Click the link below for a video introduction to EMDR
AM I A GOOD CANDIDATE FOR THIS TREATMENT?
EMDR has been shown to be effective with children, adolescents and adults who have experienced trauma, both simple and complex, and who are experiencing various levels of trauma responses including clinical PTSD.
While research is ongoing, preliminary evidence suggests that EMDR may also be an effective treatment for the following:
- Panic Disorder
- Generalized Anxiety Disorder
- Attachment Disorder
- Conduct Problems & Self-Esteem
- Grief & Loss
- Body Dysmorphic Disorder
- Sexual Dysfunction
- Chronic Pain
- Migraine Headaches
- Phantom Limb Pain
- Medically Unexplained Physical Symptoms
WHAT IS EMDR?
EMDR (Eye Movement Desensitization and Reprocessing) is a psychotherapy that enables people to heal from the symptoms and emotional distress that are the result of disturbing life experiences. Repeated studies show that by using EMDR therapy people can experience the benefits of psychotherapy that once took years to make a difference. It is widely assumed that severe emotional pain requires a long time to heal. EMDR therapy shows that the mind can in fact heal from psychological trauma much as the body recovers from physical trauma. When you cut your hand, your body works to close the wound. If a foreign object or repeated injury irritates the wound, it festers and causes pain. Once the block is removed, healing resumes. EMDR therapy demonstrates that a similar sequence of events occurs with mental processes. The brain’s information processing system naturally moves toward mental health. If the system is blocked or imbalanced by the impact of a disturbing event, the emotional wound festers and can cause intense suffering. Once the block is removed, healing resumes. Using the detailed protocols and procedures learned in EMDR therapy training sessions, clinicians help clients activate their natural healing processes.
More than 30 positive controlled outcome studies have been done on EMDR therapy. Some of the studies show that 84%-90% of single-trauma victims no longer have post-traumatic stress disorder after only three 90-minute sessions. Another study, funded by the HMO Kaiser Permanente, found that 100% of the single-trauma victims and 77% of multiple trauma victims no longer were diagnosed with PTSD after only six 50-minute sessions. In another study, 77% of combat veterans were free of PTSD in 12 sessions. There has been so much research on EMDR therapy that it is now recognized as an effective form of treatment for trauma and other disturbing experiences by organizations such as the American Psychiatric Association, the World Health Organization and the Department of Defense. Given the worldwide recognition as an effective treatment of trauma, you can easily see how EMDR therapy would be effective in treating the “everyday” memories that are the reason people have low self-esteem, feelings of powerlessness, and all the myriad problems that bring them in for therapy. Over 100,000 clinicians throughout the world use the therapy. Millions of people have been treated successfully over the past 25 years.
EMDR therapy is an eight-phase treatment. Eye movements (or other bilateral stimulation) are used during one part of the session. After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist’s hand as it moves back and forth across the client’s field of vision. As this happens, for reasons believed to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level. For instance, a rape victim shifts from feeling horror and self-disgust to holding the firm belief that, “I survived it and I am strong.” Unlike talk therapy, the insights clients gain in EMDR therapy result not so much from clinician interpretation, but from the client’s own accelerated intellectual and emotional processes. The net effect is that clients conclude EMDR therapy feeling empowered by the very experiences that once debased them. Their wounds have not just closed, they have transformed. As a natural outcome of the EMDR therapeutic process, the clients’ thoughts, feelings and behavior are all robust indicators of emotional health and resolution—all without speaking in detail or doing homework used in other therapies.
EMDR therapy combines different elements to maximize treatment effects. A full description of the theory, sequence of treatment, and research on protocols and active mechanisms can be found in F. Shapiro (2001) Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd edition) New York: Guilford Press.
EMDR therapy involves attention to three time periods: the past, present, and future. Focus is given to past disturbing memories and related events. Also, it is given to current situations that cause distress, and to developing the skills and attitudes needed for positive future actions. With EMDR therapy, these items are addressed using an eight-phase treatment approach.
Phase 1: The first phase is a history-taking session(s). The therapist assesses the client’s readiness and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include distressing memories and current situations that cause emotional distress. Other targets may include related incidents in the past. Emphasis is placed on the development of specific skills and behaviors that will be needed by the client in future situations.
Initial EMDR processing may be directed to childhood events rather than to adult onset stressors or the identified critical incident if the client had a problematic childhood. Clients generally gain insight on their situations, the emotional distress resolves and they start to change their behaviors. The length of treatment depends upon the number of traumas and the age of PTSD onset. Generally, those with single event adult onset trauma can be successfully treated in under 5 hours. Multiple trauma victims may require a longer treatment time.
Phase 2: During the second phase of treatment, the therapist ensures that the client has several different ways of handling emotional distress. The therapist may teach the client a variety of imagery and stress reduction techniques the client can use during and between sessions. A goal of EMDR therapy is to produce rapid and effective change while the client maintains equilibrium during and between sessions.
Phases 3-6: In phases three to six, a target is identified and processed using EMDR therapy procedures. These involve the client identifying three things:
1. The vivid visual image related to the memory
2. A negative belief about self
3. Related emotions and body sensations.
In addition, the client identifies a positive belief. The therapist helps the client rate the positive belief as well as the intensity of the negative emotions. After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously engaging in EMDR processing using sets of bilateral stimulation. These sets may include eye movements, taps, or tones. The type and length of these sets is different for each client. At this point, the EMDR client is instructed to just notice whatever spontaneously happens.
After each set of stimulation, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client’s report, the clinician will choose the next focus of attention. These repeated sets with directed focused attention occur numerous times throughout the session. If the client becomes distressed or has difficulty in progressing, the therapist follows established procedures to help the client get back on track.
