Alberta's first EMDR (Eye Movement Desensitization and Reprocessing) Pilot Program targeting inpatients with suicidal thoughts is underway at Alberta Hospital Edmonton (AHE).
Dr. Lisa Burback, Consultant Psychiatrist, Young Adult Services at AHE and an Assistant Clinical Professor in the Department of Psychiatry at the University of Alberta, launched the project in February in partnership with AHS (Alberta Health Services) Young Adult Services and AHE. Dr. Olga Winkler has recently also joined the pilot.
Young adults who are hospitalized for suicidal or self-injurious behavior are eligible for the pilot program. "These are patients aged 18 to 26 with illnesses requiring hospitalization, usually involving self-harm urges or suicidality," says Dr. Burback.
Patients start treatment while in hospital and are then seen as outpatients after discharge until treatment is complete.
"We've had about 19 patients referred and we've enrolled about 11 so far. Some have had to be excluded because of the level of dissociative symptoms. Two have completed EMDR treatments and are doing very well," she says.
Plans are also underway to conduct a study of the impact of the EMDR pilot program, in partnership with Dr. Andrew Greenshaw, Associate Chair of the University of Alberta's Department of Psychiatry.
"We hope to collect data that will help us to learn how we can treat these patients more effectively. There is great opportunity to use this information to train future students, residents and other professional staff in the future."
Dr. Burback hopes that the pilot will one day grow into a trauma program integrated into the rest of Youth Mental Health Services and possibly serving the whole zone. This would help fill a large gap in the system, she notes, as the only current organized trauma program is the Operational Stress Injury Clinic, which is limited to members of the military and police forces.
"Our goals are quite ambitions," she says, "and management and staff at AHE have been very encouraging and supportive. In talking with Mark Snaterse (Executive Director for Addiction and Mental Health, Edmonton Zone) and other AHS leadership, there is recognition that there is a real need to develop services to address psychological trauma."
Dr. Burback, who completed her Psychiatry Residency at the University of Alberta in 2012, became intrigued with EMDR psychotherapy after treating suicidal, severely depressed and traumatized patients with Dialectical Behaviour Therapy (DBT).
"DBT is a form of therapy for people who have suicidal thoughts or self-harm urges. Many of them have depression, anxiety, and posttraumatic symptoms too. The more I listened to their stories, the more it made sense to me that these suicidal thoughts and urges are rooted in previous adverse experiences," she explains.
"Usually there is something that prompts overwhelming emotions. It could be thoughts related to a negative core belief, a memory of a previous adverse experience, or something happening now that is a symbolic reminder of a traumatic experience from the past," she says.
"These overwhelming states often have intense physical sensations and urges associated with them. These are difficult to manage and the person resorts to efforts to escape, which could be urges to cut, thoughts of suicide, substance use, or other problem behaviors."
With DBT, patients are taught the skills to identify and manage intense and painful emotions. EMDR takes a different and complementary approach.
"The associated experiences are brought into awareness, while bilateral stimulation (either rapid lateral eye movements or alternating tactile stimulation in the form of tapping) is applied by the psychotherapist. This facilitates the mindful reviewing of emotionally charged, adverse memories and their associations, while also increasing parasympathetic tone," says Dr. Burback.
Although EMDR has mainly been used since it was first developed in the 1980s to overcome symptoms associated with Post-Traumatic Stress Disorder (PTSD), it is now also used to treat mood and anxiety disorders such as depression, phobias, and panic disorders.
Here's how a recent study in the European Journal of Psychotraumatology explains the complex neurobiological connections between eye movements, traumatic memories and emotional regulation:
"Oculomotor movements have been shown to aid in the retrieval of episodic memories, serving as sensory cues that engage frontoparietal brain regions to reconstruct visuospatial details of a memory," it states. "Frontoparietal brain regions not only are involved in oculomotion, but also mediate, in part, the retrieval of autobiographical episodic memories and assist in emotion regulation."
Before a patient undergoes EMDR, the therapist assesses their history and whether they are suitable candidates for treatment. The therapist then does preparation work with the patient, teaching them strategies for setting aside memories after and between sessions.
"The next step is to find the target memories that we're going to work on and there is a process for that," says Dr. Burback.
"You have the patient bring up the experience in their mind while you do what is called bilateral stimulation, stimulating one side of the brain and then the other. You're activating the prefrontal cortex, but you might also engage areas involved in emotion, sensory experience, attention, etcetera," she says.
"After a memory is reviewed, the patient can think of that memory and it won't cause all that activation. It feels like it's in the past. What EMDR does is change the person's experience so it no longer causes distress. That's what makes it so exciting."
The EMDR International Association (EMDRIA) - a professional association of EMDR therapy practitioners and researchers - says more than 30 positive controlled studies have been conducted on EMDR therapy.
Some studies found that as many as 84% to 90% of single-trauma victims no longer suffered PTSD symptoms after just three 90-minute EMDR therapy sessions. However, hospitalized patients often have complex trauma histories, with developmental (attachment) trauma and other comorbidities, making treatment more complicated and prolonged.
