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EMDR and Trauma Work: A Conversation with Sandra Paulsen

Sandra Paulsen, PhD, is a thought leader in the area of trauma and the use of eye movement desensitization and reprocessing (EMDR) as a treatment modality, specifically when it involves complex trauma and/or dissociation. In this interview, Sandra discusses her illustrious career, where she sees the fields of trauma and EMDR heading, practicing virtual EMDR, and her advice for providers.

Sandra, for those who may not be familiar with your work, can you please share a brief overview of your history in the field of trauma and why you were initially drawn to it?

In 1991, when I was trained in EMDR by Francine Shapiro, I immediately started uncovering undiagnosed dissociative disorder, then called multiple personality disorder. I quickly got additional training on dissociation, so I have always used EMDR in conjunction with ego-state therapy when people have any degree of dissociation.

I asked Dr. Shapiro about the possibility of modifying EMDR training to address dissociation. Dr. Shapiro, however, originally thought dissociation was too “out there” to be accepted in universities, so she instead formulated EMDR as a cognitive behavioral treatment.  It is still largely true that most EMDR skeptics reside in academia, whereas clinicians tend to be much more vocal advocates.

I went on to be the first to formulate a protocol for treating Dissociative Identity Disorder (DID, formerly multiple personality disorder) with EMDR using ego state therapy. I wrote a book on that subject called Looking Through the Eyes of Trauma and Dissociation: An Illustrated Guide for EMDR Therapists and Clients. I also collaborated with John G. Watkins, the father of ego state therapy, in the early 2000s.

Katie O’Shea (the originator of the early trauma approach) and I then collaborated for several years on how to work in implicit memory to address trauma in the first years of life and the attachment period. I went on to publish a book about that approach and extended it to complex DID cases.

In 2018, I published an article about bringing all those methods together systematically in an integrated approach called Neuroaffective Embodied Self Therapy (N.E.S.T.). This helps the clinician assess which of those methods needs to be used for a given client in complex cases. It also incorporates the affective neuroscience of the late great Jaak Panksepp, who redefined how we understand emotions. There are lots of implications for that, including how we understand EMDR as integrating affect and soma at the periaqueductal gray and the superior colliculus, respectively.

How have you seen the fields of trauma and EMDR evolve over the years, and where do you see it going? 


When I started, I was a lone voice, like Paul Revere, cautioning the citizenry of EMDR to assess for dissociative disorders. Now, it’s widely accepted that one must assess and do parts work on complex cases of structural dissociation before doing EMDR. Whether you're dealing with ego state therapy, internal family systems, or other parts approaches, it’s the standard now.

I think in a decade or two EMDR will be very differently applied, as I’ve described, to accommodate these complexities in the mainstream.  For simpler cases, standard EMDR works great, but most cases are complex!

Where would you like to see the field go?

I would like to see EMDR taught with an emphasis on case formulation that triages either standard EMDR or modified to accommodate structural and/or somatic dissociation at the outset. That means clinicians have to be aware of how to assess those conditions well with little information.

This poses at least two major challenges to the conventionally trained, namely that:

  1. Dissociation exists (though currently it is still taught that it's rare); and

  2. We actually can work in implicit memory, for many clients, without pictures or narratives. We can do this by attuning to and discerning such channels of information as:

  • Historical narrative

  • Client emotions and body sensations

  • The therapist’s behavioral observations of the client

  • Mirror neuronal information

  • Intuitive information

  • What is in the relationship field

  • Movements of the energy field

These channels of information all produce fragments of the untold, unheard story, which are like puzzle pieces we can assemble in a hypothesis-testing mode without leading the client past the evidence. With continued learning and teaching, I think this can be a successful endeavor.

You utilize blinkEMDR, Empathic Clinical Software’s EMDR telehealth system. Can you speak a bit about your experience conducting EMDR sessions virtually?

During COVID, that’s the only way I saw anyone. I have used it for standard EMDR on obvious traumas in explicit memory with pictures and narrative. I have also used it for early trauma repair working in implicit memory.  Curiously enough, I still find myself able to perceive energy movements online; I have no idea what law of physics is involved there!

I have people drop into the felt sense in their bodies easily during a blinkEMDR session. While blinkEMDR's auditory and eye movements almost always achieve the desired state, I also train the client to add self-tapping if needed so they can continue through a deep, intense sobbing episode. I also use blinkEMDR for intake interviews before launching into EMDR.