When the client reports no distress related to the targeted memory, (s)he is asked to think of the preferred positive belief that was identified at the beginning of the session. At this time, the client may adjust the positive belief if necessary, and then focus on it during the next set of distressing events.
Phase 7: In phase seven, closure, the therapist asks the client to keep a log during the week. The log should document any related material that may arise. It serves to remind the client of the self-calming activities that were mastered in phase two.
Phase 8: The next session begins with phase eight. Phase eight consists of examining the progress made thus far. The EMDR treatment processes all related historical events, current incidents that elicit distress, and future events that will require different responses
What is the theoretical basis for EMDR therapy?
Shapiro (1995) developed the Accelerated Information Processing model to describe and predict the effects of EMDR therapy. More recently, Shapiro (2001) expanded this into the Adaptive Information Processing (AIP) model to broaden its applicability. She hypothesizes that humans have an inherent information processing system that generally processes the multiple elements of experiences to an adaptive state where learning takes place. She conceptualizes memory as being stored in linked networks that are organized around the earliest related event and its associated affect. Memory networks are understood to contain related thoughts, images, emotions, and sensations. The AIP model hypothesizes that if the information related to a distressing or traumatic experience is not fully processed, the initial perceptions, emotions, and distorted thoughts will be stored as they were experienced at the time of the event. Shapiro argues that such unprocessed experiences become the basis of current dysfunctional reactions and are the cause of many mental disorders. She proposes that EMDR therapy successfully alleviates mental disorders by processing the components of the distressing memory. These effects are thought to occur when the targeted memory is linked with other more adaptive information. When this occurs, learning takes place, and the experience is stored with appropriate emotions able to guide the person in the future.
Is EMDR therapy a one-session cure?
No. When Shapiro (1989a) first introduced EMDR therapy into the professional literature, she included the following caveat: “It must be emphasized that the EMD procedure, as presented here, serves to desensitize the anxiety related to traumatic memories, not to eliminate all PTSD-symptomology and complications, nor to provide coping strategies to victims” (p 221). In this first study, the focus was on one memory, with effects measured by changes in the Subjective Units of Disturbance (SUD) scale. The literature consistently reports similar effects for EMDR with SUD measures of in-session anxiety. Since that time, EMDR therapy has evolved into an integrative approach that addresses the full clinical picture. Two studies (Lee, Gavriel, Drummond, Richards, & Greenwald, 2002; Rothbaum, 1997) have indicated an elimination of diagnosis of posttraumatic stress disorder (PTSD) in 83-90% of civilian participants after four to seven sessions. Other studies using participants with PTSD (e.g. Ironson, Freund, Strauss, & Williams, 2002; Scheck, Schaeffer, & Gillette, 1998; S. A. Wilson, Becker, & Tinker, 1995) have found significant decreases in a wide range of symptoms after three-four sessions. The only study (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998) of combat veterans to address the multiple traumas of this population reported that 12 sessions of treatment resulted in a 77% elimination of PTSD. Clients with multiple traumas and/or complex histories of childhood abuse, neglect, and poor attachment may require more extensive therapy, including substantial preparatory work in phase two of EMDR (Korn & Leeds, 2002; Maxfield & Hyer, 2002; Shapiro, 2001).
Is EMDR therapy an efficacious treatment for PTSD?
EMDR therapy is recognized as an effective trauma treatment and recommended worldwide in the practice guidelines of both domestic and international organizations:
American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines.
EMDR is recommended as an effective treatment for trauma.
Bleich, A., Kotler, M., Kutz, I., & Shalev, A. (2002). A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel.
EMDR is one of three methods recommended for treatment of terror victims.
California Evidence-Based Clearinghouse for Child Welfare (2010). Trauma Treatment for Children: http://www.cebc4cw.org.
EMDR and Trauma-focused CBT are considered “Well-Supported by Research Evidence.”
Chambless, D.L. et al. (1998). Update of empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.
According to a taskforce of the Clinical Division of the American Psychological Association, the only methods empirically supported (“probably efficacious”) for the treatment of any post-traumatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy. Note that this evaluation does not cover the last decade of research.
CREST (2003). The management of post traumatic stress disorder in adults. A publication of the Clinical Resource Efficiency Support Team of the Northern Ireland Department of Health, Social Services and Public Safety, Belfast.
EMDR and CBT were stated to be the treatments of choice.
Department of Veterans Affairs & Department of Defense (2010). VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense.
EMDR was placed in the category of the most effective PTSD psychotherapies. This “A” category is described as “A strong recommendation that clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.”
Dutch National Steering Committee Guidelines Mental Health Care (2003). Multidisciplinary Guideline Anxiety Disorders. Quality Institute Heath Care CBO/Trimbos Intitute. Utrecht, Netherlands.
EMDR and CBT both designated as treatments of choice for PTSD.
Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press.
EMDR was listed as an effective and empirically supported treatment for PTSD, and was given an AHCPR “A” rating for adult PTSD. This guideline specifically rejected the findings of the previous Institute of Medicine report, which stated that more research was needed to judge EMDR effective for adult PTSD. With regard to the application of EMDR to children, an AHCPR rating of Level B was assigned. Since the time of this publication, three additional randomized studies on EMDR have been completed (see below).
INSERM (2004). Psychotherapy: An evaluation of three approaches. French National Institute of Health and Medical Research, Paris, France.
EMDR and CBT were stated to be the treatments of choice for trauma victims.
National Collaborating Centre for Mental Health (2005). Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care. London: National Institute for Clinical Excellence.
Trauma-focused CBT and EMDR were stated to be empirically supported treatments for choice for adult PTSD.
SAMHSA’s National Registry of Evidence-based Programs and Practices (2011): http://nrepp.samhsa.gov/ViewIn...
The Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency of the U.S. Department of Health and Human Services (HHS). This national registry (NREPP) cites EMDR as evidence based practice for treatment of PTSD, anxiety, and depression symptoms. Their review of the evidence also indicated that EMDR leads to an improvement in mental health functioning.
Therapy Advisor (2004-11): http://www.therapyadvisor.com
An NIMH sponsored website listing empirically supported methods for a variety of disorders. EMDR is one of three treatments listed for PTSD.
United Kingdom Department of Health (2001). Treatment choice in psychological therapies and counselling evidence based clinical practice guideline. London, England.
Best evidence of efficacy was reported for EMDR, exposure, and stress inoculation.
World Health Organization (2013). Guidelines for the management of conditions that are specifically related to stress. Geneva, WHO.
Trauma-focused CBT and EMDR are the only psychotherapies recommended for children, adolescents and adults with PTSD. “Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.” (p.1).
For an annotated list of research: Research Overview.
Are treatment effects maintained over time?
Twelve studies with PTSD populations assessed treatment maintenance by analyzing differences in outcome between post-treatment and follow-up. Follow-up times have varied and include periods of 3, 4, 9, 15 months, and 5 years after treatment. Treatment effects were maintained in eight of the nine studies with civilian participants; one study (Devilly & Spence, 1999) reported a trend for deterioration. Of the three studies with combat veteran participants only one (Carlson et al., 1998) provided a full course of treatment (12 sessions). This study found that treatment effects were maintained at 9 months. The other two studies provided limited treatment: Devilly, Spence and Rapee (1998) provided two sessions and moderate effects at post-test were not maintained at follow-up. Pitman et al. (1996) treated only two of multiple traumatic memories, and treatment effects were not maintained at 5 year follow-up (Macklin et al., 2000). It appears that the provision of limited treatment may be inadequate to fully treat the disorder, resulting in remission of the partial effects originally achieved.
Is EMDR therapy effective in the treatment of phobias, panic disorder, or agoraphobia?
There is much anecdotal information that EMDR therapy is effective in the treatment of specific phobias. Unfortunately, the research that has investigated EMDR treatment of phobias, panic disorder, and agoraphobia has failed to find strong empirical support for such applications. Although these results are due in part to methodological limitations in the various studies, it is also possible that EMDR therapy may not be consistently effective with these disorders. De Jongh, Ten Broeke, and Renssen (1999) suggest that since EMDR therapy is a treatment for distressing memories and related pathologies, it may be most effective in treating anxiety disorders which follow a traumatic experience (e.g., dog phobia after a dog bite), and less effective for those of unknown onset (e.g., snake phobia).
There have been several randomized clinical trials assessing EMDR treatment of spider phobia (Muris & Merckelbach, 1997; Muris, Merckelbach, van Haaften, & Nayer, 1997; Muris, Merkelbach, Holdrinet, & Sijsenaar, 1998). These studies indicated that EMDR was less effective than in vivo exposure therapy in eliminating the phobia. Methodological limitations of these studies include failure to use the full EMDR treatment protocol (see Shapiro, 1999) and confounding of effects, by using the exposure treatment protocol as the post-treatment assessment. When the full EMDR phobia protocol was used in case studies with medical and dental phobias (De Jongh et al., 1999; De Jongh, van den Oord, & Ten Broeke, 2002), good results were achieved. A randomized controlled trial (Doering et al., 2013) indicated that three sessions of EMDR therapy memory processing resulted in remission of dental phobia. “After 1 yr, 83.3% of the patients were in regular dental treatment (d = 3.20).”
Clinical utility is an important consideration in treatment selection. The application of in vivo exposure may be impractical for clinicians who do not have easy access to feared objects (e.g., spiders) in their office settings; some phobias are limited to specific events (e.g., thunderstorms) or places (e.g., bridges). EMDR therapy may be a more practical treatment than in vivo exposure, and the in vivo aspect can often be added as homework (De Jongh et al., 1999).
There have been three studies that investigated EMDR treatment of panic disorder with/out agoraphobia. The first two studies were preliminary (Feske & Goldstein, 1997;Goldstein & Feske, 1994) and provided a short course (six sessions) of treatment for panic disorder. The results were promising, but limited by the short course of treatment. Feske and Goldstein write, “Even 10 to 16 sessions of the most powerful treatments rarely result in a normalization of panic symptoms, especially when these are complicated by agoraphobia” (p. 1034). The EMDR therapy effects were generally maintained at follow-up. A third study (Goldstein et al., 2000) was conducted to assess the benefits of a longer treatment course. This study however changed the target population and treated agoraphobic patients. Participants suffering from Panic Disorder with Agoraphobia did not respond well to EMDR therapy. Goldstein (quoted in Shapiro, 2001) suggests that these participants needed more extensive preparation, than was provided in the study, to develop anxiety tolerance. The authors suggest that EMDR therapy may not be as effective as CBT in the treatment of panic disorder with/out agoraphobia; however no direct comparison studies have yet been conducted. A study (Faretta, 2013) compared 12 sessions of EMDR with CBT in the treatment of panic disorder with or without accompanying agoraphobia. The processing of etiological events, triggers and memory templates was accomplished in session without the use of treatment-specific homework. In contrast, the CBT group utilized in-session breathing and relaxation exercises plus imaginal exposure, and was assigned both relaxation and exposure homework. Both treatments demonstrated a substantial decrease in anxiety symptoms, intensity and frequency of panic attacks. EMDR resulted in significantly fewer panic attacks than CBT at posttest and follow-up.
Is EMDR therapy applied to every clinical disorder?
