DeTUR Protocol

What is DeTUR for EMDR Therapy?

Eye Movement Desensitization and Reprocessing (EMDR) Therapy is an empirically supported therapy for treating trauma. Since Francine Shapiro (1948-2019) initially developed EMDR in 1987 to treat post-traumatic stress disorder (PTSD), it has become a widely used style in a variety of other cognitive and behavioral symptoms. With treating PTSD, EMDR therapist typically use the standard protocol, an organized outline of steps for treatment. However, treatment of other specialized populations often requires flexibility, adjusting to special needs of that specific group. One such group is those seeking treatment for chemical and behavioral addictions. The DeTUR protocol, which stands for Desensitization of Triggers and Urge Reprocessing, is a specific protocol for addiction treatment.

EMDR Protocols

The protocols in EMDR Therapy “help the therapist determine a particular sequence in the targeting of memories that are driving the client’s disturbance in the present” (Hase, 2021). The standard EMDR protocol is three pronged, consisting of past experiences that ignite present symptoms, unresolved present triggers tied to the past, and a positive follow up future template.

Shapiro suggested that EMDR could be used for “substance abuse by targeting (a) the memories that precipitate and drive substance abuse. (b) the relapse triggers and cravings to use drugs, (c) future healthy and adaptive coping, and (d) treatment motivation and compliance. Initially, treatment for addiction relied on the standard EMDR protocol, relying on the assumption that addiction was typically a symptom of unprocessed trauma—treat the trauma cure the addiction.

Authors April Wise and Jamie Marich suggest that Trauma and Addiction often create a vicious cycle “where PTSD symptoms trigger substance abuse, substance abuse in turn increases risk for future trauma experiences, and withdrawal from substances can trigger PTSD symptoms” (2016). However, not every addiction is a symptom of trauma. Can therapist use EMDR therapy to treat addiction where no trauma is detected?

Arnold J. Popky and the DeTUR Protocol

In 2005, Arnold J. Popky Ph.D. “focused and condensed the last three targets (i.e., treatment goal, triggers, and urge, and future action) into the desensitization of triggers and urge reprocessing (DeTUR) protocol (Bae and Kim, 2012). Popky’s DeTUR protocol does not target traumatic memories, like the standard EMDR protocol. Instead the DeTUR protocol targets, desensitizes, and reprocesses the triggers and urges that evoke addictive compulsive behaviors. The DeTUR protocol is an addiction specific protocol whether the addiction is a symptom of trauma or not.

Similar to exposure therapy, “a hierarchy of triggers is first constructed with the client, and from the lowest urge to the highest, each trigger is desensitized until the urge becomes zero” (Bae, Han, & Kim, 2013). The overall goal is to desensitize the triggers to urge while simultaneously empowering clients by installing positive resource goals. Basically, DeTUR protocol has a two pronged approach of removing urges and increasing resistance through building self regulation and other resources.

Popky explains that even within the DeTUR protocol there is room for flexibility. He explains there is no one size fits all solutions, and that this protocol must adapt to individual client’s needs, goals, and values. Accordingly, the DeTUR protocol, explains Popky, is only “a small part of a complete treatment model.” He continues, “the therapist role is that of a case manager, orchestrating any/all resources necessary to aid the patient through recovery to a successful and healthy state of functioning and coping” (2007).

Five Significant Differences to Popky’s Treatment Approach

1. Client’s attention is directed towards a positive, achievable goal of coping and functioning as opposed to away from a negative behavior.
2. Abstinence is highly recommended but not required as the treatment goal. Functioning and coping in a healthy manner is the treatment goal.
3. Relapse is reframed from a failure to new targets of opportunity to discuss in following sessions.
4. Chemical withdrawal and anxiety often take place out of the client’s awareness, not requiring constant attention.
5. The therapy targets the individual’s triggers for desensitization, allowing this model to be used early in recovery.

Differences Between DeTUR Protocol and the Standard Protocol of EMDR

Both the standard EMDR protocol and DeTUR protocol use bilateral stimulation and installation of positive. Both require thorough history taking, assessment and diagnosis. The main differences is the focus. The EMDR protocol targets affect and known traumatic issues, while DeTUR only addresses the past if it happens to come up during a session. The primary focus of DeTUR is its “focus on the present situation, events, or stimuli that bring up uncomfortable feelings leading to urges to use” (Wise and Marich, 2016).

During the desensitization stage EMDR protocol uses Subjective Units of Disturbance (SUD) during the session and the Validity of Cognition (VoC) scale to measure cognitive restructuring. DeTUR protocol only uses the Level of Urge (LOU) scale for measurement of desensitization (Wise and Marich, 2016).

DeTUR Protocol Steps

The DeTUR protocol has twelve steps. The therapist covers the first seven steps during the initial session before desensitization begins. Steps 8-10 are utilized with each known trigger. And step 11 is part of the closing of each session. Step 12 is the follow up sessions, revisiting the previous steps as needed (Bae, Han, & Kim, 2013).

1. Rapport
2. History, Assessment, Diagnosis
3. Support Resources
4. Accessing Internal Resource State
5. Positive Treatment Goal
6. Associated Positive State
7. Identifying Urge Triggers
8. Desensitize Triggers
9. Install Positive State to Each Trigger
10. Test and Future Check
11. Closure and Self Work
12. Follow Up On Sessions

Rapport

Treatment fails when the client feels threatened. A key element for successful treatment is security. The therapist must create trust and safety in the therapeutic process.

History, Assessment, Diagnosis

During this phase, the therapist tests for any contributing disorders (depression, personality disorders, anxiety, etc…). The therapist may use a variety of empirically supported inventories, as well as medical and psychological records. Therapist also should obtain family history, methods of coping, substance use history, and previous attempts to recover from the addiction.

