10 TIPS Using EMDR Therapy with Survivors of Sexual Assault and Intimate Partner Violence

By Viviana Urdaneta Melo, MDiv, LCSW

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Maria (24-year-old female) came to a community mental health center because she has been experiencing anxiety and nightmares and does not want to leave the house by herself. A boyfriend sexually assaulted Maria ve years ago. Maria has not seen that person since the assault, but recently, she encountered this boyfriend’s sister in a mall. Maria thought that she had processed this experience. However, the symptoms came back after she saw his sister recently. Survivors sometimes think that they can forget the assault by not thinking about it. Eye Movement Desensitization and Reprocessing (EMDR) therapists can support clients in linking current symptoms with past events by providing psychoeducation about the Adaptive Information Processing (AIP) Model, normalizing trauma reactions, and developing a treatment plan that processes the past events of abuse, the current triggers, and any future concerns. Some clients might bene t from beginning in future concerns or in the present triggers, so consider the use of the EMDR Reverse protocol (Adler-Tapia, 2012) or the Inverted EMDR protocol (Hofmann, 2009).

All clients’ names are fictional and do not represent exact factual information

Every 68 seconds, an American is sexually assaulted. These clients represent a large percentage of clients in need of mental health services. Due to these high numbers, all therapists are very likely to encounter many survivors during their careers. Sexual violence can cause acute and long-term effects, including post-traumatic stress disorder, anxiety, depression, nightmares, sleep disturbances, and more (Postmontier, Dovydaitis & Lipman, 2010). EMDR can provide relief for those symptoms. Survivors can become desensitized to the traumatic event and embrace new adaptive beliefs about self. It is imperative that therapists develop skills to support these clients since the effects of sexual violence and intimate relatives, friends, and society in general. The estimated lifetime cost of rape is $122,461 per victim, including medical costs, loss of work productivity, loss of property or damage, and lifetime economic burden.

The U.S. Centers for Disease Control and Prevention (CDC) identifies IPV as a serious public health problem that can profoundly impact survivors’ physical and mental health, opportunities, and well-being. The CDC describes four types of intimate partner violence: physical violence, sexual violence, stalking, and psychological aggression. According to the National Coalition Against Domestic Violence, on average, nearly 20 people per minute are physically abused by an intimate partner in the United States. Additionally, research suggests that EMDR is an effective treatment modality for survivors of intimate partner violence (Schwarz, Baber, Barter & Dorfman, 2017).

The following tips might work with both survivors of sexual assault and survivors of IPV because these two populations often overlap. Unfortunately, many times, survivors of sexual assault are also survivors of IPV and vice versa.

1.

Support survivors in reprocessing feelings of guilt and shame without judgment. Survivors usually experience feelings of guilt and responsibility due to the reactions from others who might ask them about what they were doing or wearing during the abuse. Make sure to say and demonstrate that the survivor is NOT responsible for the abuse under any circumstances. Be intentional and check your biases, so you do not unintentionally pass any judgment on the survivor. Ensure that you address any cultural norms during the preparation phase that perpetuate victim blaming and minimization. Provide information about consent, such as the YouTube video about Tea and Consent: protocol the response they got when they disclosed the abuse to family and/or friends (or the response they think they would get). Negative responses from others increase their feelings of guilt and self-blame. Explore any blocking beliefs that might be related to cultural values. One of my clients, Jose na,* was sexually assaulted during college. She was terrified to disclose the abuse to her father because “virginity” was highly valued in her family. She was sexually assaulted and lost her virginity. We used the standard protocol to process the possibility of disclosing the abuse to her father (if she decided to do so at some point) because she was terri ed and had nightmares about it. During EMDR reprocessing, we needed to use an interweave: “Let’s pretend to rede ne virginity for you. Think about what you want it to mean for you.” Jose na rede ned de ned her virginity between sets of bilateral stimulation. She said, “I am still a virgin because virginity is a gift that you decide to give to someone. I have not given it to anyone, so the capacity to give is still mine.” She felt neutral about the event, and her nightmares stopped.

