Eye movement desensitization and reprocessing
|This article relies on references to primary sources. (June 2012)|
Eye movement desensitization and reprocessing (EMDR) is a psychotherapy developed by Francine Shapiro that emphasizes disturbing memories as the cause of psychopathology  and alleviates the symptoms of post-traumatic stress disorder (PTSD). EMDR is used for individuals who have experienced severe trauma that remains unresolved. According to Shapiro, when a traumatic or distressing experience occurs, it may overwhelm normal cognitive and neurological coping mechanisms. The memory and associated stimuli are inadequately processed and stored in an isolated memory network. The goal of EMDR therapy is to process these distressing memories, reducing their lingering effects and allowing clients to develop more adaptive coping mechanisms. This is done in an eight-step protocol that includes having clients recall distressing images while receiving one of several types of bilateral sensory input, including side to side eye movements. The use of EMDR was originally developed to treat adults suffering from PTSD; however, it is also used to treat other conditions and children.
EMDR was first developed by Francine Shapiro upon noticing that certain eye movements reduced the intensity of disturbing thought. She then conducted a scientific study in 1989. The success rate of that first study using trauma victims was posted in the Journal of Traumatic Stress. Shapiro noted that, when she was experiencing a disturbing thought, her eyes were involuntarily moving rapidly. She noticed further that, when she brought her eye movements under voluntary control while thinking a traumatic thought, anxiety was reduced. Shapiro developed EMDR therapy for post-traumatic stress disorder. She speculated that traumatic events "upset the excitatory/inhibitatory balance in the brain, causing a pathological change in the neural elements." EMDR is now recommended as an effective treatment for trauma in the Practice Guidelines of the American Psychiatric Association.
EMDR uses a structured eight-phase approach to address the past, present, and future aspects of a traumatic or distressing memory. The therapy process and procedures are according to Shapiro.
Phase I History and Treatment Planning
- The therapist will conduct an initial evaluation of the client’s history and develop a general plan for treatment.
Phase II Processing
- During the processing phases of EMDR, the client focuses on the disturbing memory in multiple brief sets of about 15–30 seconds. Simultaneously, the client focuses on the dual attention stimulus, which consist on focusing on the trauma while the clinician initiates lateral eye movement. Following each set, the client is asked what associative information was elicited during the procedure. This new material usually becomes the focus of the next set. This process of personal association is repeated many times during the session.
Phase III Assessment
- During phase III, the therapist will ask the client to visualize an image that represents the disturbing event. Along with it, the client will describe a thought or negative cognition (NC) associated with the image. The client will be asked to develop a positive cognition (PC) to be associated with the same image that is desired in place of the negative one. The client is asked how strongly he or she believes in the negative and positive cognitions to be true. The client is also asked to identify where in the body he or she is sensing discomfort.
Phase IV Desensitization
- At this time, when the client is focused on the negative cognition as well as the disturbing image together, the therapist begins the bilateral gestures and requests the client to follow the gestures with their eyes. This process continues until the client no longer feels as strongly about the negative cognition in conjunction with the image.
Phase V Installation
- At this time, the therapist will ask the client to focus on the positive cognition developed in phase III. The therapist will continue with the gestures and the client is to continue following with the eyes while focusing on the new and positive thought. When the client feels he or she is certain the positive cognition has replaced the negative cognition, the installation phase is complete.
Phase VI Body Scan
- At this phase the goal of the therapist is to identify any uncomfortable sensations that could be lingering in the body. While thinking about the originally disturbing event, the client is asked to scan over his or her body entirely, searching for tension or other physical discomfort. Any negative sensations are targeted and then diminished, using the same bilateral stimulation technique from phases IV and V. The EMDR network has asserted that positive cognitions should be incorporated physically as well as intellectually. Phase VI is considered complete when the client is able to think and speak about the event without feeling any physical or emotional discomfort.
