Any doctor would rather heal patients than simply manage their symptoms, whether the illness or injury affects the body or the mind.
That idea is what attracted Dr. Ricky Greenwald to eye-movement desensitization and reprocessing (EMDR), a behavioral-health treatment that helps victims of post-traumatic stress disorder (PTSD) and other types of psychological trauma to overcome the ongoing mental burden of past disturbing events.
Greenwald learned about EMDR — then a fairly new concept — in graduate school during the 1990s, when he was already a trauma therapist, and wrote his dissertation on the subject.
“It already had a clearly articulated model,” he told HCN. “It wasn’t just about managing symptoms, which was the focus of most trauma-focused therapy. EMDR helped take that memory that caused the wound and really process through it and heal from it, and it was doing that more thoroughly and quickly than anything that had been attempted before. Trauma therapy could be very long and painstaking, and would only get you so far. With EMDR, you could get quicker and, in many cases, complete results — complete healing.”
As one of the early adopters of EMDR, Greenwald happened to be working in New York not long after 9/11, training health professionals there in the technique, and not long after, he launched the Trauma Institute and Child Trauma Institute, now located in Florence. “We’re a very small shop, but our training approach is so highly regarded, it’s become a model, nationally and internationally.”
He later developed a technique called progressive counting, a spinoff from a trauma-treatment technique called the counting method (more on that later), and today, he and a team of therapists offer both EMDR and PC to victims of physical or emotional abuse, domestic violence, sexual assault, combat trauma, violent crime, death of a loved one, motor-vehicle accidents, and more.
“You get a profound, permanent benefit as opposed to symptomatic treatments, like yoga, mindfulness, meditation — things that calm the system down, but require constant maintenance,” he explained. “If you ask people, ‘do you want to overcome your problem next week or next year?’ they’ll tell you ‘next week.’ And if you ask them, ‘do you want to spend 60 hours in therapy or 30 and get the same results?’ of course they’ll choose 30.”
To explain how that happens, it’s helpful to go to the beginning — which, for EMDR, is only 30 years ago.
The technqiue was first developed by psychologist and educator Francine Shapiro, who noticed that certain eye movements reduced the intensity of disturbing thoughts. She noted that, when she was experiencing a disturbing thought, her eyes were involuntarily moving rapidly, but when she brought her eye movements under voluntary control while thinking a traumatic thought, the level of anxiety was reduced.
Her research into this phenomenon was published in the Journal of Traumatic Stress in 1989, and formed the basis of what soon became a widely accepted treatment.
The technique involves helping patients achieve what’s known as ‘dual-attention awareness,’ which requires them to mentally focus on the trauma while the therapist guides their eyes back and forth. It essentially plants one foot in the past and one in the present, and when they’re positioned between these two poles, the information begins to be digested, and the person is able to let go of the disturbance and allow the related pain, anxiety, depression, anger, and frustration to fall away, to be replaced by a new (and less painful) understanding about the traumatic memory.
By the turn of the century, EMDR had been approved as a first-line treatment for PTSD by the Department of Defense, the Department of Veterans Affairs, the American Psychiatric Assoc., the National Institute for Clinical Excellence, the International Society for the Study of Traumatic Stress, the governments of Israel and Great Britain, and other bodies.
The emergence of EMDR led to further developments in the trauma field, most notably the counting method (CM), developed by psychiatrist Frank Ochberg in the early 1990s. During this treatment, the therapist asks the patient to recall a traumatic memory while the clinician counts out loud to 100. Afterward, the patient discusses their traumatic memory and works with the therapist to reframe the memory and minimize or eliminate the negative feelings associated with it.
Greenwald was intrigued when he read about it around 2005 and wanted to delve deeper, but the developers of CM were revising their teaching materials at the time, and no seminars were immediately available. Still, he felt he understood enough to include the technique in a five-day trauma-therapy training he was teaching.
“I thought it went great, and then we taught it to another group,” he told HCN, but when the CM developers finally sent him a revised treatment manual, he realized he’d taught it incorrectly.
