🧠 Neuro EMDR: Applying EMDR Therapy with Clients Who Have Impaired Cognitive Abilities (Neuro EMDR: Applying EMDR therapy with clients who have impaired cognitive abilities)

Authors:

Dr. Jonathan Hutchins, EMDR Supervision, UK, www.emdrsupervision.uk 

Simon Proudlock, EMDR Consultancy, UK. www.emdrconsultancy.com

Translated by: Specialist Psychologist Elena Gizem Pozam

EMDR therapy has been shown to be highly effective and time-efficient in addressing traumatic memories in both adults and children. However, questions remain about how EMDR can be effective for adults who have sustained a brain injury or experience other cognitive difficulties. This article summarizes some current research in this area and proposes adaptations to the standard protocol to optimize the use of EMDR therapy with this population.

 

Introduction

Between 2019 and 2020, 356,669 people in the United Kingdom were admitted to hospital with an acquired brain injury (ABI), which refers to any brain injury occurring after birth, including traumatic brain injury (TBI), stroke, or brain tumors. This represents a 12% increase since 2005–2006 (Headway, 2023). In 2019, there were approximately 977 TBI admissions per day to UK hospitals, equivalent to one admission every 90 seconds.

The diagnostic criteria for TBI in DSM-5 require: "An impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, accompanied by one or more of the following: loss of consciousness, posttraumatic amnesia, disorientation and confusion, neurological signs indicating injury on neuroimaging, or worsening of a pre-existing seizure disorder" (American Psychiatric Association, 2013). The diagnostic criteria also consider severity ratings for TBI, summarized in the table below.

 

Causes of TBI and Prevalence Data

The diagnostic criteria for mild TBI were recently reviewed and updated by the American Congress of Rehabilitation Medicine, expanding them to include a range of external forces that cause TBI. These include a blow to the head with an object (which may involve intimate partner violence), the head striking a hard object or surface, acceleration/deceleration movements of the brain such as those occurring in road traffic collisions (RTCs), and forces generated by a blast or explosion (Silverberg & Iverson, 2023). Considering these causes, we may be seeing far more people with TBI in our routine clinical practice than we realize.

• Prevalence rates for brain injury in the general population have been suggested to range from 8% to 12% (Frost et al., 2013; Silver et al., 2001).


• Williams and colleagues (2010) found that nearly 60% of adult male prisoners had experienced a head injury, and approximately 15% had experienced moderate to severe TBI.


• McMillan and colleagues (2021) found that 78% of female prisoners across four prisons had experienced a significant head injury, and 40% of these women had an associated disability. Of the women who had experienced a significant head injury, 84% had sustained repeated injuries, and 89% of these repeated injuries resulted from domestic violence.


• In their research with young male offenders aged 16–18, Kent and Williams (2021) found that 74% reported a TBI of any severity during their lifetime, and 46% had experienced a head injury resulting in loss of consciousness.


• Furthermore, adolescents in young offender institutions who have sustained a TBI are more likely to experience mental health problems, including self-harm and suicide (Chitsabesan et al., 2015).

 

The Link Between TBI and Posttraumatic Stress Disorder (PTSD)

Bryant (2011) suggested that people who sustain a TBI may also develop PTSD. Quershi and colleagues (2019) conducted a cross-sectional study of 171 individuals attending a TBI clinic over an 18-month period. Participants were asked to complete the PTSD Checklist–Civilian Version (PCL-C), alongside other psychometric tests. The results showed that PTSD was 21% more prevalent in this population and that there was a clear link between TBI and PTSD within the UK civilian population (Quershi et al., 2019).

Based on this research, it could be argued that mild TBI is a more common problem among clients routinely presenting to practitioners for EMDR therapy. For example, we may frequently see clients who have experienced significant trauma due to domestic violence, which may include impact trauma to the head and brain. It is therefore appropriate to consider how we can adapt EMDR to meet the needs of people who have sustained a TBI.

