Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro in the 1980s that was originally designed to alleviate the distress associated with traumatic memories such as post traumatic stress disorder (PTSD). In EMDR, the person being treated recalls distressing experiences whilst doing bilateral stimulation, such as side-to-side eye movement or physical stimulation, such as tapping either side of the body.
The 2013 World Health Organization (WHO) practice guideline states that EMDR "is based on the idea that negative thoughts, feelings, and behaviors are the result of unprocessed memories. The treatment involves standardized procedures that include focusing simultaneously on spontaneous associations of traumatic images, thoughts, emotions and bodily sensations and bilateral stimulation that is most commonly in the form of repeated eye movements."
Exposure therapy began in the 1950s, when South African psychologists and psychiatrists used it to reduce pathological fears. They then brought their methods to England in the Maudsley Hospital training program. Since the 1950s several sorts of exposure therapy have been developed, including systematic desensitization, flooding, implosive therapy, prolonged exposure therapy, in vivo exposure therapy, and imaginal exposure therapy.
EMDR therapy was first developed by American psychologist Francine Shapiro after noticing, in 1987, that eye movements appeared to decrease the negative emotion associated with her own distressing memories. She then conducted a scientific study with trauma victims in 1988 and the research was published in the Journal of Traumatic Stress in 1989. Her hypothesis was that when a traumatic or distressing experience occurs, it may overwhelm normal coping mechanisms, with the memory and associated stimuli being inadequately processed and stored in an isolated memory network.
Shapiro noted that, when she was experiencing a disturbing thought, her eyes were involuntarily moving rapidly. She further noted that her anxiety was reduced when she brought her eye movements under voluntary control while thinking a traumatic thought. Shapiro developed EMDR therapy for post-traumatic stress disorder (PTSD). She speculated that traumatic events "upset the excitatory/inhibitory balance in the brain, causing a pathological change in the neural elements".
Formal EMDR therapy consists of eight phases. The first phase includes history taking and treatment planning. The second phase includes preparation. The third phase is an assessment phase followed by the fourth phase of desensitization. Phases 5 and 6 involve installing positive cognitions and 'body scan"[clarification needed]. The last phase is the reevaluation phase. EMDR is typically undertaken in a series of sessions with a trained therapist. The number of sessions can vary depending on the progress made. A typical EMDR therapy session lasts from 60 to 90 minutes.
Trauma and PTSD
The person being treated is asked to recall an image, phrase, and emotions that represent a level of distress related to a trigger while generating one of several types of bilateral sensory input, such as side-to-side eye movements or hand tapping. The 2013 World Health Organization practice guideline says that "Like cognitive behavioral therapy (CBT) with a trauma focus, EMDR aims to reduce subjective distress and strengthen adaptive beliefs 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."
Evidence of effectiveness
While multiple meta-analyses have found EMDR to be as effective as trauma focused cognitive behavioral therapy for the treatment of PTSD, these findings have been regarded as tentative given the low numbers in the studies, high-risk rates of researcher bias, and high dropout rates.
- A 2002 meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy.
- A 2005 and a 2006 meta-analysis each suggested that traditional exposure therapy and EMDR have equivalent effects immediately after treatment and at follow-up.
- Two meta-analyses in 2006 found EMDR to be at least equivalent in effect size to specific exposure therapies.
- A 2009 review of rape treatment outcomes concluded that EMDR had some efficacy. Another 2009 review concluded EMDR to be of similar efficacy to other exposure therapies and more effective than SSRIs, problem-centered therapy, or "treatment as usual".
- A 2010 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 2013 systematic review examined 15 clinical trials of EMDR with and without eye movements, finding that the effect size was larger when eye movements were used. Again, interpretation of this meta-analysis was tentative. Lee and Cuijpers (2013) stated that "the quality of included studies was not optimal. This may have distorted the outcomes of the studies and our meta-analysis. Apart from ensuring adequate checks on treatment quality, there were other serious methodological problems with the studies in the therapy context." A meta-analysis in 2020, could not confirm the results of this 2013 study, due to "differences in inclusion criteria."