EMDR therapy involves a total of eight distinct phases, including patient history taking, client preparation, assessment, desensitization, installation, body scan, closure and reevaluation of treatment effect, according to the EMDRIA website.
"My job is to coach the patient through the process of doing this. I'm keeping a watch on their level of emotional activation, and checking in periodically to monitor and guide the process until the memory no longer causes any distress," Dr. Burback says.
"I don't add interpretations. I don't add anything unless the process gets stuck. I'm letting the person's own mind work things out. I'm also ensuring the person is in a state of dual attention, meaning that they are able to be aware of both the 'here and now' with me and also pay attention to their internal experience," she explains.
"Sometimes, people will go so deeply into a memory that they lose touch with the here and now. If that happens it's not activating the network in the brain that we need to activate for this therapy to work. Part of my job is titrating the experience so the person can stay present and mindful."
Often, patients carry negative beliefs about themselves or negative associations that are attached to their traumatic memories. Through EMDR therapy, the goal is to "install" a positive belief about the patient's self to replace such negative beliefs.
"EMDR is a radically different approach. I've seen people who have gone through traditional forms of therapy and they still feel that they are consciously having to white-knuckle it all the time. But once they go through this process, they don't have those painful memories coming up all the time anymore."
At a recent EMDR conference in Vancouver, Dr. Burback attended a presentation by Simon Proudlock, an EMDR specialist, Consultant Psychologist and Associate Fellow of the British Psychological Society who works for Britain's National Health Service.
"He talked about a pilot study he did involving people in suicidal crisis. A total of 50 people completed EMDR therapy targeting the experiences associated with their distress. These people were on the verge of being admitted to hospital, they were in crisis and wanted to self-harm or commit suicide," she says.
"He and his colleagues used EMDR therapy and found that it reduced their desire for suicide. In fact, 42% of the people who completed the therapy exited mental health services; there was a 78% reduction in inpatient admissions; and about a 70% reduction in contact with their Crisis Team. That is radical."
So where does Dr. Burback plan to go from here with her EMDR Pilot Project?
"I'm preparing an application to the Mental Health Foundation for funding. The really exciting thing about this is if we can target the experiences that are leading to suicidality, my hope is that we can get people when they're young and prevent a pattern of repeat hospitalizations," she says.
"If we can treat their disorders early, then hopefully we can change their life trajectory, so they're not suffering, their families don't suffer, there is less risk of suicide, and they don't require as many resources from the mental health system."
Dr. Lisa Burback, Consultant Psychiatrist, Young Adult Services at AHE and an Assistant Clinical Professor in the Department of Psychiatry at the University of Alberta, launched the project in February in partnership with AHS (Alberta Health Services) Young Adult Services and AHE. Dr. Olga Winkler has recently also joined the pilot.
Young adults who are hospitalized for suicidal or self-injurious behavior are eligible for the pilot program. "These are patients aged 18 to 26 with illnesses requiring hospitalization, usually involving self-harm urges or suicidality," says Dr. Burback.
Patients start treatment while in hospital and are then seen as outpatients after discharge until treatment is complete.
"We've had about 19 patients referred and we've enrolled about 11 so far. Some have had to be excluded because of the level of dissociative symptoms. Two have completed EMDR treatments and are doing very well," she says.
Plans are also underway to conduct a study of the impact of the EMDR pilot program, in partnership with Dr. Andrew Greenshaw, Associate Chair of the University of Alberta's Department of Psychiatry.
"We hope to collect data that will help us to learn how we can treat these patients more effectively. There is great opportunity to use this information to train future students, residents and other professional staff in the future."
Dr. Burback hopes that the pilot will one day grow into a trauma program integrated into the rest of Youth Mental Health Services and possibly serving the whole zone. This would help fill a large gap in the system, she notes, as the only current organized trauma program is the Operational Stress Injury Clinic, which is limited to members of the military and police forces.
"Our goals are quite ambitions," she says, "and management and staff at AHE have been very encouraging and supportive. In talking with Mark Snaterse (Executive Director for Addiction and Mental Health, Edmonton Zone) and other AHS leadership, there is recognition that there is a real need to develop services to address psychological trauma."
Dr. Burback, who completed her Psychiatry Residency at the University of Alberta in 2012, became intrigued with EMDR psychotherapy after treating suicidal, severely depressed and traumatized patients with Dialectical Behaviour Therapy (DBT).
"DBT is a form of therapy for people who have suicidal thoughts or self-harm urges. Many of them have depression, anxiety, and posttraumatic symptoms too. The more I listened to their stories, the more it made sense to me that these suicidal thoughts and urges are rooted in previous adverse experiences," she explains.
"Usually there is something that prompts overwhelming emotions. It could be thoughts related to a negative core belief, a memory of a previous adverse experience, or something happening now that is a symbolic reminder of a traumatic experience from the past," she says.
