The Eyes Have It
The most talked-about treatment in Texas these days for trauma-related anxiety and depression sounds incredible, but seeing is believing.
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By the time that vietnam veteran Jerry Smith (not his real name) found his way to psychologist John Black at the Veterans Administration North Texas Health Care System in Dallas in the fall of 1995, he was an absolute mess. In and out of the V.A. system since 1976 suffering from depression, anxiety, alcoholism, and post-traumatic stress disorder (PTSD), he had tried various medications and sat through hours of conventional therapy to no avail. He was an unemployable shut-in: Driving anywhere or visiting the mall—being in any crowd, in fact—made him anxious. He was tormented by sleep terrors, meaning he would wake up in the middle of the night in a cold sweat. And he was so morose that in the previous year he had checked into the V.A. center ten times, five for attempting or considering suicide.
The V.A. first tackled 53-year-old Smith’s drinking problem in the center’s substance-abuse unit, then eased him into occupational therapy. And then, after a few months, Black set about treating Smith’s underlying pathology, combat-related PTSD, with eye-movement desensitization and reprocessing (EMDR), a voguish treatment whose guiding principle is that rapid eye movements similar to those that occur involuntarily during deep sleep can help heal the psychological wounds inflicted by traumatic experiences.
Like many doctors who treat PTSD, Black had initially been skeptical of EMDR’s value when it became the talk of his profession in the late eighties. The brainchild of California psychologist Francine Shapiro in 1987, EMDR sounded implausible, but it gained credibility after she published the results of experiments on 22 trauma victims in 1989: Study after study showed that something about repeated left-right brain activity prompted the psyche to desensitize and reprocess traumatic memories. As word spread, other therapists—particularly those with patients suffering from PTSD—gave EMDR a try, and they too had great success. By the mid-nineties it had become one of the most debated treatment protocols in modern clinical psychiatry. And though some skeptics held firm, there was no denying EMDR’s success rate: 80 percent to 90 percent, compared with only 55 percent for conventional PTSD treatments. No wonder, then, that EMDR was the choice of many doctors treating survivors of the 1995 Oklahoma City bombing. “It can work faster than other techniques, and patients seem to like it better,” says Black, who tried out EMDR in 1991 and has used it in hundreds of sessions since.
In Jerry’s case, Black first took a thorough personal and psychiatric history, emphasizing the traumatic events Jerry had experienced in Vietnam. He then had Jerry rate the level of distress that the memories caused him on the Subjective Units of Disturbance Scale, from zero (no distress) to ten (extreme distress). One incident in particular seemed profoundly troubling—what Jerry called the shoot-don’t-shoot episode. During the war, he and his platoon were ambushed after a patrol and pinned down by a sniper. As they ran for cover, they realized that one of their group had been shot and was down in a clearing directly in the sniper’s line of sight. “Every time we fired on the sniper, he would fire at the wounded man,” Jerry recalled. “But if we didn’t fire, then he was just stuck there.”
Such “double binds,” Black says, are common among sufferers of PTSD. “Many traumas are formed around a damned-if-you-do-damned-if-you-don’t situation,” he says. “There’s the impact of the event itself but also guilt about not having done enough and a sense of helplessness. It can be all the more acute when a life is involved.” To counteract those feelings, Black had Jerry envision the incident in his mind and supplement the memory with smells, sounds, and other sensory components. Then he began moving his hand back and forth, and he asked Jerry to follow it with his eyes. After a minute or two of rapid eye movement, Black told Jerry to take a break and tell him what else had come to mind. “Frequently with EMDR you’re not only processing the traumatic memory,” he explains. “The eye movement will unearth other aspects of the memory or other traumatic memories entirely. When those things come up, we address them with more eye movement. It’s like you’re tracking pathological memories.” The results of Jerry’s first EMDR sessions were startling: The shoot-don’t-shoot memory, which he’d initially given a rating of ten, dropped to zero. “There was immediate relief,” Black recalls, “and that made all the difference.”
Of course, even EMDR has its limits. By the time Jerry returned to see Black the next week, the nightmares and disturbing thoughts had returned, so he went through the treatment again and again, eventually stepping up his regimen to two visits a week. Over time, his distress over his war memories steadily abated to the point that his ratings were consistently down to two or three. Meanwhile, Black eased him back into a normal life, persuading him to buy a car and shop at the mall. “It wasn’t the easiest thing in the world, but I could do it,” Jerry says. He still has an anxiety disorder, and he still has the occasional nightmare, but eye-movement therapy has gotten his PTSD under control. “This is a good outcome,” Black says. “He’s had no drinking, no suicide attempts, and no hospitalizations since he started EMDR. Conventional techniques might have produced the same result, but they would have been much rougher on him.”
So how does it work? Even Shapiro admits that she is at a loss to explain what causes such dramatic psychological healing, but she and other researchers have a few theories. We know, for instance, that the human brain has an intricate system for processing traumatic life experiences. This processing system, which involves memory, learning, and regulating emotions, records the traumatic events in the memory and then sorts through them, absorbing the valuable lessons they can teach (don’t touch the stove top until you’ve checked to see if it’s turned on) and discarding the negative ones. This filtering takes place during our waking hours, when we ruminate on or talk about an experience, and during sleep, when we dream.