No. EMDR therapy was developed as a treatment for traumatic memories and research has demonstrated its effectiveness in the treatment of PTSD (see Is EMDR an efficacious treatment for PTSD? ). Shapiro (2001) states that it should be helpful in reducing or eliminating other disorders that originate following a distressing experience. For example, Brown, McGoldrick, and Buchanan (1997) found successful remission in five of seven consecutive cases of Body Dysmorphic Disorder cases after 1-3 EMDR therapy sessions that processed the etiological memory. Similarly there have been reports of elimination of phantom limb pain following EMDR treatment of the etiological memory and the pain sensations (Vanderlaan, 2000; Wilensky, 2000; S. A. Wilson, Tinker, Becker, Hofmann, & Cole, 2000). It is not anticipated that EMDR therapy will be able to alleviate fully the symptoms arising from physiologically based disorders, such as schizophrenia or bipolar disorder. However, experiential contributors may play a major role in some symptoms, and there are anecdotal reports of persons with such disorders being treated successfully with EMDR therapy for distress related to traumatic events.
In addition to studies assessing the effectiveness of EMDR therapy in the treatment of PTSD, phobias, and panic disorders (see Is EMDR an effective treatment of phobias, panic disorder, and agoraphobia? ), some preliminary investigations have indicated that EMDR therapy might be helpful with other disorders. These include dissociative disorders (e.g, Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen, 1995); performance anxiety (Foster & Lendl, 1996; Maxfield & Melnyk, 2000); body dysmorphic disorder (Brown et al., 1997); pain disorder (Grant & Threlfo, 2002); and personality disorders (e.g., Korn & Leeds, 2002; Manfield, 1998). These findings are preliminary and further research is required before any conclusions can be drawn. In Shapiro, 2002, applications of EMDR are described for complaints such as depression (Shapiro, 2002), attachment disorder (Siegel, 2002), social phobia (Smyth, & Poole, 2002), anger dyscontrol (Young, Zangwill, & Behary , 2002), generalized anxiety disorder (Lazarus, & Lazarus , 2002), distress related to infertility (Bohart & Greenberg, 2002), body image disturbance (Brown, 2002), marital discord (Kaslow, Nurse, & Thompson, 2002), and existential angst (Krystal, Prendergast, Krystal, Fenner, Shapiro, Shapiro, 2002); all such applications should be considered in need of controlled research for comprehensive examination.
Can the effects of EMDR therapy be attributed to placebo or non-specific effects?
No. A number of studies have found EMDR therapy superior in outcome to placebo treatments, and to treatments not specifically validated for PTSD. EMDR has outperformed active listening (Scheck et al., 1998), standard outpatient care consisting of individual cognitive, psychodynamic, or behavioural therapy in a Kaiser Permanente Hospital (Marcus et al., 1997), relaxation training with biofeedback (Carlson et al., 1998). EMDR therapy as been found to be relatively equivalent to CBT therapies in seven randomized clinical trials that compared the two approaches. Because the treatment effects are large and clinically meaningful, it can be concluded that EMDR therapy is not a placebo treatment. For example, in a meta-analysis of PTSD treatments, Van Etten and Taylor (1998), calculated the mean effect sizes on self-report measures for placebo and control conditions as 0. 43, for EMDR as 1.24, and for CBT as 1.27 (p. 135). Several studies (e.g., Thordarson et al., 2001) have measured the credibility of the treatments being provided, as a way to determine if EMDR therapy elicited more confidence from clients, thereby producing larger effects; no study found EMDR more or less credible. Because EMDR therapy is not more credible than these other therapies, it appears that the effects cannot be attributed to suggestion or a heightened placebo effect.
What have meta-analyses revealed about EMDR therapy?
EMDR therapy has been compared to numerous psychotherapy protocols. It should be noted that trauma-focused CBT and exposure therapy use one to two hours of daily homework and EMDR therapy uses none. The most recent meta-analyses are listed here.
Bisson, J., Roberts, N.P., Andrew, M., Cooper, R. & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews 2013, DOI: 10.1002/14651858.CD003388.pub4
Research indicates that CBT and EMDR therapy are superior to all other treatments.
Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227.
EMDR is equivalent to exposure and other cognitive behavioral treatments and all “ are highly efficacious in reducing PTSD symptoms.”
Davidson, P.R., & Parker, K.C.H. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-316.
EMDR therapy is equivalent to exposure and other cognitive behavioral treatments.
Lee, C.W. & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy & Experimental Psychiatry, 44, 231-239.
The effect size for the additive effect of eye movements in EMDR treatment studies was moderate and significant (Cohen’s d = 0.41). For the second group of laboratory studies the effect size was large and significant (d = 0.74).
Maxfield, L., & Hyer, L.A. (2002). The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD. Journal of Clinical Psychology, 58, 23-41.
A comprehensive meta-analysis reported the more rigorous the study, the larger the effect.
Rodenburg, R., Benjamin, A., de Roos, C, Meijer, A.M., & Stams, G.J. (2009). Efficacy of EMDR in children: A meta – analysis. Clinical Psychology Review, 29 , 599-606 .
Results indicate efficacy of EMDR when effect sizes are based on comparisons between EMDR and non-established trauma treatment or no-treatment control groups, and incremental efficacy when effect sizes are based on comparisons between EMDR and established (CBT) trauma treatment.
Seidler, G.H., & Wagner, F.E. (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychological Medicine, 36, 1515-1522.
Results suggest that in the treatment of PTSD, both therapy methods tend to be equally efficacious.
Watts, B.V. et al. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry , 74, e541-550. doi: 10.4088/JCP.12r08225
CBT and eye movement desensitization and reprocessing were the most often-studied types of psychotherapy. Both were effective.
Is fidelity to treatment important?