 

🧠 The Current Evidence Base for Using EMDR with Clients Who Have Sustained a TBI

Numerous articles and case studies highlight that EMDR may be effective for individuals who have experienced mild TBI and have PTSD.

 

📝 Notable Case Studies and Presentations

• A conference presentation described a single case study of adapting EMDR for a client who had sustained a TBI and was experiencing aphasia (difficulty speaking) (Gene-Cos, 2010). The presenter emphasized that every person with TBI is unique and that adaptations therefore need to be individualized.


• In another case series, EMDR was used with three clients to address the emotional and behavioral aspects of mild TBI (Jayatunge, 2013).


• In a case study of a 17-year-old young man who sustained significant facial injuries and brain damage following an explosion, EMDR was used as part of his rehabilitation to address the resulting PTSD (Fritzche, Hyckel, & Ziegenthaler, 2013). EMDR was effective in reducing PTSD symptoms and significantly supported his rehabilitation. The authors argue that EMDR used soon after TBI may have substantial positive effects.


• A conference presentation by Gibson (2015) highlighted how EMDR could be adapted for a client with TBI and the importance of offering EMDR to this client group because of the relationship between TBI and PTSD (Gibson, 2015).

 

📊 Long-Term Follow-Up Studies

• One case study examined the effectiveness of EMDR in addressing persistent post-concussion symptoms (PCS), depression, anxiety, and PTSD (Moore, 2021). A 57-year-old man who sustained a mild TBI and developed PCS following a serious road traffic collision (RTC) received nine 90-minute EMDR sessions over a five-month period.
  
  
  
  • The client was assessed before, during, and at the end of treatment, as well as at 18-month and 5-year reviews.
  
  
  • Measures included the PHQ-9, GAD-7, Impact of Event Scale–Revised (IES-R), and Rivermead Post-Concussion Symptoms Questionnaire. The Phobia Scale and Work and Social Adjustment Scale (WSAS) were also used.
  
  
  • Moore (2021) also used SUD and VoC scores relating to the specific traumatic memory treated with EMDR.
  
  
  • The results showed a significant reduction in all PTSD, depression, anxiety, and PCS symptoms following EMDR, which was maintained at both the 18-month and 5-year follow-ups (Moore, 2021).
  
  
  
  


• A more recent case study highlighted how more intensive EMDR successfully treated PTSD in a client who had sustained a TBI (Yasar et al., 2022). The researchers completed a 16-month follow-up, and PTSD symptoms remained at a substantially reduced level.


• Another single-case study completed by Moore (2023) used EMDR to address posttraumatic distress related to posttraumatic amnesia (PTA) following a severe TBI.
  
  
  
  • Using outcome measures such as the Impact of Event Scale, SUD, and VoC before and after eight EMDR sessions and at a 4-year follow-up, the case study demonstrated considerable success in reducing PTSD symptoms to a subclinical level, with low SUD and high VoC levels maintained at the 4-year follow-up.
  
  
  
  

 

🧠 The Neuro EMDR Perspective

A central aspect of EMDR is the Adaptive Information Processing (AIP) model. This model describes the brain's ability to process information adaptively, enabling people to adapt to their environment and experiences, survive, heal, and integrate (Shapiro, 2018).

When taking a neuropsychological approach to understanding TBI, we generally focus on three aspects when formulating a client's difficulties:

1. The individual's diagnosis based on a CT or MRI scan identifying the location of the brain injury.


2. Direct observations by family members or members of the multidisciplinary team (MDT).


3. The results of cognitive assessments (Wilson & Betteridge, 2019).

This information is then considered within a neuropsychological formulation, outlined in Figure 1 below.

 

🧠 The Neuropsychological Formulation Model and the Role of EMDR

The formulation model shown in Figure 1 is a key tool used by neuropsychologists when working with a client who has sustained a TBI. The model focuses on the impact of TBI on the individual's cognition (such as its effects on memory or attention), affect (such as possible depression or anxiety following TBI), and physical functioning (Wilson et al., 2009).