"These overwhelming states often have intense physical sensations and urges associated with them. These are difficult to manage and the person resorts to efforts to escape, which could be urges to cut, thoughts of suicide, substance use, or other problem behaviors."
With DBT, patients are taught the skills to identify and manage intense and painful emotions. EMDR takes a different and complementary approach.
"The associated experiences are brought into awareness, while bilateral stimulation (either rapid lateral eye movements or alternating tactile stimulation in the form of tapping) is applied by the psychotherapist. This facilitates the mindful reviewing of emotionally charged, adverse memories and their associations, while also increasing parasympathetic tone," says Dr. Burback.
Although EMDR has mainly been used since it was first developed in the 1980s to overcome symptoms associated with Post-Traumatic Stress Disorder (PTSD), it is now also used to treat mood and anxiety disorders such as depression, phobias, and panic disorders.
Here's how a recent study in the European Journal of Psychotraumatology explains the complex neurobiological connections between eye movements, traumatic memories and emotional regulation:
"Oculomotor movements have been shown to aid in the retrieval of episodic memories, serving as sensory cues that engage frontoparietal brain regions to reconstruct visuospatial details of a memory," it states. "Frontoparietal brain regions not only are involved in oculomotion, but also mediate, in part, the retrieval of autobiographical episodic memories and assist in emotion regulation."
Before a patient undergoes EMDR, the therapist assesses their history and whether they are suitable candidates for treatment. The therapist then does preparation work with the patient, teaching them strategies for setting aside memories after and between sessions.
"The next step is to find the target memories that we're going to work on and there is a process for that," says Dr. Burback.
"You have the patient bring up the experience in their mind while you do what is called bilateral stimulation, stimulating one side of the brain and then the other. You're activating the prefrontal cortex, but you might also engage areas involved in emotion, sensory experience, attention, etcetera," she says.
"After a memory is reviewed, the patient can think of that memory and it won't cause all that activation. It feels like it's in the past. What EMDR does is change the person's experience so it no longer causes distress. That's what makes it so exciting."
The EMDR International Association (EMDRIA) - a professional association of EMDR therapy practitioners and researchers - says more than 30 positive controlled studies have been conducted on EMDR therapy.
Some studies found that as many as 84% to 90% of single-trauma victims no longer suffered PTSD symptoms after just three 90-minute EMDR therapy sessions. However, hospitalized patients often have complex trauma histories, with developmental (attachment) trauma and other comorbidities, making treatment more complicated and prolonged.
EMDR therapy involves a total of eight distinct phases, including patient history taking, client preparation, assessment, desensitization, installation, body scan, closure and reevaluation of treatment effect, according to the EMDRIA website.
"My job is to coach the patient through the process of doing this. I'm keeping a watch on their level of emotional activation, and checking in periodically to monitor and guide the process until the memory no longer causes any distress," Dr. Burback says.
"I don't add interpretations. I don't add anything unless the process gets stuck. I'm letting the person's own mind work things out. I'm also ensuring the person is in a state of dual attention, meaning that they are able to be aware of both the 'here and now' with me and also pay attention to their internal experience," she explains.
"Sometimes, people will go so deeply into a memory that they lose touch with the here and now. If that happens it's not activating the network in the brain that we need to activate for this therapy to work. Part of my job is titrating the experience so the person can stay present and mindful."
Often, patients carry negative beliefs about themselves or negative associations that are attached to their traumatic memories. Through EMDR therapy, the goal is to "install" a positive belief about the patient's self to replace such negative beliefs.
"EMDR is a radically different approach. I've seen people who have gone through traditional forms of therapy and they still feel that they are consciously having to white-knuckle it all the time. But once they go through this process, they don't have those painful memories coming up all the time anymore."
At a recent EMDR conference in Vancouver, Dr. Burback attended a presentation by Simon Proudlock, an EMDR specialist, Consultant Psychologist and Associate Fellow of the British Psychological Society who works for Britain's National Health Service.
"He talked about a pilot study he did involving people in suicidal crisis. A total of 50 people completed EMDR therapy targeting the experiences associated with their distress. These people were on the verge of being admitted to hospital, they were in crisis and wanted to self-harm or commit suicide," she says.
"He and his colleagues used EMDR therapy and found that it reduced their desire for suicide. In fact, 42% of the people who completed the therapy exited mental health services; there was a 78% reduction in inpatient admissions; and about a 70% reduction in contact with their Crisis Team. That is radical."
So where does Dr. Burback plan to go from here with her EMDR Pilot Project?
"I'm preparing an application to the Mental Health Foundation for funding. The really exciting thing about this is if we can target the experiences that are leading to suicidality, my hope is that we can get people when they're young and prevent a pattern of repeat hospitalizations," she says.
"If we can treat their disorders early, then hopefully we can change their life trajectory, so they're not suffering, their families don't suffer, there is less risk of suicide, and they don't require as many resources from the mental health system."