Art Therapy and Eye Movement Desensitisation and Reprocessing (EMDR) for the treatment of Post-Traumatic Stress Disorder (PTSD) and trauma processing

Art therapist Nili Sigal tells us about art therapy and EMDR…

I qualified as an art therapist in 2009 and started to train in Eye Movement Desensitisation and Reprocessing (EMDR) in 2014. I currently work in a community mental health setting, with clients who have diagnoses such as PTSD, dissociation, complex trauma and who often have a history of sexual, psychological and/or physical abuse. Working with this client group led me to combine art psychotherapy with EMDR (or use art-based trauma processing) as with some clients, a combination of EMDR and art therapy seems to be especially beneficial.

While art therapy remains at the core of my work, I use EMDR to address specific memories which are particularly distressing, especially ones that might be re-experienced or appear in nightmares and flashbacks. Working through these memories in EMDR, then returning to art therapy for the rest of the therapeutic process, can help clients to integrate insights and emotions with the re-framed, processed memories which have formed the client’s negative perception of themselves and the world.

EMDR is one of the two approaches (alongside trauma-focused CBT) recommended in the NICE guidelines for treatment of PTSD. Training is only open to qualified psychologists, therapists and other professionals with relevant training and qualifications. It is taught as a tool to be used in an integrative way and can be introduced as a standalone treatment or added as a targeted piece of work within a longer-term therapeutic intervention. It is possible to begin practicing EMDR after completing the first level, although level three is focused on clients with complex trauma, which has been my main area of interest.

I have found different aspects of EMDR very useful in my practice, especially its focus on embodiment and “felt sense”, encouraging clients to pay attention to body states and encouraging somatic awareness, as well as “safe place” exercise and other resourcing techniques to help clients who struggle to self-soothe or to regulate their emotions. There is no scope in this article to go fully into the practice and theory of EMDR, but a great deal of information is available online and I include two quotes which provide a brief summary:

“If your therapist feels EMDR is suited for your difficulty, then s/he will describe the EMDR model to you and explain the theory. Your therapist will spend some time doing some relaxation exercises with you, which could include ‘safe or pleasant place’ exercises, guided visualisation, deep muscle relaxation, breathing retraining etc.”

“Once you and your therapist feel that you are sufficiently prepared, you can then target a distressing memory with the eye movements or other forms of left-right alternating stimulation, such as sound or taps. Your therapist will ask you to select an image that represents the distressing event. You will then be asked to think about negative and positive thoughts, your feelings, the amount of distress you feel and where you feel it in your body. In the process the distressing memories seem to lose their intensity, so that the memories are less distressing and seem more like ‘ordinary’ memories. The effect is believed to be similar to that which occurs naturally during REM sleep (Rapid Eye Movement) when your eyes rapidly move from side to side. EMDR helps reduce the distress of all the different kinds of memories, whether it was what you saw, heard, smelt, tasted, felt or thought…”
(http://emdrassociation.org.uk/what-is-emdr/background-and-basics/)

From the EMDR Institution’s website:
“In successful EMDR therapy, the meaning of painful events is transformed on an emotional level.  For instance, a rape victim shifts from feeling horror and self-disgust to holding the firm belief that, “I survived it and I am strong.”  Unlike talk therapy, the insights clients gain in EMDR therapy result not so much from clinician interpretation, but from the client’s own accelerated intellectual and emotional processes.  The net effect is that clients conclude EMDR therapy feeling empowered by the very experiences that once debased them.  Their wounds have not just closed, they have transformed.”
(http://www.emdr.com/what-is-emdr/)

I became interested in trauma processing due to the level of trauma-related distress, anxiety/terror and feelings of “stuckness” reported by my clients. This led me to look at the current thinking about the impact of trauma on the brain and personality, and especially on the developing brain and attachment styles in case of childhood trauma – Positive Outcomes for Dissociation Survivors (PODS – see http://www.pods-online.org.uk/) have useful resources and training on trauma and dissociation.

The initial stage of trauma-informed therapy is focused on helping clients to feel safer and more settled in the face of the disturbances and distress related to the trauma. In art therapy this often happens intuitively, as clients gradually establish trust (in the room and the therapist), develop the courage to express themselves, re-connect with (or learn to) play and grow in confidence. However, some grounding might be necessary before transference can develop with highly traumatised clients, especially if there is an absence of an internalised object or if that internalised object is the abuser; in such cases, closeness and being able to achieve openness and trust in the therapeutic relationship can be one of the outcomes, not the starting point.