What do you appreciate about doing this kind of trauma work virtually?

I think it opens a world of new possibilities. My favorite glimpse into the future is the idea of working with the incarcerated in prisons and jails to reduce recidivism and intervene in the intergenerational transmission of trauma. I’m collaborating with Ret. Lt. Kenneth Gardner, a former homicide detective of 19 years with 34 years in law enforcement, on getting the word out.

blinkEMDR would make it possible for clinicians to do the work safely from the comfort of a swivel chair. Prison officials wouldn’t have to worry about us being on the prison unit, and problems like unexpected unit lockdowns or prisoner transfers would be less impactful than if the clinician had driven to the prison. I think prisoners might also prefer the telehealth modality for their own reasons. We’re collaborating with the Compassion Prison Project on these ideas and hope to make this vision a reality. 

blinkEMDR also allows us to overcome barriers to accessibility. We can “travel” to rural areas in North America or other countries (as permitted by law) to provide leading-edge treatments.


Are there challenges or concerns about conducting treatment virtually? If so, how can providers prepare themselves to respond to unexpected events? For example, what do you do if someone goes into an abreaction during therapy?

Challenges include that one can’t tell if the client is, say, intoxicated (by smell anyway), or who else is listening in the room. In other words, one doesn’t control the environment as much.

Abreactions don’t worry me. I hear them as exactly what we should be doing, processing through the disturbance that is encysted, under pressure. Now, that assumes that one is previously assessed for DID, because a DID abreacting isn’t ideal. Clinicians should always assess with the MID, the SCID-D, or an appropriate interview format (described elsewhere) to make sure there isn’t an undiagnosed DID issue for each client. The DES II is not enough (it’s a screening instrument and is famous for false negatives). 

Now to be clear, if the therapist has overlooked a dissociative disorder, just sailing through CAN’T work, because protective parts will put the kabbosh on it.  That’s why one has to check first and do the necessary parts work, especially with perpetrator introjects (that is, appreciating their survival function and orienting them to current circumstances). 

Short of that, just stay on it. Harm is done if the therapist freaks out and shuts the EMDR down just because of strong emotions or abreaction. We have to give the work a chance to complete, like letting the pressured air out of a balloon. We have to keep reminding the client it’s a memory and not something happening now. The provider must keep the dual attention awareness paramount at all times.

Binaural beats have been around for up to 200 years, and some research speaks to the benefits of using these frequencies for anxiety and improved sleep. Binaural beats are available all over the internet for people to use at will, and they are used as soothing frequencies during some meditation music. What are your thoughts on incorporating binaural beats into EMDR and/or trauma work?

When it comes to bilateral stimulation (BLS) methods, the research indicates that eye movements are the most powerful method, tactile is second, and auditory is third. For resilient people, eye movements are my first choice. For fragile people, the gentler the better, so auditory or tactile is better. In telehealth, I utilize an auditory approach (the client wears earphones) and ask them to add eye movements by looking from corner to corner in their room. 

When it comes to binaural beats, I conceptualize it as a form of auditory BLS with a means that taxes working memory additionally, and serves as a resource. I'm not aware of research directly connecting them to EMDR, but I think it holds interesting possibilities. 

What is something about you (personally or professionally) that people may not know about you? 

I started out life with a newspaper column at age 16, and a radio show. I was an exchange student in Greece, then became a technical writer and cartoonist for a large bank. I put myself through graduate school at the University of Hawaii Manoa by consulting in San Francisco between semesters. I chose Hawaii because of my enduring interest in cross-cultural psychology, which continues to this day. I brought together all my interests: writing, cartooning, teaching, psychology, and culture in one gloriously satisfying career. 

What advice do you have for providers entering the world of EMDR and trauma?  

Study standard protocol, but also study dissociation in earnest to do no harm. Learn the early trauma approach and an ego state approach as well as somatic therapy and you can treat nearly any trauma condition that walks in the door. 

What areas of research and discovery might you steer newer providers towards to lead the way into new frontiers of psychotherapy?

I'm especially interested in the effects of low-dose naltrexone (up to 4.5 mg) on somatic dissociation, alexithymia, and some autistic individuals to hook up their dashboard wires of awareness of emotion. Another exciting area right now is working in implicit memory, so we can repair injuries from the attachment period even in the absence of picture memory or narrative. 


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