- A Cochrane systematic review comparing EMDR with other psychotherapies in the treatment of Chronic PTSD, found EMDR to be just as effective as Trauma-Focused Cognitive Behavior Therapy (TF-CBT) and more effective than the other non-TF-CBT psychotherapies. Caution was urged interpreting the results due to low numbers in included studies, risk of researcher bias, high drop out rates, and overall "very low" quality of evidence for the comparisons with other psychotherapies.
- A 2016 systematic review and meta-analysis found that the effect size of EMDR for PTSD is comparable to other evidence-based treatments, but that the strength of evidence was of a low quality, indicating that the effect sizes achieved are associated with substantial uncertainty.
- A 2020 systematic review and meta-analysis was the "first systematic review of randomized trials examining the effects of EMDR for any mental health problem." The authors raised concerns about bias in previous studies, concluding:
Despite these limitations, the results of this meta-analysis aid us in concluding that EMDR may be effective in the treatment of PTSD in the short term and possibly have comparable effects as other treatments. However, the quality of studies is too low to draw definite conclusions. Further, it is evident that the long-term effects of EMDR are unclear and that there is certainly not enough evidence to advise its use in patients with mental health problems other than PTSD.
Some smaller studies have produced positive results.
The 2009 International Society for Traumatic Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults. Other guidelines recommending EMDR therapy – as well as CBT and exposure therapy – for treating trauma have included NICE starting in 2005, Australian Centre for Posttraumatic Mental Health in 2007, the Dutch National Steering Committee Guidelines Mental Health and Care in 2003,[page needed] the American Psychiatric Association in 2004, the Departments of Veterans Affairs and Defense in 2010, SAMHSA in 2011, the International Society for Traumatic Stress Studies in 2009,[page needed] and the World Health Organization in 2013 (only for PTSD, not for acute stress treatment). The American Psychological Association "conditionally recommends" EMDR for the treatment of PTSD.
EMDR is included in a 2009 practice guideline for helping children who have experienced trauma.[page needed] EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.[page needed]
A 2017 meta-analysis of randomized controlled trials in children and adolescents with PTSD found that EMDR was at least as efficacious as cognitive behavior therapy (CBT), and superior to waitlist or placebo.
Studies have indicated EMDR effectiveness in depression.[page needed] A 2019 review found that "Although the selected studies are few and with different methodological critical issues, the findings reported by the different authors suggest in a preliminary way that EMDR can be a useful treatment for depression."
Dissociative identity disorder
EMDR may have application for psychosis when co-morbid with trauma. Other studies have investigated EMDR therapy's efficacy with borderline personality disorder, and somatic disorders such as phantom limb pain. EMDR has also been found to improve stress management symptoms. EMDR has been found to reduce suicidal ideation, and help low self-esteem. Other studies focus on effectiveness in substance craving and pain management. EMDR may help people with autism spectrum disorder (ASD) who suffer from exposure to distressing events.
- A 2020 systematic review and meta-analysis was the "first systematic review of randomized trials examining the effects of EMDR for any mental health problem." The authors concluded: "it is evident that the long-term effects of EMDR are unclear, and... there is certainly not enough evidence to advise its use in patients with mental health problems other than PTSD."
- A 2021 major review that included randomized controlled trials, group studies, and case studies that specifically did not focus on the use of EMDR in the treatment of trauma or PTSD, found that EMDR may be beneficial in at least fourteen conditions that included: addictions, somatoform disorders, sexual dysfunction, eating disorders, disorders of adult personality, mood disorders, reaction to severe stress, anxiety disorders, performance anxiety, Obsessive-Compulsive Disorder (OCD), pain, neurodegenerative disorders, mental disorders of childhood and adolescence, and sleep. The authors concluded that "Results shed light on several aspects that support the interest of its practice in mental health care."