While art therapy can be highly effective in helping clients to develop and experience a sense of interpersonal safety in the sessions with the therapist, we need to consider what happens to particularly distressed clients between sessions, especially those who might be at risk of hurting themselves. Art-making, journaling or writing for clients between sessions can be helpful – it is certainly a tool I often use in my own clinical work. Yet for clients who are living in the personal hell often called PTSD, haunted by the ghosts and traumas of their past, who feel unsafe, distressed and hypervigilant every day in the supposed safety of their own homes, I strongly believe that help with symptom relief, learning to cope between sessions and building internal resources to stay grounded can be a vital part of the work.

I have also found that psychoeducation on trauma and our current understanding of its impact on the brain can be invaluable for many clients, because having an explanation for some of the difficulties they experience can help them become more self-compassionate, develop a better understanding of their own symptoms and to be less self-critical and more patient towards themselves and their recovery. This includes information about different parts of the brain and the way they react to chronic traumatisation, the role of cortisol and hypervigilance, “fight, flight and freeze” responses, body sensations, disruption of memory related to the trauma and so on.

While some clients can successfully use the art materials to depict and process the trauma event/s and their feelings about it in an organic way and as part of the non-directly art therapy work, or as part of art-based trauma-processing protocols (such as CATT – Children’s Accelerated Children’s Trauma Treatment by Carly Raby), for others it might feel too overwhelming to depict or to talk about what had happened to them. Clients who avoid trauma material may develop a pattern of making images which are either escapist, or which unconsciously bring up aspects of the trauma, yet are very reluctant to discuss it directly or to use art-making intentionally in the processing. The trauma material can become “split off” from the rest of the therapeutic work, in the same way that it might have done in the client’s personal lives, where dissociation or repression led to a separation between the “traumatised self” and the “functioning self”.

Clients might seek therapy when the traumatised self begins to intrude on the functional self’s capacity for perfunctory existence, through flashbacks or other symptoms. They might be able to reflect on their avoidance of the trauma and have insight into this, but feel unable to change it. Clients might seem to have constant upheaval in their personal lives which fills the session time and there is never enough space to consider the past. However, on closer examination, much of this chaos is a re-enactment of earlier trauma. This trauma material needs to be accessed for the client to move forward, but ambivalence from clients (and sometimes therapists) means it can be easily avoided, even in long-term therapy. While this can be an indication that the client is not ready for trauma processing, something which must be carefully assessed, the client might be ready but need guidance and support to venture into a memory they might have spent most of their lives trying to forget and are terrified of accessing. In my opinion the therapist should then offer to help the client to face his/her trauma in a way that feels contained and safe.

Trauma-focused work can feel more prescriptive or directive compared with psychodynamic approaches, which means it might seem incompatible with the non-directive way many of us (myself included) often work with our clients. However, the process of EMDR is very similar to “free association”, as the therapist invites the client to allow any thoughts, feelings or images that emerge to come to mind without analysing or judging them, and mostly without any suggestions or inference from the therapist due to the adaptive information processing model underlying EMDR, which is based on the client’s drive and ability for self-healing. This makes the process non-directive within a very structured framework. While some clinicians only use EMDR for single-event trauma it also used, and is suitable for, complex trauma. When I have clients who are affected by PTSD and other traumatic event/s, who are ready to work on the trauma yet are afraid of doing so, where visualisation might be more accessible than art-making for trauma processing and where some structure and support is needed to make the work feel safe for the client – in these cases, if clinically appropriate, I tend to suggest EMDR.

My way of combining EMDR with my art therapy practice is always led by the needs of the client, making each intervention individual; however, it seems there is a name for what I do: “integrative trauma treatment”, and that I am not alone in combining art therapy with trauma-informed approaches. While the costs of EMDR training can make it prohibitive, it is not (by any stretch) the only approach for trauma processing; in art therapy we can use CATT or art-making to work through traumatic memories, while  trauma-focused CBT and other approaches can also be highly effective. I would be very interested in hearing from other art therapists who are working in a similar way and I wonder whether there might be interest in a trauma-focused BAAT special interest group?

I believe that as a profession we could all benefit from more discussion about complex trauma, something that I do not recall having a single lecture about while I was training (although things may have changed). I would argue that, as our understanding of the impact of trauma on the brain and of the role of chronic traumatisation on development, neural pathways, attachment styles and a variety of mental health difficulties continues to develop and improve, so should our ability to work with this client group. As Carolyn Spring, the Director of PODS, succinctly puts it in her training for working with trauma and dissociation, we need to ask: “What has happened to you?” rather than, “What is wrong with you?”’