Yes. Treatment fidelity is considered one of the gold standards of clinical research (Foa & Meadows, 1997). Clearly, if the treatment being tested does not adhere to the standard protocol, then the treatment being examined is not the standard treatment; the study will have poor internal validity and the results may not be informative about the actual treatment. Treatment fidelity has been a subject of much controversy (Greenwald, 1996; Rosen, 1999). There is evidence that EMDR therapy is a robust treatment, not affected by some changes to protocol; for example, variations in the eye movement or stimulus component do not appear to interfere with outcome (Renfrey & Spates, 1994). On the other hand, there is evidence that truncating the procedure may result in poor outcomes; for example, an analysis (Shapiro, 1999) of the procedures used in the EMDR therapy phobia studies found that those omitting more than half of the EMDR therapy phases, achieved poor outcomes compared to those using the full protocol. In a methodological meta-analysis, Maxfield and Hyer (2002) found a significant positive correlation between pre-post effect size and assessments of fidelity. Specifically those studies with fidelity that was assessed as adequate, tended to have larger effects than those with fidelity that was assessed as variable or poor, or not assessed.
What elements of EMDR therapy contribute to its effectiveness?
EMDR therapy is a complex therapeutic approach that integrates elements of many traditional psychological orientations and combines these in structured protocols. These include psychodynamic(Fensterheim, 1996; Solomon & Neborsky, 2001; Wachtel, 2002), cognitive behavioural (Smyth & Poole, 2002; Wolpe, 1990; Young, Zangwill, & Behary, 2002), experiential (e.g., Bohart & Greenberg, 2002), physiological (Siegel, 2002; van der Kolk, 2002), and interactional therapies (Kaslow, Nurse, &Thompson, 2002). Consequently EMDR contains many effective components, all of which are thought to contribute to treatment outcome.
Marks, Lovell, Noshirvani, Livanou, & Thrasher (1998) propose that emotion can be conceptualised as a “skein of responses,” viewed as “loosely linked reactions of many physiological, behavioural, and cognitive kinds” (p. 324). They suggest that different types of treatment will weaken different strands within the skein of responses and that “some treatments may act on several strands simultaneously” (p. 324). EMDR therapy is a multi-component approach that works with strands of imagery, cognition, affect, somatic sensation, and related memories. This complexity makes it difficult to isolate and measure the contribution of any single component, especially as different clients with the same diagnosis may respond differently to different elements.
Shapiro’s (2001) AIP model conceptualizes EMDR therapy as working directly with cognitive, affective, and somatic components of memory to forge new associative links with more adaptive material. A number of treatment elements are formulated to enhance the processing and assimilation needed for adaptive resolution. These include: (1) Linking of memory components The client’s simultaneous focus on the image of the event, the associated negative belief, and the attendant physical sensations, may serve to forge initial connections among various elements of the traumatic memory, thus initiating information processing. (2) Mindfulness. Mindfulness is encouraged by instructing clients to “just notice” and to “let whatever happens, happen.” This cultivation of a stabilized observer stance in EMDR therapy appears similar to processes advocated by Teasdale (1999) as facilitating emotional processing. (3) Free association. During processing, clients are asked to report on any new insights, associations, emotions, sensations, images, that emerge into consciousness. This non-directive free association method may create associative links between the original targeted trauma and other related experiences and information, thus contributing to processing of the traumatic material (see Rogers & Silver, 2002). (4) Repeated access and dismissal of traumatic imagery. The brief exposures of EMDR therapy provide clients with repeated practice in controlling and dismissing disturbing internal stimuli. This may provide clients with a sense of mastery, contributing to treatment effects by increasing their ability to reduce or manage negative interpretations and ruminations. (5) Eye movements and other dual attention stimuli. There are many theories about how and why eye movements may contribute to information processing, and these are discussed in detail below.
Are eye movements considered essential to EMDR therapy?
Although eye movements are often considered its most distinctive element, EMDR therapy is not a simple procedure dominated by the use of eye movements. It is a complex psychotherapy, containing numerous components that are considered to contribute to treatment effects. Eye movements are used to engage the client’s attention to an external stimulus, while the client is simultaneously focusing on internal distressing material. Shapiro describes eye movements as “dual attention stimuli,” to identify the process in which the client attends to both external and internal stimuli. Therapist directed eye movements are the most commonly used dual attention stimulus but a variety of other stimuli including hand-tapping and auditory stimulation are often used. The use of such alternate stimuli has been an integral part of the EMDR protocol for more than 10 years (Shapiro 1991, 1993).
What has research determined about the eye movement component of EMDR therapy?
In 1989, Francine Shapiro (1995) noticed that the emotional distress accompanying disturbing thoughts disappeared as her eyes moved spontaneously and rapidly. She began experimenting with this effect and determined that when others moved their eyes, their distressing emotions also dissipated. She conducted a case study (1989b) and controlled study (1989a), and her hypothesis that eye movements (EMs) were related to desensitization of traumatic memories was supported. The role of eye movement had been previously documented in connection to cognitive processing mechanisms. A series of systematic experiments (Antrobus, 1973; Antrobus, Antrobus, & Singer, 1964) revealed that spontaneous EMs were associated with unpleasant emotions and cognitive changes.
There have been more than two dozen published randomized studies that investigated the role of EMs in EMDR therapy. Studies have typically compared EMDR-with-EMs to a control condition in which the EM component was modified (e.g., EMDR-with-eyes-focused-and-unmoving). There have been four different types of studies: (1) case studies, (2) dismantling studies using clinical participants (3) dismantling studies using nonclinical analogue participants, and (4) component action studies in which eye movements are examined in isolation.
A recent meta-analysis has demonstrated the positive effects of the eye movement component.