Some survivors might feel so embarrassed to talk about the abuse that they have a hard time nding words to set up the target during reprocessing phases. In those cases, it will be helpful to use the Blind to Therapist protocol (Blore & Holmshaw, 2009b) or unknown to the therapist as I prefer to call it to avoid being insensitive to those who are physically blind. Jose was so embarrassed to say anything about the abuse that he could not describe anything about the image, so the therapist asked about a name for the worst part. Jose chose “yellow” without giving more details about it. After reprocessing with the “unknown to therapist protocol,” he reported that “yellow” was the color of his shirt when he was assaulted.

2.

Don’t withhold reprocessing due to the possibility of going to court. Sometimes the legal procedures related to sexual violence might take years or not happen at all. Provide psychoeducation to survivors and validate their stories independently of prosecution of the case. Some therapists have the perception that using EMDR therapy might decrease the credibility of survivors if they testify. However, other therapists hold the opposite belief. Survivors feel relieved after reprocessing, and they are more capable of tolerating the process of providing testimony (Urbaniak, 2022). Survivors might feel calmer during court and provide more information about the facts of the case. Take the example of a medical issue: A surgeon would not withhold a heart surgery due to a court case; on the contrary, the surgeon would explain to the court/attorneys (or whom it might concern) about the procedure and continue with the heart surgery (Rollins, personal communication, 2010). Therapists can discuss the bene ts of EMDR therapy with the district attorney or with any other party involved in the legal procedure (with the permission of the client).

Clients can bene t from using a positive future template if they must go to court. For example, clients can run a movie of how they want to feel, think, and see themselves during the court procedure while doing bilateral stimulation. However, the client must focus on his/her reactions and behaviors and not on the ones from other people in the courtroom (“I want to feel calm and con dent to tell my story” vs. “I want people to believe me”). If the client cannot do a positive future template, the experience of going to court could be processed with standard EMDR therapy as a future target. The therapist can ask a client: “When you think about going to court, what image represents the worst part of it? What negative belief comes about yourself? What would you like to believe about yourself? How truthful does it feel in your body? What are your feelings? How much is the disturbance in your body from 0 to 10? Where do you feel that in your body?” And then continue reprocessing with EMDR therapy the experience of going to court.

3.

Be creative and maximize your resources using group and individual EMDR therapy. Survivors of sexual assault bene t from group interventions because they help to normalize symptoms and reactions. Group settings provide opportunities to discuss safety planning and receive peer support. Survivors of sexual assault indicate that EMDR provides trauma resolution (Edmond, Sloan, & Mccarty, 2004). The EMDR- Integrative Group Treatment Protocol (IGTP)© has been used successfully to treat survivors of sexual assault to decrease symptoms (Allon, 2015). Other group protocols, such as Group Traumatic Episode Protocol (GTEP)© and Acute Stress Syndrome Stabilization (ASSYST),© have been found helpful, effective, and efficient for working with this population. Because of the number of clients that experience sexual assault and intimate partner violence, groups are a cost-effective and efficient way to work with survivors. A therapist and a small group of helpers can work with several survivors at the same time.

Hope (a 24-year-old) survivor of sexual assault reported that when she entered a group for survivors, she realized that she was not alone. Just that initial encounter reduced feelings of shame and guilt. The EMDR IGTP and other group protocols allow clients to reprocess using drawings. Hope reported that she felt, during reprocessing, that all the other group members were participants in her healing and co-regulators, even when they did not know all her story details.

4.

Do not try to force forgiveness or any change in the emotional reactions of the survivors. It is common for survivors to experience various emotions, including anger, sadness, grief, acceptance, and sometimes forgiveness. Do not try to force clients to experience any of them. EMDR is a client-centered approach, and therapists should encourage clients to simply notice their experience without judgment or trying to change. It is common that survivors might experience images or thoughts of revenge. Encourage clients to notice, observe, and allow their brains and bodies to reprocess. “Since forgiveness can neither be mandated nor controlled, the EMDR Clinician is advised to allow it to emerge spontaneously, when (and if) the client is ready to do so (Shapiro, 2017, p.299).” Using imaginative interweaves that allow clients to express their feelings without judgment is helpful to reprocessing. “Imagine what you want to say now to this person that harmed you. I do not mean to say it in real life but only in your imagination. You do not have to tell me. Just go with that.”

5.