The model also emphasizes the importance of:

• The individual's pre-existing coping style or potential cognitive reserve (i.e., their level of cognitive functioning before TBI) (Wilson et al., 2009).


• The importance of family and social support for affect.


• The individual's level of insight into their difficulties, their experience of loss, and the functional consequences of TBI (Wilson et al., 2009).


• Based on this formulation model, it could be argued that EMDR may have a powerful role in addressing many of these factors, such as the individual's experience of loss and possible depression or anxiety, and in supporting family members who may be traumatized by the impact of TBI on their loved one.

 

Key Cognitive Domains

Considering these factors and drawing on the authors' experience in neuropsychology and working with clients who have sustained brain injuries, the following key cognitive domains can be considered:

The figure above draws on a broad range of cognitive models and concepts in cognitive rehabilitation therapy (Schneider & Shiffrin, 1977; Warren, 1993; Baddeley & Hitch, 1974; Diamant & Hakkart, 1989; Brannagan & Malia, 2005) and has been used by the author to help consider each individual's cognitive functioning and the domain-specific aspects of different cognitive functions. These include attention, visual processing, information processing, executive functions, and memory. Although framed as separate aspects, in reality all these cognitive functions often occur simultaneously when an individual is undergoing EMDR therapy. These cognitive domains are discussed below, and cognitive rehabilitation strategies for individuals with difficulties in each domain are proposed in relation to how EMDR can be delivered.

 

🧠 The Adaptive Information Processing (AIP) Model Perspective

EMDR relies on an individual's ability to hold a traumatic memory in mind while also focusing on bilateral stimulation, such as eye movements, tactile stimulators, or auditory stimulation (Shapiro, 2018). We therefore need to consider the individual's ability to selectively attend, sustain attention, and divide attention over periods lasting up to 30–40 seconds, depending on the material that emerges during processing.

We also need to consider the individual's information-processing capacity, control, and speed. From a neuropsychological perspective, we assess this through direct observation; for example, we observe whether someone can maintain attention to questions they are asked and stay on topic during an assessment session. We can also consider the results of neuropsychological assessments, as attention and information processing underpin the individual's memory.

 

🛠️ Using Cognitive Rehabilitation Strategies in the Standard Eight-Phase EMDR Protocol

There are some general cognitive rehabilitation strategies we would recommend to clients who have sustained a TBI and to the family members involved in their care or staff working with them. Drawing on the authors' experience of using EMDR with this client group, we describe these strategies and show how they can help in our work.

 

📋 1. History Taking

• Reduce distractions in the client's environment and slow your speaking pace. Use more verbal cues (verbal prompts) to bring the client back to the task, gently repeating the same question if necessary.


• Write down the different targets reported in the client's trauma history together with them. You are more likely to be able to identify memories from before the event that caused the traumatic brain injury (TBI), and the client may not remember the accident/event itself. However, consider asking when they first woke up or first became aware of the impact of the TBI/injuries.


• Consider adjusting the pace (tempo) of sessions  depending on the degree of fatigue or pain the client is experiencing.


• If the client has significant memory problems with encoding new information into memory, reintroduce yourself at each session and emphasize that you have discussed EMDR and that there are past traumatic memories you have both noted down, although they may not remember this. Then ask the client again whether they are comfortable continuing


• As an additional strategy, with the client's permission, you could make a video or audio recording explaining EMDR and the date of the next session. Family members or care staff can then prompt them to review this recording before the next session.

 

🧘 2. Stabilization

• With the client's consent, record strategies such as grounding, using an imaginary container for traumatic memories, and a safe place, either in writing or using other memory strategies such as a voice memo on the client's mobile phone.


• With the client's permission, set reminders on their mobile phone at appropriate times to practice these new skills.


• When planning to begin EMDR, have the skills written down in front of the client so they can easily access and follow them rather than relying on memory.