When it’s functioning properly, our processing system can deal with the worst consequences of a trauma. However, some traumas strike so suddenly and with such force that they overload or jam the works. In these instances the memory of the trauma remains stuck in the psyche, where it can wreak all manner of havoc on the victim through flashbacks, terror-filled thoughts, nightmares, and collateral anxiety or depression. “The brain is hard-wired to protect us,” says Jamie Zabukovec, a clinical psychologist who practices at the North Texas V.A. center and frequently uses EMDR. “If that memory is not processed out, any future sensory hint of the trauma—a similar smell or sound—can ignite a fight-or-flight response.” Studies at Yale University and the National Institutes of Health, among others, suggest that this hitch in processing involves neurochemical changes: When thrust into a traumatic situation, the body secretes large amounts of adrenaline to prepare itself to fight for survival. These substances are crucial to the fight-or-flight response, but they can also have detrimental side effects, including confusion and impaired learning and memory. If the survival response system becomes jammed as the result of a particularly traumatic experience, the victim can become jumpy and predisposed to panic at any given moment.
The impaired neurochemistry of PTSD, in fact, results in a range of maladaptive behaviors. To avoid the psychological pain caused by the unpleasant memory, victims will often withdraw from society or seek relief in alcohol or drugs. In each case the avoidance rituals are progressive: A war veteran may initially be panic-stricken at the sound of helicopter blades, but as the PTSD becomes more chronic, he finds himself afraid of anything that sounds remotely like a chopper engine. Fear of crowds may progress to fear of any remotely claustrophobic situation—say, driving on a crowded freeway. Even the most trivial of life’s problems can take on traumatic proportions to a psyche battered by PTSD: Minor accidents or illnesses can prompt depression or a worsening of substance abuse.
Shapiro has postulated that the rapid eye movement of EMDR serves to jump-start the shorted-out trauma-processing system, perhaps by reinvigorating the inhibitory receptors or maybe by simply increasing electrical current in the brain and thereby enhancing memory-processing. Studies she cites in her 1997 book, EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma, suggest that rats hit with low-voltage current through electrodes implanted in their brains experienced a change in synaptical potential (the electrical charge in the space between brain receptors) that had to do with memory function. More recently, a test performed on six PTSD sufferers at the Human Resource Institute in Brookline, Massachusetts, revealed that EMDR puts two critical areas of the brain back on line: the anterior cingulate gyrus, the area associated with perceived threat, and the left frontal lobe, where many cognitive functions—learning and memory—are regulated. These early results would seem to indicate that the hypotheses of Shapiro and others are correct: that rapid eye movement somehow reawakens portions of the brain crucial to the perception and processing of traumatic events.
Though EMDR has received the most attention for its role in treating war veterans and disaster victims, it has also proved helpful to individuals who’ve suffered so-called “small t” traumas that are the root cause of drug abuse, phobias, and depression. Take the case of Susan Jones (not her real name), who back in 1995 thought she had her life in pretty good order. Then she suddenly became suicidal. “I called it my dark night of the soul,” the 45-year-old former dental technician recalls. “I had no idea where it came from. I thought maybe it was because we’d recently moved from Austin to San Antonio or because my daughter was now a teenager and that relationship was changing. But nothing I did could shake it.” Susan was no stranger to emotional difficulty. For most of the previous twenty years, she’d struggled through a troubled marriage, though she thought all of that was behind her. Her husband had quit using drugs and had even joined her in couples counseling. But no amount of therapy could lift the black cloud, nor could a prescription for Prozac.
Through a friend, Susan heard about a San Antonio counselor, Shirley Jean Schmidt, who used EMDR. “I figured, ‘Why not?’” she says. After only a single EMDR session, she began to get at the root of her depression. “There were immediate results once she turned on the light bar and I began moving my eyes,” Susan says. “I could remember how depressed I was as a child. It pulled me right back into it, and I could see that my parents hadn’t merely been strict; they had abused me. What happens is that the eye movement lets you reexperience all that in a safe place. It wasn’t really recovered memory. It was more like clarifying it.”
Susan remembered that she was often severely punished, even when she felt she’d done the right thing. “It was not a life or death situation,” Schmidt says, “but to a young child, that can be serious trauma, especially if it stays with her.” With patients like Susan, Schmidt adds, the task is not so much to desensitize and reprocess one or a handful of serious traumas, but to “untangle the knot of many small, repeated traumas. The process allows them to pull each thread out of the knot, lay it out flat, and look at it.”
Susan underwent two hours of EMDR therapy a week with occasional breaks over a year and a half in 1996 and 1997. She currently lives in another state and is studying to become a therapist herself. “The thing about EMDR is that you don’t just process the old, bad memories,” she says. “Once you’ve done that, you can begin to work on your beliefs about yourself as a result of those memories. It ran deeper than anything I’d done—and I’d done a lot of things.”