Incomplete processing of experiences in trauma
Many proposals of EMDR efficacy share an assumption that, as Shapiro posited, when a traumatic or very negative event occurs, information processing of the experience in memory may be incomplete. The trauma causes a disruption of normal adaptive information processing, which results in unprocessed information being dysfunctionally held in memory networks. According to the 2013 World Health Organization practice guideline: "This therapy [EMDR] is based on the idea that negative thoughts, feelings and behaviours are the result of unprocessed memories."
EMDR allowing correct processing of memories
EMDR is posited to help in the correct processing of the components of the contributing distressing memories. EMDR may allow the client to access and reprocess negative memories (leading to decreased psychological arousal associated with the memory). This is sometimes known as the Adaptive Information Processing (AIP) model.[unreliable medical source]
Proposed mechanisms by which EMDR achieves efficacy
The mechanism by which EMDR achieves efficacy is unknown, with no definitive finding. Several possible mechanisms have been posited;
- EMDR may impact working memory. If a patient performs bilateral stimulation task while remembering the trauma, the amount of information they can recall is reduced, which makes the resulting negative emotions less intense, and more bearable. This is seen by some as a 'distancing effect'. The client is then able to re-evaluate the trauma and to process it correctly.
- EMDR may enable ‘dual attention’ in which the trauma is recalled whilst also remaining aware of the present.
- Connectivity among several brain regions has been found to be changed by bilateral eye movement and by EMDR. In one 15 person study, EMDR was found to lead to reduced connectivity between some brain areas. These changes may cause EMDRs efficacy.
- EMDR efficacy has been linked to the Zeigarnik effect (i.e. better memory for interrupted rather than completed tasks).
- Horizontal eye movement triggers an evolutionary 'orienting response' in the brain, used in scanning the environment for threats and opportunities.
- EMDR gives an effect similar to the effects of sleep,[unreliable medical source] and posit that traumatic experiences are processed during sleep.
- Trauma can be overcome or mastered, and EMDR facilitates a form of mindfulness or other forms of mastery over the trauma.
It may be that several mechanisms are at work in EMDR.
Bilateral stimulation, including eye movement
Bilateral stimulation is a generalization of the left and right repetitive eye movement technique first used by Shapiro. Alternative stimuli include auditory stimuli that alternate between left and right speakers or headphones and physical stimuli such as tapping of the therapist's hands or tapping devices. Research has attempted to correlate other types of rhythmic side-to-side stimuli, such as sound and touch, with mood, memory, and cerebral hemispheric interaction. Francine Shapiro noticed that eye movements appeared to decrease the negative emotion associated with her own distressing memories. Bilateral stimulation seems to cause dissipation of emotions. Research results and opinions have been mixed on the effectiveness and importance of the technique;
- A small 1996 study found that the eye movements employed in EMDR did not add to its effectiveness.
- A 2000 review found that the eye movements did not play a central role, and that the mechanisms of eye movements were speculative.
- A 2001 meta-analysis suggested that EMDR with the eye movements was no more efficacious than EMDR without the eye movements (Davidson & Parker, 2001).
- A 2002 review reported that the eye movement is irrelevant, and that the effectiveness of EMDR was solely due to its having properties similar to CBT, such as desensitization and exposure.
- A 2012 review found that the evidence provided support for the contention that eye movements are essential to this therapy and that a theoretical rationale exists for their use.
- A 2013 meta-study found the effect size of eye movement was large and significant, with the strongest effect size difference being for vividness measures.
- In a 2019 Nature research article, neuroscientists found a direct link between EMDR's alternating bilateral sensory stimulation (ABS) in mice, and a neuronal pathway driven by the superior colliculus (SC) that mediates persistent attenuation of fear. The researchers found that ABS provided the strongest fear reducing effect and yielded sustained increases in the activities of the SC and mediodorsal thalamus (MD), thus providing a mechanistic clue for how EMDR works in humans.