Lee, C.W. & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy & Experimental Psychiatry, 44, 231-239.
The effect size for the additive effect of eye movements in EMDR treatment studies was moderate and significant (Cohen’s d = 0.41). For the second group of laboratory studies the effect size was large and significant (d = 0.74).
A consistent significant effect for EMs in isolation in the 26 studies evaluated was found in reducing the vividness of, and affect associated with, autobiographical memories
An additional set of studies have demonstrated a number of other memory effects including the elicitation of episodic memory and the increased recognition of true information.
For an annotated list of studies see Research Overview.
What are some hypothesized mechanisms of action for eye movements in EMDR therapy?
A commonly proposed hypothesis is that dual attention stimulation elicits an orienting response. The orienting response is a natural response of interest and attention that is elicited when attention is drawn to a new stimulus. There are three different models for conceptualizing the role of the orienting response in EMDR: cognitive/information processing (Andrade et al., 1997; Lipke, 1999), neurobiological (Bergmann, 2000; Servan-Schreiber, 2000; Stickgold, 2002) and behavioral (Armstrong & Vaughan, 1996; MacCulloch & Feldman, 1996). These models are not exclusive; to some extent, they view the same phenomenon from different perspectives. Barrowcliff et al. (2001) posit that the orienting in EMDR therapy is actually an “investigatory reflex,” that results in a basic relaxation response, upon determination that there is no threat; this relaxation contributes to outcome through a process of reciprocal inhibition. Others suggest that the inauguration of an orienting response may disrupt the traumatic memory network, interrupting previous associations to negative emotions, and allowing for the integration of new information. A study by Kuiken, Bears, Miall & Smitth (2001-2002) which tested the orienting response theory indicated that the eye movement condition was correlated with increased attentional flexibility. It is further possible that the orienting response induces neurobiological mechanisms, which facilitate the activation of episodic memories and their integration into cortical semantic memory(Stickgold, 2002). According to Stickgold, the orienting response stimulates the same processes that occur during rapid eye movement sleep.
There are numerous research studies (e.g., Andrade et al., 1997; Kavanaugh et al., 2001; van den Hout et al., 2001) indicating that EMs and other stimuli have an effect on perceptions of the targeted memory, decreasing image vividness and associated affect. Two possible mechanisms have been proposed to explain how this effect may contribute to EMDR treatment. Kavanaugh et al. (2001) hypothesize that this effect occurs when EMs disrupt working memory, decreasing vividness, and that this results in decreased emotionality. They further suggest that this effect may contribute to treatment as a “response aid for imaginal exposure” (p. 278), by titrating exposure for those clients who are distressed by memory images and/or affect. Van den Hout et al. (2001)hypothesize that EMs change the somatic perceptions accompanying retrieval, leading to decreased affect, and therefore decreasing vividness. They propose that that this effect “may be to temporarily assist patients in recollecting memories that may otherwise appear to be unbearable” (p. 129). This explanation has many similarities to reciprocal inhibition.
What does the research show about the neurobiological aspects of EMDR therapy?
Given the infancy of the field of neurobiology, the physiological foundations of all psychotherapies are currently unknown, and therefore, all neurobiological models of psychotherapy are speculative. Testing of hypotheses about the neurological mechanisms of any form of psychotherapy and most pharmaceuticals awaits the development of advanced brain imaging techniques. Hypotheses concerning EMDR therapy’s neurobiological mechanisms are, at this time, purely speculative.
Rauch, van der Kolk, and colleagues (1996) conducted positron emission studies of patients with PTSD in which they were exposed to vivid, detailed narratives which they had written about their own traumatic experiences. Patients showed heightened activity only in the right hemisphere, in the areas most involved in emotional arousal, and heightened activity on the right visual cortex, reflecting the flashbacks reported by these patients. Perhaps most significantly, Broca’s area – the part of the left hemisphere responsible for translating personal experiences into communicable language -“turned off”. These findings indicate that PTSD symptoms are reflected in actual changes in brain activity.
Case study research by van der Kolk and colleagues (Levin, Lazrove, & van der Kolk, 1999; van der Kolk, Burbridge, & Suzuki, 1997; Zoler, 1998) has provided some preliminary evidence that changes in brain activation patterns may follow effective treatment. SPECT scans were administered pre and post-EMDR for 6 PTSD subjects who each received 3 EMDR sessions. The Zoler article has photos of pre and post SPECT scans. Findings indicated metabolic changes after EMDR in two specific brain regions. First, there was an increase in bilateral activity of the anterior cyngulate. This area moderates the experience of real versus perceived threat, indicating that after EMDR, PTSD sufferers may no longer be hypervigilant. Second, there appeared to be an increase in pre-frontal lobe metabolism. An increase in frontal lobe functioning may indicate improvement in the ability to make sense of incoming sensory stimulation. Levin et al. concluded that EMDR appeared to facilitate information processing. Because there was no control group, there is no evidence that these effects were unique to EMDR; effective treatment of any kind may produce similar results.
Lansing, K., Amen, D.G., Hanks, C. & Rudy, L. (2005) reported that pre- post treatment SPECT scans indicated a decrease in anterior cingulate, basal ganglia and deep limbic activity. The 12th chapter of Shapiro’s (2001) text details some related recent neurological research and explains the possible relevance of these findings to EMDR. Also of interest is an article by Stickgold (2002), a sleep researcher, who has developed a theory to explain the effects of EMDR’s alternating, bilateral stimulation which forces the client to constantly shift his or her attention across the midline. He proposed that REM-like neurobiological mechanisms are facilitated by this shifting attention, resulting in the activation of episodic memories, and their integration into cortical semantic memory. Independent research by Christman, S. D., Garvey, K. J., Propper, R. E., & Phaneuf, K. A. (2003) provides some support for this theory. They determined that alternating leftward and rightward eye movements produced a beneficial effect for episodic, but not semantic, retrieval memory tasks. See also Kuiken et al., 2002, 2010 (Research Overview)
All psychophysiological studies have indicated significant de-arousal. Neurobiological studies have indicated significant effects, including changes in cortical, and limbic activation patterns, and increase in hippocampal volume.