Phase VII Closure
- Naturally, not all traumatic events will be resolved completely within the timeframe allotted. In this case the therapist will guide the client through relaxation techniques that are designed to bring about emotional stability and tranquility. The client will also be able to use these same techniques for experiences that might arise in between sessions such as, strong emotions, unwanted imagery, and dismal thoughts. The client may be encouraged to keep a journal of these experiences, allowing for easy recall and processing during the next session.
Phase VIII Reevaluation
- With every new session, the therapist will reevaluate the work done in the prior session. The therapist will also assess how well the client managed on his or her own in between visits. At this point, the therapist will decide whether it is best to continue working on previous targets or continue to newer ones.
Empirical evidence and comparison
In a 2007 review of 33 randomised controlled trials of various psychological treatments for PTSD, EMDR was rated as an effective method, not significantly different in effect from Trauma-Focused CBT (Cognitive Behavioral Therapy) or SM (Stress Management) treatments. EMDR did significantly better than other therapies, according to patient self-reports. The International Society of Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults. A number of international guidelines include EMDR as a recommended treatment for trauma.
Research on the application of EMDR therapy continues, and several meta-analyses have been performed to further evaluate its efficacy in the treatment of PTSD. In one meta-analysis of PTSD, EMDR was reported to be as effective as exposure therapy and SSRIs. Two separate meta-analyses suggested that traditional exposure therapy and EMDR have equivalent effects both immediately after treatment and at follow-up. A 2007 meta-analysis of 38 randomized controlled trials for PTSD treatment suggested that the first-line psychological treatment for PTSD should be Trauma-Focused CBT (Cognitive Behavioral Therapy) or EMDR. A review of rape treatment outcomes concluded that EMDR had some efficacy. Another meta-analysis concluded that all "bona fide" treatments were equally effective, but there was some debate regarding the study's selection of which treatments were "bona fide". A comparative review concluded EMDR to be of similar efficacy to other exposure therapies and more effective than SSRIs, problem-centred therapy, or treatment as usual.
Although EMDR is established as an evidence-based treatment for PTSD there are two main perspectives on EMDR therapy. First, Shapiro proposed that although a number of different processes underlie EMDR, the eye movements add to the therapy's effectiveness by evoking neurological and physiological changes that may aid in the processing of the trauma memories being treated. The other perspective is that the eye movements are an unnecessary epiphenomenon, and that EMDR is simply a form of desensitization.
Recent research, however, shows that the efficacy of EMDR therapy manifests through bilateral stimulation rather than eye movements specifically. This includes not only eye movements, but alternating hand taps, alternating auditory tones, and other bilateral stimuli that address all facets of the targeted memory network. The exact psychophysiology of bilateral stimulation is still largely unknown, although several correlations with eye movements and clinical results have been observed.
Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR’s efficacy with other disorders, for instance borderline personality disorder.
EMDR has been used effectively in the treatment of children who have experienced trauma and complex trauma, for instance child abuse. EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.
Controversy over mechanisms and effectiveness
EMDR has generated a great deal of controversy since its inception in 1989. Critics of EMDR argue that the eye movements do not play a central role, that the mechanisms of eye movements are speculative, and that the theory leading to the practice is not falsifiable and therefore not amenable to scientific inquiry.
The working mechanisms that underlie the effectiveness of EMDR, and whether the eye movement component in EMDR contributes to its clinical effectiveness are still points of uncertainty and contentious debate.
Although one meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy, several other researchers using meta-analysis have found EMDR to be at least equivalent in effect size to specific exposure therapies.
An early critical review and meta-analysis that looked at the contribution of eye movement to treatment effectiveness in EMDR concluded that eye movement is not necessary to the treatment effect. Salkovskis (2002) reported that the eye movement is irrelevant, and that the effectiveness of the procedure is solely due to its having properties similar to cognitive behavioral therapies, such as desensitization and exposure.
A 2009 review of EMDR suggests that further research with different populations is needed.
- Shapiro, Francine; Laliotis, Deany (12 October 2010). "EMDR and the adaptive information processing model: Integrative treatment and case conceptualization". Clinical Social Work Journal 39 (2): 191–200. doi:10.1007/s10615-010-0300-7.
- "What is EMDR?". Retrieved 30 March 2013.