- A 2020 systematic review and meta-analysis including nine dismantling[clarification needed] randomized controlled trials of EMDR with or without bilateral eye-movements found that the efficacy between EMDR with and without eye-movements were negligible to non-existent.
- 2020 research showed that bilateral alternating stimulation caused a significant increase in connectivity between several areas of the brain, including the two superior temporal gyri, the precuneus, the middle frontal gyrus and a set of structures involved in multisensory integration, executive control, emotional processing, salience and memory.
- A 2020 review questioned the consistency and generalizability of the technique.
Effectiveness and theoretical basis
Concerns have included questions about its effectiveness and the importance of the eye movement component of EMDR. In 2012, Hal Arkowitz, and Scott Lilienfeld summed up the state of the research at the time, saying that while EMDR is better than no treatment and probably better than merely talking to a supportive listener,
Yet not a shred of good evidence exists that EMDR is superior to exposure-based treatments that behavior and cognitive-behavior therapists have been administering routinely for decades. Paraphrasing British writer and critic Samuel Johnson, Harvard University psychologist Richard McNally nicely summed up the case for EMDR: "What is effective in EMDR is not new, and what is new is not effective."
Client perceptions of effectiveness are also mixed.
EMDR has been characterized as pseudoscience, because the underlying theory is unfalsifiable. Also, the results of the therapy are non-specific, especially if the eye movement component is irrelevant to the results. What remains is a broadly therapeutic interaction and deceptive marketing. According to Yale neurologist and skeptic Steven Novella:
[T]he false specificity of these treatments is a massive clinical distraction. Time and effort are wasted clinically in studying, perfecting, and using these methods, rather than focusing on the components of the interaction that actually work.
Shapiro has been criticized for repeatedly increasing the length and expense of training and certification, allegedly in response to the results of controlled trials that cast doubt on EMDR's efficacy. This included requiring the completion of an EMDR training program in order to be qualified to administer EMDR properly after researchers using the initial written instructions found no difference between no-eye-movement control groups and EMDR-as-written experimental groups. Further changes in training requirements and/or the definition of EMDR included requiring level II training when researchers with level I training still found no difference between eye-movement experimental groups and no-eye-movement controls and deeming "alternate forms of bilateral stimulation" (such as finger-tapping) as variants of EMDR by the time a study found no difference between EMDR and a finger-tapping control group. Such changes in definition and training for EMDR have been described as "ad hoc moves [made] when confronted by embarrassing data".
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1.6.20 EMDR for adults should: be based on a validated manual; typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas; be delivered by trained practitioners with ongoing supervision; be delivered in a phased manner and include psychoeducation about reactions to trauma, managing distressing memories and situations, identifying and treating target memories (often visual images), and promoting alternative positive beliefs about the self; use repeated in-session bilateral stimulation (normally with eye movements) for specific target memories until the memories are no longer distressing; include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions.
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- van den Hout, Marcel A.; Engelhard, Iris M.; Beetsma, Daniel; Slofstra, Christien; Hornsveld, Hellen; Houtveen, Jan; Leer, Arne (1 December 2011). "EMDR and mindfulness. Eye movements and attentional breathing tax working memory and reduce vividness and emotionality of aversive ideation". Journal of Behavior Therapy and Experimental Psychiatry. 42 (4): 423–431. doi:10.1016/j.jbtep.2011.03.004. PMID 21570931.
- Chen, Ling; Zhang, Guiqing; Hu, Min; Liang, Xia (June 2015). "Eye Movement Desensitization and Reprocessing Versus Cognitive-Behavioral Therapy for Adult Posttraumatic Stress Disorder". The Journal of Nervous and Mental Disease. 203 (6): 443–451. doi:10.1097/NMD.0000000000000306. PMID 25974059. S2CID 34850645.