Aubert-Khalfa, S., Roques, J. & Blin, O. (2008). Evidence of a decrease in heart rate and skin conductance responses in PTSD patients after a single EMDR session. Journal of EMDR Practice and Research, 2, 51-56.
Bossini L. Fagiolini, A. & Castrogiovanni, P. (2007). Neuroanatomical changes after EMDR in posttraumatic stress disorder. Journal of Neuropsychiatry and Clinical Neuroscience, 19, 457-458 .
Bossini, L., Tavanti, M., Calossi, S., Polizzotto, N. R., Vatti, G., Marino, D., & Castrogiovanni, P. (2011). EMDR treatment for posttraumatic stress disorder, with focus on hippocampal volumes: A pilot study. The Journal of Neuropsychiatry and Clinical Neurosciences, 23 , E1-2. doi:10.1176/appi. neuropsych.23.2.E1
Frustaci, A., Lanza, G.A., Fernandez, I., di Giannantonio, M. & Pozzi, G. (2010). Changes in psychological symptoms and heart rate variability during EMDR treatment: A case series of subthreshold PTSD. Journal of EMDR Practice and Research, 4, 3-11.
Grbesa et al. (2010). Electrophysiological changes during EMDR treatment in patients with combat-related PTSD. Annals of General Psychiatry 9 (Suppl 1):S209.
Harper, M. L., Rasolkhani-Kalhorn, T., & Drozd, J. F. (2009). On the neural basis of EMDR therapy: Insights from qeeg studies. Traumatology , 15 , 81-95.
Kowal, J. A. (2005). QEEG analysis of treating PTSD and bulimia nervosa using EMDR. Journal of Neurotherapy, 9 (Part 4), 114-115.
Lamprecht, F., Kohnke, C., Lempa, W., Sack, M., Matzke, M., & Munte, T. (2004). Event-related potentials and EMDR treatment of post-traumatic stress disorder. Neuroscience Research, 49 , 267-272.
Landin-Romero, R., et al. (2013). EMDR therapy modulates the default mode network in a subsyndromal, traumatized bipolar patient. Neuropsychobiology , 67 , 181-184.
Lansing, K., Amen, D.G., Hanks, C. & Rudy, L. (2005). High resolution brain SPECT imaging and EMDR in police officers with PTSD. Journal of Neuropsychiatry and Clinical Neurosciences, 17, 526-532 .
Levin, P., Lazrove, S., & van der Kolk, B. A. (1999). What psychological testing and neuroimaging tell us about the treatment of posttraumatic stress disorder (PTSD) by eye movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 13, 159-172.
Nardo D et al. (2010). Gray matter density in limbic and paralimbic cortices is associated with trauma load and EMDR outcome in PTSD patients. Journal of Psychiatric Research, 44, 477-485.
Oh, D.-H., & Choi, J. (2004). Changes in the regional cerebral perfusion after eye movement desensitization and reprocessing: A SPECT study of two cases. Journal of EMDR Practice and Research, 1, 24-30.
Ohta ni, T., Matsuo, K., Kasai, K., Kato, T., & Kato, N. (2009). Hemodynamic responses of eye movement desensitization and reprocessing in posttraumatic stress disorder. Neuroscience Research , 65, 375–383.
Pagani, M. et al. (2007). Effects of EMDR psychotherapy on 99mTc-HMPAO distribution in occupation-related post-traumatic stress disorder. Nuclear Medicine Communications, 28, 757–765.
Pagani, M. et al. (2011). Pretreatment, intratreatment, and posttreatment EEG imaging of EMDR: Methodology and preliminary results from a single case. Journal of EMDR Practice and Research, 5, 42-56.
Pagani, M. et al. (2012). Neurobiological correlates of EMDR monitoring – An EEG study. PLoS ONE, 7( 9) e45753 doi:10.1371/journal.pone.0045753
Propper, R., Pierce, J.P., Geisler, M.W., Christman, S.D., & Bellorado, N. (2007). Effect of bilateral eye movements on frontal interhemispheric gamma EEG coherence: Implications for EMDR therapy. Journal of Nervous and Mental Disease, 195 , 785-788.
Richardson, R., Williams, S.R., Hepenstall, S., Gregory, L., McKie, S. & Corrigan, F. (2009). A single-case fMRI study: EMDR treatment of a patient with posttraumatic stress disorder. Journal of EMDR Practice and Research, 3, 10-23.
Sack, M., Lempa, W., & Lemprecht, W. (2007). Assessment of psychophysiological stress reactions during a traumatic reminder in patients treated with EMDR. Journal of EMDR Practice and Research, 1, 15-23.
Sack, M., Nickel, L., Lempa, W., & Lamprecht, F. (2003) Psychophysiological regulation in patients suffering from PTSD: Changes after EMDR treatment. Journal of Psychotraumatology and Psychological Medicine, 1, 47 -57. (German)
van der Kolk, B., Burbridge, J., & Suzuki, J. (1997). The psychobiology of traumatic memory: Clinical implications of neuroimaging studies. Annals of the New York Academy of Sciences, 821, 99-113.
What are the side effects?
As with any form of psychotherapy, there may be a temporary increase in distress.