External Support Resources

External support is necessary for recovery. Identifying and encouraging use existing support networks is critical in recovery. Unfortunately, because addiction is often seen and critically judged by others those suffering from addiction try to recover privately. This path typically fails. Clients need a safe place to express their feelings, fears, and troubles. 12 step groups, religious organizations, friends and family, or others organizations may provide these resources. A therapist should help the client identify and use these necessary resources during the recovery process.

Accessing Internal Resource State

Before beginning any bi-lateral stimulation for desensitizing triggers, Popky would have clients “recall a time when they experienced feelings of being resourceful, powerful and in -control.” He stated that by accessing these positive internal resource states first allowed the desensitization process to move faster (2007). During the first session, therapist identify internal resources so they can help the client draw upon them during future sessions.

Positive Treatment Goal

A client must have a clearly defined positive treatment goal. This goal must be attractive and achievable. Popky describes that the goal must have a “magnetic pull that they can easily maintain their focus on.” Too many people suffering from addiction set negative focused goals, such as ‘to quick drinking or smoking’. These goals sometimes have the opposite effect, leaving one craving for that which they are in the process of giving up.

Positive treatment goals may include the desired lifestyle (happy marriage, prosperous career, etc…) that addiction prevents. By focusing on the image of fulfillment of these treatment goals, the client stays motivated.

Associated Positive State

A client must associate with their goal. Instead state of treatment being some unimaginable place, far in the future. The experience of the end state must provide an anchor. This step is closely related to positive psychology. Through associative representaion the client can experience some of the feelings of achievement of the goal while still working towards that end.

Identifying Urge Triggers

During this phase, the therapist identifies known triggers that brings up the urge to use. These triggers may be a person, place, time, emotion, smell, taste, etc…. The therapist should gather as much specifics about each trigger and then label the trigger and place it on a hierarchy from weakest to strongest.

Desensitize Triggers

Beginning with the weakest triggers, the therapist has the client visualize the trigger along with a free association of any thoughts, emotions, or sensory experiences that may go with it. The therapist will have the client identify the Level of Urge measured from 0 to 10. While holding this representative picture in their mind, the therapist begins the bilateral stimulation (eye movement). The therapist continues with free association during this phase and client’s LOU assessments until the urge drops to 0. Popky explains this can be thought of as “cutting the wire between the stimulus and the learned dysfunctional response” (2007).

If a client experiences no drop in LOU assessments of the urge, the therapist should adjust the rhythm, pattern, or length of time of the bilateral stimulation. In one study, researchers found that longer bilateral stimulation sessions reignited the urge while shorter ones were effective (Bae & Kim, 2012).

Install Positive State to Each Trigger

While desensitization is cutting the wire between trigger and dysfunctional response, therapist use this phase to link the positive state identified in stage six to the triggers. The theory is that moving forward whenever the previous events that triggered the urge arise they now will activate the positive state.

The therapist achieves this linkage by having the client visualize the trigger while holding the positive state in their mind during another set of bilateral stimulation.

Test and Future Check

A Therapist measures progress of session by bringing up triggers and asking the client to provide a LOU score. If there is any remaining urge, then the therapist and client repeat the desensitization process. The therapist and client repeat this for every identified trigger.

Closure and Self Work

Typically, recovery requires several sessions. The therapist must remind the client that healing takes time, directing the client to take note of any urges experienced in-between sessions and record the surrounding events.

Follow Up On Sessions

During the follow up sessions a therapist should check for any new information, along with testing any previous desensitized triggers, and address any relapses.

Empirical Research for the DeTUR Protocol

EMDR is a widely used and tested therapy with an abundance of supporting studies. However, while research for the DeTUR protocol has some positive findings, the documented studies are relatively few. Most of the studies I found were limited to small samples. Perhaps, the DeTUR protocol may be a viable option for some when other methods of treatment have failed. However, if trauma is at the heart of the addiction, a better option may be to first try the standard EMDR protocol.

Trained Therapist

EMDR therapy, including the DeTUR method, should be done by trained professionals. It’s important to consult a qualified therapist for safe and effective treatment.

References:

Bae, Hwallip; Han, Changwoo, & Kim, Daeho (2013). Desensitization of Triggers and Urge Reprocessing for Pathological Gambling: A Case Series. Journal of Gambling Studies, 31(1), 331-342. DOI: 10.1007/s10899-013-9422-5

Bae, Hwallip & Kim, Daeho (2012). Desensitization of Triggers and Urge Reprocessing for an Adolescent With Internet Addiction Disorder. Journal of EMDR Practice and Research, 6(2), 73-81. DOI:10.1891/1933-3196.6.2.73

Hase, Michael (2021). The Structure of EMDR Therapy: A Guide for the Therapist. Frontiers in psychology, 12, 660753. DOI: 10.3389/fpsyg.2021.660753.

Popky, Arnold J. (2007). DeTUR (Desensitization of Triggers and Urge Reprocessing). A New Approach to Working with Addiction and Dysfunctional Behaviors.

Popky, A. J. (2005). DeTUR, an Urge Reduction Protocol for Addictions and Dysfunctional Behaviors. In R. Shapiro (Ed.), EMDR solutions: Pathways to healing (pp. 167–188). W W Norton & Co.

Wise, April & Marich, Jamie (2016). The Perceived Effects of Standard and Addiction-Specific EMDR Therapy Protocols. Journal of EMDR Practice and Research, 10(4), 231-244. DOI: 10.1891/1933-3196.10.4.231

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