- Verger, A.; Rousseau, P. F.; Malbos, E.; Chawki, M. B.; Nicolas, F.; Lançon, C.; Khalfa, S.; Guedj, E. (2020). "Involvement of the cerebellum in EMDR efficiency: a metabolic connectivity PET study in PTSD". European Journal of Psychotraumatology. 11 (1). doi:10.1080/20008198.2020.1767986. PMC 7473141. PMID 33029312.
- Rousseau, Pierre-François; Boukezzi, Sarah; Garcia, René; Chaminade, Thierry; Khalfa, Stéphanie (August 2020). "Cracking the EMDR code: Recruitment of sensory, memory and emotional networks during bilateral alternating auditory stimulation". Australian & New Zealand Journal of Psychiatry. 54 (8): 818–831. doi:10.1177/0004867420913623. PMID 32271126. S2CID 215598663.
- Verger, A.; Rousseau, P. F.; Malbos, E.; Chawki, M. B.; Nicolas, F.; Lançon, C.; Khalfa, S.; Guedj, E. (2020-12-31). "Involvement of the cerebellum in EMDR efficiency: a metabolic connectivity PET study in PTSD". European Journal of Psychotraumatology. 11 (1): 1767986. doi:10.1080/20008198.2020.1767986. PMC 7473141. PMID 33029312.
- Fox, Jeremy G. (2020-08-01). "Recovery, Interrupted: The Zeigarnik Effect in EMDR Therapy and the Adaptive Information Processing Model". Journal of EMDR Practice and Research. 14 (3): 175–185. doi:10.1891/EMDR-D-20-00011. S2CID 221190511.
- Jeffries, Fiona W.; Davis, Paul (29 October 2012). "What is the Role of Eye Movements in Eye Movement Desensitization and Reprocessing (EMDR) for Post-Traumatic Stress Disorder (PTSD)? A Review". Behavioural and Cognitive Psychotherapy. 41 (3): 290–300. doi:10.1017/S1352465812000793. PMID 23102050. S2CID 33309479.
- A slowing of brain waves has been seen during bilateral stimulation (eye movement), somewhat similar to what occurs during sleep.Pagani, Marco; Amann, Benedikt L.; Landin-Romero, Ramon; Carletto, Sara (7 November 2017). "Eye Movement Desensitization and Reprocessing and Slow Wave Sleep: A Putative Mechanism of Action". Frontiers in Psychology. 8: 1935. doi:10.3389/fpsyg.2017.01935. PMC 5681964. PMID 29163309.[unreliable medical source] A possibly related finding is that brain waves during EMDR treatment shows changes in brain activity, specifically the limbic system showed its highest level of activity prior to commencing EMDR treatment.Pagani M, Di Lorenzo G, Verardo AR, Nicolais G, Monaco L, Lauretti G, Russo R, Niolu C, Ammaniti M, Fernandez I, Siracusano A (2012-09-26). "Neurobiological correlates of EMDR monitoring – an EEG study". PLOS ONE. 7 (9): e45753. Bibcode:2012PLoSO...745753P. doi:10.1371/journal.pone.0045753. PMC 3458957. PMID 23049852.
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- Shapiro; "FS: It’s been demonstrated in about 16 randomized controlled trials now that the eye movement also rapidly causes the vividness to shift and emotion to decrease." https://www.psychotherapy.net/interview/francine-shapiro-emdr#section-eye-movement
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- Herbert JD, Lilienfeld SO, Lohr JM, Montgomery RW, O'Donohue WT, Rosen GM, Tolin DF (November 2000). "Science and pseudoscience in the development of eye movement desensitization and reprocessing: implications for clinical psychology". Clinical Psychology Review. 20 (8): 945–71. doi:10.1016/s0272-7358(99)00017-3. PMID 11098395.
- Davidson, Paul R.; Parker, Kevin C. H. (2001). "Eye movement desensitization and reprocessing (EMDR): A meta-analysis". Journal of Consulting and Clinical Psychology. 69 (2): 305–316. doi:10.1037//0022-006x.69.2.305. PMID 11393607. S2CID 8526886.