- Horton, Hilary (June 2011). "Dealing with self distress". Occupational Health 63 (6): 20–22.
- Feske, Ulrike (1998). "Eye movement desensitization and reprocessing treatment for posttraumatic stress disorder". Clinical Psychology: Science and Practice 5 (2): 171. doi:10.1111/j.1468-2850.1998.tb00142.x.
- Greyber, Laura; Catherine Dulmus, Maria Cristalli (17 June 2012). "Eye movement desensitization reprocessing, posttraumatic stress disorder, and trauma: A review of randomized controlled trials with children and adolescents". Child Adolescent Social Work Journal 29 (5): 409–425. doi:10.1007/s10560-012-0266-0.
- Glaser, Tom. "How was EMDR Developed?". Retrieved 8 March 2013.
- Shapiro, F (1989). "Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories". Journal of Traumatic Stress 2 (2): 199–223. doi:10.1002/jts.2490020207.
- EMDR Institute, Inc. "Francine Shapiro, Ph.D,". Retrieved 8 March 2013.
- Soderberg, M (2006). "EMDR and the Energy Therapies Psychoanalytic Perspectives". Clinical Social Work Journal 34 (2): 241–242. doi:10.1192/bjp.189.2.193a.
- "Eye Movement Desensitization and Reprocessing for Adults (EMDR)". The California Evidence-Based Clearinghouse for Child Welfare. Unknown parameter
|access date=ignored (
- "EMDR Therapy". Anapsys. March 2013.
- Bednar, J. "Clearing the Block". Businesswest. Retrieved 25 March 2013.
- Shapiro, F (2012). "EMDR and early psychological intervention following trauma". Revue europeenne de psychologie appliquee 62 (4): 241. doi:10.1016/j.erap.2012.09.003.
- Bisson, J.; Andrew, M. (2007). "Psychological treatment of post-traumatic stress disorder (PTSD)". In Bisson, Jonathan. Cochrane Database of Systematic Reviews (3): CD003388. doi:10.1002/14651858.CD003388.pub3. PMID 17636720.
- Foa EB; Keane TM; Friedman MJ (2009). Effective treatments for PTST: Practice guidelines of the International Society for Traumatic Stress Studies. New York: Guilford Press
- National Institute for Clinical Excellence (2005). Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care. London: NICE Guidelines
- Australian Centre for Posttraumatic Mental Health. (2007). Australian guidelines for the treatment of adults with acute stress disorder and post traumatic stress disorder. Melbourne, Victoria: ACPTMH. ISBN 978-0-9752246-6-3
- Dutch National Steering Committee Guidelines Mental Health and Care (2003). Guidelines for the diagnosis treatment and management of adult clients with an anxiety disorder. Utrecht, Netherlands: The Dutch Institute for Healthcare Improvement (CBO)
- Van Etten, M. L.; Taylor, S. (1998). "Comparative efficacy of treatments for post-traumatic stress disorder: a meta-analysis". Clinical Psychology & Psychotherapy 5 (3): 126–144. doi:10.1002/(SICI)1099-0879(199809)5:3<126::AID-CPP153>3.0.CO;2-H.
- Bradley, R.; Greene, J.; Russ, E.; Dutra, L.; Westen, D. (2005). "A multidimensional meta-analysis of psychotherapy for PTSD". The American Journal of Psychiatry 162 (2): 214–227. doi:10.1176/appi.ajp.162.2.214. PMID 15677582.
- Seidler, G.; Wagner, F. (2006). "Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study". Psychological Medicine 36 (11): 1515–1522. doi:10.1017/S0033291706007963. PMID 16740177.
- Bisson, J. I.; Ehlers, A.; Matthews, R.; Pilling, S.; Richards, D.; Turner, S. (2007). "Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis". The British Journal of Psychiatry 190 (2): 97–104. doi:10.1192/bjp.bp.106.021402. PMID 17267924.