- distressing and unresolved memories may emerge
- some clients may experience reactions during a treatment session that neither they nor the administering clinician may have anticipated, including a high level of emotion or physical sensations
- subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories feelings, etc., may emerge.
What can I expect with EMDR therapy, ie., what should/could happen?
Each case is unique, but there is a standard eight phase approach that each clinician should follow. This includes taking a complete history, preparing the client, identifying targets and their components, actively processing the past, present and future aspects, and on-going evaluation. The processing of a target includes the use of dual stimulation (eye movements, taps, tones) while the client concentrates on various aspects. After each set of movements the client briefly describes to the clinician what s/he experienced. At the end of each session, the client should use the techniques s/he has been taught by the clinician in order to leave the session feeling in control and empowered. At the end of EMDR therapy, previously disturbing memories and present situations should no longer be problematic, and new healthy responses should be the norm. A full description of multiple cases is available in the book Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy by Shapiro
How many sessions will it take?
The number of sessions depends upon the specific problem and client history. However, repeated controlled studies have shown that a single trauma can be processed within 3 sessions in 80-90% of the participants. While every disturbing event need not be processed, the amount of therapy will depend upon the complexity of the history. In a controlled study, 80% of multiple civilian trauma victims no longer had PTSD after approximately 6 hours of treatment. A study of combat veterans reported that after 12 sessions 77% no longer had post-traumatic stress disorder.
How many sessions with the therapist BEFORE (s)he begins EMDR therapy?
This depends upon the client’s ability to “self-soothe” and use a variety of self-control techniques to decrease potential disturbance. The clinician should teach the client these techniques during the preparation phase. The amount of preparation needed will vary from client to client. In the majority of instances the active processing of memories should begin after one or two sessions.
What questions should be asked to find out if clincians are qualified and if they have expertise using EMDR therapy with my problem/disorder?
- Have they received both levels of training;
- Was the training approved by EMDRIA;
- Have they kept informed of the latest protocols and developments;
- How many cases have they treated with your particular problem/disorder;
- What is their success rate.
Is EMDR therapy the same as hypnosis..what are the differences/similarities?
The American Journal of Hypnosis published a special issue on the use of EMDR therapy and hypnosis. An introductory article by the editor and past president of the American Association of Clinical Hypnosis directly addressed the issue: “While it has been argued against categorizing hypnosis as a specific type of treatment method (e.g., Fischolz, 1995; 1997a; 1997b; 2000; Fischholz & Spiegel, 1983), this is not the case for EMDR. Like psychoanalysis, EMDR is both an evolving theory about how information is perceived, stored and retrieved in the human brain and a specific treatment method based on this theory (Shapiro, 1995, 2001). In fact, EMDR is a very unique treatment method, which like other types of treatment/methods/techniques (e.g. psychoanalytic/psychodynamic therapy, behavior, cognitive-behavioral therapy, ego-state therapy) can also be incorportated with hypnosis (Hammond, 1990).
We note there are some distinctive differences between hypnosis and EMDR therapy, which we would like to briefly highlight. First, one of the major uses of hypnosis among clinical practitioners is to deliberately begin by inducing in the patient an altered state of mental relaxation. In contrast, when beginning EMDR mental relaxation is not typically attempted. In fact, deliberate attempts are often actually made to connect with an anxious (i.e. an emotionally disturbing as opposed to relaxed) mental state.
Second, therapists often use hypnosis to help a patient develop a single, highly focused state of aroused receptivity (Spiegel & Spiegel, 1978). In contrast, with EMDR attempts are made to maintain a duality of focus on both positive and negative currently held self-referencing beliefs, as well as the emotional arousal brought about by imaging the worst part of a disturbing memory. However, in this sense, EMDR does have a similarity to Spiegel’s (Spiegel & Spiegel, 1978) split-screen cognitive restructuring technique.
Third, one of the proposed effects of hypnotizing a person is that they will have a decrease in their generalized reality orientation (GRO: Shor, 1979). This induced decrease in a person’s GRO is often utilized in order to promote an increase in fantasy and imagination, perhaps by capitalizing on an increase in trance logic (Orne, 1977). In contrast, in EMDR attempts are made towards repeatedly grounding the patient by referencing current feelings and body sensations to prevent the patient from drifting away from reality. Specific encouragement/inducement is made towards rejecting previously irrational/self-blaming beliefs in favor of a newly, reframed positive belief with an increase in subjective conviction about that belief. Shapiro and Forrest (1997) and Nicosia (1995) have also noted additional differences between hypnosis and EMDR.
Will EMDR therapy or the eye movements increase the frequency of seizures?
There is no indication that EMDR therapy will increase the frequency of seizures.
Will EMDR/eye movements cause seizures?
There is no indication that EMDR therapy will cause seizures. In thousands of cases there have been only three reports of seizures occurring with people already diagnosed with epilepsy. Two of these cases occurred when using a lightbar. One case seemed to be caused by the processing of an old seizure. The client later reported that her experience made later seizures more manageable.
Will I live the trauma as intensely as before?
Many people are conscious of only a shadow of the experience, while others feel it to a greater degree. Unlike some other therapies, EMDR therapy clients are not asked to relive the trauma intensely and for prolonged periods of time. In EMDR therapy, when there is a high level of intensity it only lasts for a few moments and then decreases rapidly. If it does not decrease rapidly on its own, the clinician has been trained in techniques to assist it to dissipate. The client has also been trained in techniques to immediately relieve the distress.
What are the adverse effects?
As with any form of psychotherapy, there may be a temporary increase in distress.
- distressing and unresolved memories may emerge
- some clients may experience reactions during a treatment session that neither they nor the administrating clinician may have anticipated, including a high level of emotion or physical sensation
- subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories, feelings, etc., may emerge.