Clarify expectations, especially with survivors who want to use EMDR to remember details about the abuse or to corroborate that it happened. The goal of therapy is not to determine the circumstances in which the abuse occurred or not: “EMDR processing is not designed to bring visual memories to surface but, rather to process information that is dysfunctionally stored in the brain” (Shapiro, 2017, p. 293-294). The goal of therapy focuses on relief from current situation. It is important to discuss with the client that whatever information comes during reprocessing should not be considered as a fact in a legal sense. There is a possibility that the client might experience symbolic representations during reprocessing: “Because clients recall what they have perceived at the time of the event, their memory will be influenced by the developmental phase in which the trauma occurs and by the functional capacity of the brain to encode information at the time of the abuse (for example, if the client was under the e ect of a drug)” (Shapiro, 2017, p. 302). Standard EMDR protocol can be used even if the client does not remember specific details about it. For example, when survivors have been under the effects of any substance, they do not remember details, but they might remember smells, sounds, and sensations in their bodies. The therapist can use the same question to target: “What image [sound/smell] represents the worst part of the event now?” Therapists need to support clients in keeping a non-judgmental curiosity and just noticing.

6.

Safety is important, and survivors need to reprocess issues of responsibility so that they can be more engaged in safety planning. Many survivors struggle because the perpetrator of the violence has made them believe that they are responsible for the abuse. When survivors process with EMDR, a therapist can use interweaves to help them place guilt and responsibility where it belongs—on the perpetrator. Encourage survivors to increase self-nurturing and self-acceptance. “Imagine that you come back to the event and see yourself there. Notice with curiosity, what do you see? How do you see yourself? [start Bilateral Stimulation (BLS)];” “I am confused. What did you do wrong at the time of the abuse? Think about that [start BLS].” “If it were your best friend/daughter, would and begin the bilateral stimulation right after the question without waiting for any long response aloud. By thinking about this question while doing bilateral stimulation, clients are engaging not only the cognitive part of their brains but all the parts of their brains.

Sometimes feelings of guilt and responsibility are masked under issues of safety. Sammy wanted to target an event, and the cognitions were related to safety: “I am not safe” and “I am safe now.” However, the reprocessing was stuck. The therapist asked as an interweave: “I wonder, if there is a part of you that feels responsible for what happened. Even if another part of you knows that it was not your fault. Think about that.” After sets of bilateral stimulation, Sammy was able to resolve her feelings of guilt and engage more in safety planning. Shapiro (2017) explains how clients spontaneously move through three cognitive and emotional plateaus (inappropriate feelings of guilt/responsibility, perceived lack of safety, and helplessness) to a more balanced view of the situation. However, when these spontaneous changes do not occur, clinicians can introduce interweaves in the appropriate plateaus to accelerate treatment and unstick it if needed.

7.

Adjust expectations and treatment around the goals that clients have for treatment. Use the stages of change and the AIP model to conceptualize survivors. I worked for several years in a domestic violence mental health agency, and we used the stages of change and motivational interviewing to ready to leave an abusive relationship (in preparation/ action stage of change). Others do not even know that they are experiencing abuse (pre-contemplation stage) or might have some doubts but are not ready to act further (contemplation). Others come after they are physically and emotionally safe and are ready to process past trauma. Provide information and support during the preparation phase for those clients that might be in pre-contemplation or contemplation. With clients who are in the preparation phase of the stage of change, a therapist might be able to reprocess the future possibility of leaving the abusive partner with the standard protocol. “When you think about leaving this partner, what represents the worst part of the image? The negative thought?” and finish the assessment and reprocessing the target. As mentioned before, consider the use of the EMDR Reverse protocol (Adler-Tapia, 2012) or the Inverted EMDR protocol (Hofmann, 2009). Additionally, assess for dissociation and consider the use of a progressive approach if needed (Gonzalez & Mosquera, 2012).

8.

Target “positive” memories of the relationship, especially with those survivors who are ambivalent about leaving the relationship. Mosquera and Knipe (2017) report that self-defeating, dysfunctional, and unrealistic idealization (such as “I love [him/her]. [He/she] is so good to me. This relationship is worth saving.”) can be targeted with focused sets of bilateral stimulation. The specific positive aspect memories that are the origin of the maladaptive idealization can be reprocessed so the survivor can develop adaptive resolution, which allows the client to have a more accurate perception of both past events and the present nature of the relationship. “When you think about the best part of this relationship, what is the image that comes?” By targeting the “positive” memories with bilateral stimulation, clients begin to realize that their “positive memories” Knipe (2017) are positive memories reprocessing, a survivor of domestic violence might realize that the positive memories of bringing owners and saying loving words were connected with violent events. This reprocessing allows clients to distinguish the cycle of violence from a different perspective and provides clarity to make decisions accordingly.