• Rather than asking the client to visualize a safe place, consider using more external cues, such as pictures, music, or scents/tactile materials, as this may be less cognitively demanding.

 

🔍 3. Assessment

• When asking the standard protocol questions in the assessment phase, maintain the protocol's brevity and consider repeating a summary of the target memory rather than using the words event or image. For example: "When you bring up that event when you first woke up after the accident and realized you could not walk, what words best describe your negative belief about yourself now?" Explicitly describing the target image each time helps sustain attention and also supports errorless learning; that is, providing the correct information the first time to help the client encode it more effectively into memory (Betteridge, Wilson, 2019).


• If the client is easily distracted, be prepared to repeat the assessment-phase questions several times.


• Initially use the standard protocol questions and approach when eliciting the client's negative and positive cognitions. However, if this is too abstract or difficult for the client, consider the context of the traumatic memory and offer cognitions from different domains. For example: "When you bring up that event when you woke up after the accident and realized you could not walk, what is the negative belief about yourself now? Is it 'I am powerless'? 'I am weak'? Or 'I am not safe'?"


• If the client is unable to generate their own cognitions (thoughts), depending on the type and nature of their brain injury, consider using written cognitive aids from which they can choose, as this task may place excessive demands on their executive functions.


• If the client continues to struggle to identify appropriate negative and/or positive cognitions (thoughts) even after the strategies above, consider suggesting 'I am powerless' as the negative cognition and 'I am better now' as the positive cognition, as these may fit most of the traumatic experiences clients encounter.

 

🔁 4. Reprocessing

• Eye movements may be difficult for clients with TBI who have visuospatial difficulties and unilateral neglect or impaired eye movements. We therefore advocate using tapping/tactile stimulators if clients have sensation in both hands. If sensation is absent, we recommend auditory BLS.


• Consider shorter sets of BLS depending on the client's level of fatigue.


• If the client is easily distracted, consider returning to the target image and being more explicit  about the image/event to help them return to the memory you are focusing on.


• The memory may be reprocessed quickly, much as trauma reprocessing works in children.

 

✨ 5. Installation of the Positive Cognition 

• Reassessing the original positive cognition identified by the client during the assessment phase is built into the standard protocol. This is useful as a memory prompt and for focusing the client's attention on processing.


• As in the assessment phase, the client may need additional encouragement (prompting) to identify an appropriate positive cognition that they believe is completely true. This may require the therapist to suggest different cognitions across different domains based on the material processed during the reprocessing phase or, if this is too difficult for the client, to suggest a positive cognition such as "I am better now" or "I am safer now."

 

🫀 6. Body Scan - 7. Closure 

• Some clients may experience numbness or increased sensitivity in their bodies as a result of their brain injury. We therefore recommend being patient and working with what the client presents. Remember that some sensations arising during the body scan (such as pain) may be unrelated to the original traumatic memory.


• When closing a session, consider using additional memory aids, such as the pictures, music, or scents used for the safe place during the stabilization phase.

 

🔄 8. Re-evaluation

• Depending on the client, they may not remember the previous EMDR session. They may therefore need more explicit prompts about the traumatic memory that was worked on. For example, you could say to the client: "You may not remember, but in our last session we did EMDR work on a difficult traumatic memory of when you first realized you could not walk. If you focus on that memory now, what do you feel/notice?"

 

📝 Summary and Conclusions

This article has focused on the evidence base, neuropsychological theories, and practical cognitive rehabilitation strategies for delivering EMDR to clients who have sustained a TBI (traumatic brain injury).

In the authors' experience, EMDR has been very helpful in addressing the PTSD aspect of TBI and has supported clients' engagement in neurorehabilitation. Although this article focuses on TBI, we believe the strategies presented may also be useful across a broader range of conditions, including individuals with learning disabilities, clients with attention-deficit/hyperactivity disorder (ADHD), and clients with functional neurological disorders. Larger-scale research is needed to evaluate their applicability to clients with TBI.