Instead, he had developed something different — but equally effective — which he decided to call progressive counting.
In this technique, the patient is asked to frame the memory of the traumatic event as if watching a movie in his or her head. First, the therapist guides the client in identifying the beginning moment of the movie (before the trauma happened) and the ending moment (a point after the trauma event which provided some relief).
The patient is then asked to run the movie in their head from beginning to end, while the therapist counts aloud from one to 10, then again while the therapist counts from one to 20, then to 30, and so on, all the way to a one-to-100 count. Later, when the memory is nearly resolved, the length of the counting is progressively decreased.
The therapist then asks the client to rate their level of distress on a scale of zero to 10, with the goal of bringing that memory’s rating to a score of zero, or no distress. It’s a method, Greenwald discovered, that proved as efficient as EMDR or the traditional counting method, but was better-tolerated, with fewer dropouts.
Beyond the Pain
To explain how EMDR and PC work, he noted how minor traumas ‘heal’ as quickly as a small cut on someone’s arm does.
“Our brain has a natural healing process,” he said. “If a kid goes to school and somebody calls him a name, it hurts. He may go home and cry about it, but after talking to his mom or talking to a friend, when he goes back to school the next day, it feels better. That’s our natural healing process — talk, cry, laugh, problem solved.”
He compared a major trauma, however, to a larger cut with debris lodged in it that causes an infection. He said a doctor wouldn’t just treat the symptoms, but would go after the foreign object causing the inflammation. EMDR and PC, he explained, help the patient bring the trauma out from behind a mental wall to deal with it directly, rather than just trying to mitigate the emotional symptoms.
“You don’t forget about it, but it’s something that you’ve worked out and doesn’t hurt anymore,” he explained. “People say, ‘I still remember, but it’s part of the past now, and doesn’t affect me the same way it used to.’”
Patients treated by Greenwald and his staff run the gamut — “everything from run-of-the-mill dysfunctional family dynamics in otherwise heathy people to some of the most horrific abuse cases where, if you saw it in a movie, you wouldn’t believe it.”
Persistent trauma is a widespread problem, he noted, affecting more than 6 million people a year in the U.S. alone, including all genders, races, and ages. A pioneer in intensive trauma-focused therapy, Greenwald has published 10 books and more than 40 professional articles on the topic, and has trained mental-health professionals around the world.
Meanwhile, a practice that, four years ago, included just Greenwald and an office manager has grown to a staff of 17, including seven therapists in Florence and three more in other states. Because the product is so specialized, he said, it can be easily franchised.
“This is an exciting place to work,” he said. The therapists understand they’re on the cutting edge of developing a standard of care, and many of our therapists are becoming consultants and trainers.”
The next goal, he explained, is to compile a database of pre- and post-treatment assessments for CP, then mine the data to publish studies demonstrating its effectiveness, with the goal of getting insurance companies to pay for treatments.
“The return is very good,” he said, noting that a mentally healthy patient is one who will cost payers less down the road, but insurance companies want to see the statistics backing up CP’s ability to lower those costs. “If you can pay less and get better results, why wouldn’t you? But they’ve got to see the numbers.”
Another challenge, he noted, is simply to stay upbeat when dealing with often uncomfortable situations.
“On one hand, our therapists are the happiest therapists I know because you can meet somebody on a Monday, and by Thursday or Friday, you’re saying, ‘good work; have a good life.’ It’s not quite instant gratification, but it’s often very quick results. That’s good for our clients and good for us, too. You really have a sense of being effective.”
That said, Greenwald and his team are focused on self-care to keep their own minds healthy. “A lot of the therapists are doing meditation and exercise. If a client leaves early, I’ll say, ‘take a walk; I don’t need you here every minute of the day.’ This is intensive work,” he told HCN.
“Obviously, you care about your clients, and you feel their pain — not as much as they do, but you feel it also,” he went on. “That’s difficult, but when you’re able to help them get where they need to go, that’s a pretty good feeling.”