- McNally, Richard J (November 1999). "On Eye Movements and Animal Magnetism". Journal of Anxiety Disorders. 13 (6): 617–620. doi:10.1016/S0887-6185(99)00020-1.
- Salkovskis P (February 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.
- Baek, Jinhee; Lee, Sukchan; Cho, Taesup; Kim, Seong-Wook; Kim, Minsoo; Yoon, Yongwoo; Kim, Ko Keun; Byun, Junweon; Kim, Sang Jeong; Jeong, Jaeseung; Shin, Hee-Sup (February 2019). "Neural circuits underlying a psychotherapeutic regimen for fear disorders". Nature. 566 (7744): 339–343. doi:10.1038/s41586-019-0931-y.
- Cuijpers, Pim; Veen, Suzanne C. van; Sijbrandij, Marit; Yoder, Whitney; Cristea, Ioana A. (2020-05-03). "Eye movement desensitization and reprocessing for mental health problems: a systematic review and meta-analysis". Cognitive Behaviour Therapy. 49 (3): 165–180. doi:10.1080/16506073.2019.1703801. ISSN 1650-6073. PMID 32043428. S2CID 202289231.
- Roberts, Brady R. T.; Fernandes, Myra A.; MacLeod, Colin M.; Manelis, Anna (27 January 2020). "Re-evaluating whether bilateral eye movements influence memory retrieval". PLOS ONE. 15 (1): e0227790. Bibcode:2020PLoSO..1527790R. doi:10.1371/journal.pone.0227790. PMC 6984731. PMID 31986171.
No evidence of a SIRE effect was found: Bayesian statistical analyses demonstrated significant evidence for a null effect. Taken together, these experiments suggest that the SIRE effect is inconsistent. The current experiments call into question the generalizability of the SIRE effect and suggest that its presence is very sensitive to experimental design. Future work should further assess the robustness of the effect before exploring related theories or underlying mechanisms.
- McNally, Richard J. (1999). "Research on eye movement desensitization and reprocessing (EMDR) as a treatment for PTSD". PTSD Research Quarterly. 10 (1): 1–7.
- Sikes, Charlotte; Sikes, Victoria (2003). "EMDR: Why the controversy?". Traumatology. 9 (3): 169–182. doi:10.1177/153476560300900304.
- Arkowitz, Hal; Lilienfeld, Scott (August 1, 2012). "EMDR: Taking a Closer Look Can moving your eyes back and forth help to ease anxiety?". Scientific American. Archived from the original on March 6, 2014. Retrieved 12 August 2020.
So, now to the bottom line: EMDR ameliorates symptoms of traumatic anxiety better than doing nothing and probably better than talking to a supportive listener. Yet not a shred of good evidence exists that EMDR is superior to exposure-based treatments that behavior and cognitive-behavior therapists have been administering routinely for decades. Paraphrasing British writer and critic Samuel Johnson, Harvard University psychologist Richard McNally nicely summed up the case for EMDR: 'What is effective in EMDR is not new, and what is new is not effective.'
- Shipley, Gemma; Wilde, Sarah; Hudson, Mark (April 2021). "What do clients say about their experiences of Eye Movement Desensitisation and Reprocessing therapy? A systematic review of the literature". European Journal of Trauma & Dissociation. 6 (2): 100226. doi:10.1016/j.ejtd.2021.100226. ISSN 2468-7499. S2CID 235544895.
- Novella, Steven (March 30, 2011). "EMDR and Acupuncture – Selling Non-specific Effects". Science Based Medicine. Society for SBM. Retrieved 12 July 2020.
- Rosen, Gerald M; Mcnally, Richard J; Lilienfeld, Scott O (1999). "Eye Movement Magic: Eye Movement Desensitization and Reprocessing". Skeptic. 7 (4).
- McNally, R. J. (2003). "The demise of pseudoscience". The Scientific Review of Mental Health Practice. 2 (2): 97–101.