- Vickerman, K. A.; Margolin, G. (2009). "Rape treatment outcome research: Empirical findings and state of the literature☆". Clinical Psychology Review 29 (5): 431–448. doi:10.1016/j.cpr.2009.04.004. PMC 2773678. PMID 19442425. online
- Ehlers, A.; Bisson, J.; Clark, D.; Creamer, M.; Pilling, S.; Richards, D.; Schnurr, P.; Turner, S.; Yule, W. (2010). "Do all psychological treatments really work the same in posttraumatic stress disorder?". Clinical Psychology Review 30 (2): 269–276. doi:10.1016/j.cpr.2009.12.001. PMC 2852651. PMID 20051310.
- Cloitre, M (2009). "Effective psychotherapies for posttraumatic stress disorder: a review and critique". CNS spectrums 14 (1 Suppl 1): 32–43. PMID 19169192.
- Oren, E; Solomon (October 2012). "EMDR Therapy; An Overview of its Development and Mechanisms of Action". European Review of Applications in Psychology 62: 197–203.
- SUSAN BROWN, FRANCINE SHAPIRO (October 2006). "10.1177/1534650104271773 CLINICALCASE STUDIES/ October 2006 Brown, Shapiro / EMDR IN THE TREATMENT OF BPD EMDR in the Treatment of Borderline Personality Disorder". CLINICAL CASE STUDIES 5 (5): 403–420. doi:10.1177/1534650104271773.
- Foa B; Keane, T. M.; Friedman, M. J.; &Cohen, J. A. (Eds.) (2009). Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies, 2nd Edition. New York: Guilford Press. ISBN 978-1-60623-001-5.
- Social work today: Treating Child Abuse Trauma With EMDR
- Adler-Tapia R; Settle C (2008). EMDR and The Art of Psychotherapy With Children. New York: Springer Publishing Co. ISBN 978-0-8261-1117-3.
- Scott CV; Briere J (2006). Principles of Trauma Therapy : A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks, California: Sage Publications. p. 312. ISBN 0-7619-2921-5.
- Herbert, J.; Lilienfeld, S.; Lohr, J.; Montgomery, R.; O'Donohue, W.; Rosen, G.; Tolin, D. (2000). "Science and pseudoscience in the development of eye movement desensitization and reprocessing: implications for clinical psychology". Clinical Psychology Review 20 (8): 945–971. doi:10.1016/S0272-7358(99)00017-3. PMID 11098395.
- Kenneth Fletcher; Ricky Greenwald. "PRO and CON -- Eye Movement Desensitization and Reprocessing". Retrieved 2011-03-01
- R.H. Coetzee; Stephen Regel. "Eye movement desensitisation and reprocessing: an update". Advances in Psychiatric Treatment 11: 247–354.
- "Eye Movement Desensitization and Reprocessing - EMDR". Retrieved 2011-03-01.
- Devilly GJ (2002). "Eye Movement Desensitization and Reprocessing: A chronology of its development and scientific standing". Scientific Review of Mental Health Practice 1: 113–138.
- Benish, S.; Imel, Z.; Wampold, B. (2008). "The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons". Clinical Psychology Review 28 (5): 746–758. doi:10.1016/j.cpr.2007.10.005. PMID 18055080.
- Davidson, PR; Parker, KC (2001). "Eye movement desensitization and reprocessing (EMDR): a meta-analysis". Journal of Consulting and Clinical Psychology 69 (2): 305–16. doi:10.1037/0022-006X.69.2.305. PMID 11393607.
- Cahill, S. (1999). "Does EMDR Work? And if so, Why? A Critical Review of Controlled Outcome and Dismantling Research". Journal of Anxiety Disorders 13: 5–1. doi:10.1016/S0887-6185(98)00039-5.
- Salkovskis, P (2002). "Review: eye movement desensitization and reprocessing is not better than exposure therapies for anxiety or trauma". Evidence-based mental health 5 (1): 13. doi:10.1136/ebmh.5.1.13. PMID 11915816.
- Ponniah/Hollan, K/SD. "Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review.". John Wiley & Sons, Inc. Retrieved 20 September 2012.
Creuturo, T. (2013). The EMDR Revolution, New York: Morgan James Publishing