Additional Resources

1. Rape, Abuse, Incest National Network www.rainn.org/statistics/scope-problem
2. National Sexual Violence Resource Center www.nsvrc.org/about- sexual-assault
3. EMDRIA Focal Point Blog about sexual assault www.emdria.org/category/specialty-areas/sexual-abuse/
4. CDC Intimiate Partner Violence www.cdc.gov/violenceprevention/intimatepartnerviolence/index.ht  ml
5. National Coalition Against Domestic Violence https://ncadv.org/STATISTICS
6. Let’s Talk EMDR Podcast Season 2, Episode 7: EMDR Therapy and Sexual Trauma www.emdria.org/letstalkemdrpodcast/
7. Tea and Consent—YouTube video—https://youtu.be/fGoWLWS4-kU

9.

Support the connection to a community/group. One of the common behaviors of perpetrators of abuse is to isolate victims of intimate partner violence. If survivors do not have support, they feel obligated to stay and have fewer opportunities to ask for help. Research and this therapist’s experience suggest that EMDR group therapy provides an ideal space for survivors to reprocess trauma (Harris, Urdaneta, Triana, Vo, Walden, Myers, 2018; Walsh, 2020), normalize symptoms, and provide opportunities to fight against isolation. As mentioned earlier, consider using EMDR group protocols to work with these populations

10.

Install personal and community resources ALL the time. One of the effects of intimate partner violence is that survivors experience low self-esteem due to repeated diminishing and gaslighting. Survivors of sexual assault decrease their self-esteem due to the response by others and society in general when abuse is somehow normalized and fetishized by social media, movies, and advertisements. Survivors of both intimate partner violence and sexual assault benefit from increasing internal and external resources by including Resource Development and Installation regularly in treatment. Use the installation of positive resources not only during preparation but throughout treatment.

Viviana Urdaneta Melo, MDiv, LCSW, is an EMDR certi ed therapist and consultant. Urdaneta Melo has worked with survivors of trauma, intimate intercultural and intentional approach around issues of diversity, equity, and inclusion. Urdaneta Melo has worked in di erent settings such as mental health agencies for domestic violence survivors, university health center, and private practice. She is an immigrant from Colombia, South America and practices in both English and Spanish. She works at the EMDR International Association as the chief of clinical a airs. Urdaneta Melo is committed to increasing awareness around the challenges, strengths, and opportunities of working with diverse populations and their intersection of identities.

References:

1. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, National Crime Victimization Survey, 2019 (2020). Note: RAINN applies a fiveyear rolling average to adjust for changes in the year-to-year NCVS survey data.
2. Peterson, C., DeGue, S., Florence, C., & Lokey, C. N. (2017). Lifetime economic burden of rape among U.S. adults. American Journal of Preventive Medicine, 52(6), 691–701.

Adler-Tapia, R. (2012). A Proposal for an EMDR Reverse Protocol.
www.ifemdr.fr/wp-content/uploads/2014/10/robbie-adler-tappia-1.pdf

Allon, M. (2015). EMDR group therapy with women who were sexually assaulted in the Congo. Journal of EMDR Practice and Research, 9(1), 28-34.

Brown, A. L., Testa, M., & Messman-Moore, T. L. (2009). Psychological consequences of sexual victimization resulting from force, incapacitation, or verbal coercion. Violence Against Women, 15(8), 898-919.

D. C. Blore, & M. Holmshaw (2009b). EMDR “Blind to Therapist Protocol.” In M. Luber (Ed.), Eye movement desensitization and reprocessing: EMDR scripted protocols basic and special situations (pp. 233–240). New York, NY: Springer.

Edmond, T., Sloan, L., & McCarty, D. (2004). Sexual abuse survivors’ perceptions of the effectiveness of EMDR and eclectic therapy. Research on Social Work Practice, 14(4), 259-272.

Fawson, P. R., Broce, R., MacNamara, M., & Gedney, C. (2018). Victim to aggressor: The relationship between intimate partner violence victimization, perpetration, and mental health symptoms among teenage girls. Partner Abuse, 9(1), 3-17