEIA is not to be used as a standalone treatment, but rather as an adjunct to addiction treatment, as the only intervention in the palette that is evidence-based is TF-EMDR.
Wise and Marich (2016) assessed the lived experiences of nine participants with co-occurring PTSD and addictive disorders through a qualitative, phenomenological study, following the implementation of both standard protocol EMDR therapy and addiction-specific EMDR therapy protocols. Wise and Marich (2016) used the DeTUR, CravEx, FSAP, or a combination of them. All participants recognized a remission in symptoms of both disorders.
The use of EMDR therapy to effectively treat individuals with SUDs has been studied thoroughly (Marich, 2009; Marich, 2010; Hase, Schallmayer, & Sack, 2008; Zweben & Yeary, 2006; O’Brien & Abel, 2011; Cox & Howard, 2007; Abel & O’Brien, 2010). And as research across the spectrum of psychological issues continues to show us, treating the trauma is the primary avenue to promote long term healing and recovery across the board. Therefore, viewing the EMDR trauma therapy protocol as the primary avenue to treat SUD and co-occurring issues makes sense. We can utilize the eight phases of EMDR therapy as a natural progression through the SUD treatment and recovery process.
The first two phases of EMDR therapy—client history and then stabilization and preparation—support the assessment stage and building of resourcing and resiliency with our clients. The third through sixth phases of EMDR therapy, concerned with reprocessing and adaptively transforming traumatic material, are useful in the intensive therapeutic healing process and catharsis period. Finally, phases seven and eight of EMDR therapy provide the third stage of trauma treatment, that of personality reintegration, relapse prevention, and application of new insights in day to day living. The eight-phase protocol, when seen through the AIP model and used in this way as the primary therapeutic modality, provides a trauma-focused solution that brings relief to sufferers of a variety of maladies that include and accompany their struggle with SUD. The commitment to case conceptualization through this lens leads to a broader and deeper healing of our clients.
By using EMDR therapy as the primary system for case conceptualization and treatment, we are flipping the integration paradigm; rather than fitting EMDR therapy as a technique into SUD treatment, we fit typical SUD recovery exercises into an EMDR, therapy-based, trauma-focused protocol. Based on the research of the last thirty years on EMDR therapy and addictions, and the consensus amongst thought leaders in the world of trauma and SUD, it would seem that a trauma-focused approach to SUD that is scaffolded using the EMDR therapy and AIP model would be worth continued practice and certainly more research.
In treatment centers or private practices where primary clinical practices differ from this approach, but EMDR therapy is utilized as an intervention, this reorientation toward trauma resolution as a primary goal of treatment might still promote more competent care and improved outcomes. This important clinical dialogue may result in the easing of suffering for so many, whether they have been struggling for years or are at the beginning of their difficulties. I look forward to continuing to practice in this way, to research the results, and to walk forward into new frontiers together with other researchers and practitioners.
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