Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro starting in 1988 in which the person being treated is asked to recall distressing images; the therapist then directs the patient in one type of bilateral stimulation, such as side-to-side eye rapid movement or hand tapping.[1] 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. The treatment involves standardized procedures that include focusing simultaneously on (a) spontaneous associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements."[2]
EMDR is included in several evidence-based guidelines for the treatment of post-traumatic stress disorder (PTSD), with varying levels of recommendation and evidence (very low to moderate per WHO stress guidelines).[3][2][4] As of 2020, the American Psychological Association lists EMDR as an evidence-based treatment for PTSD[5] but stresses that "the available evidence can be interpreted in several ways" and notes there is debate about the precise mechanism by which EMDR appears to relieve PTSD symptoms with some evidence EMDR may simply be a variety of exposure therapy.[6]
History
EMDR therapy was first developed by Francine Shapiro after noticing, in 1987,[7] that eye movements appeared to decrease the negative emotion associated with her own distressing memories.[8][9][10] She then conducted a scientific study with trauma victims in 1988 and the research was published in the Journal of Traumatic Stress in 1989.[11] 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.[12]
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.[13] 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".[13]
Delivery
EMDR consists of eight essential phases.
- History taking and treatment planning
- Preparation
- Assessment
- Desensitisation
- Install positive cognitions and body scan
- Install positive cognitions and body scan
- ...
- Reevaluation[2]
EMDR is typically undertaken in a series of sessions with a trained therapist.[14]The number of sessions can vary depending on the progress made. A typical EMDR therapy session lasts from 60-90 minutes.[15]
Medical uses
Trauma and PTSD
The person being treated is asked to recall distressing images while generating one of several types of bilateral sensory input, such as side-to-side eye movements or hand tapping.[1][3] 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."[2]
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.[16][17][18]
- 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:
- A 2013 systematic review examined 15 clinical trials of EMDR with and without the eye movements, finding that the effect size was larger when eye movements were used.[19][16] 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."[16] A meta-analysis in 2020, could not confirm the results of this 2013 study, due to "differences in inclusion criteria."[18]
- 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 (TFCBT) and more effective than the other non-TFCBT psychotherapies.[17][20] 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.[17]
- 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".[21]
- A 2009 review of rape treatment outcomes concluded that EMDR had some efficacy.[22] 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".[23]
- Two meta-analyses in 2006 found EMDR to be at least equivalent in effect size to specific exposure therapies.[16][24]
- 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.[25][24]
- A 2002 meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy.[26]
- A 1998 meta-analysis found that EMDR was as effective as exposure therapy and SSRIs.[27]
Some smaller studies have produced positive results.[28]
Position statements
The 2009 International Society for Traumatic Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults.[29] Other guidelines recommending EMDR therapy – as well as CBT and exposure therapy – for treating trauma have included NICE starting in 2005,[30][4][31] Australian Centre for Posttraumatic Mental Health in 2007,[32] the Dutch National Steering Committee Guidelines Mental Health and Care in 2003,[33] the American Psychiatric Association in 2004,[34] the Departments of Veterans Affairs and Defense in 2010,[35] SAMHSA in 2011,[36] the International Society for Traumatic Stress Studies in 2009,[37] and the World Health Organization in 2013 (only for PTSD, not for acute stress treatment).[2] The American Psychological Association "conditionally recommends" EMDR for the treatment of PTSD.[38]
Children
EMDR is included in a 2009 practice guideline for helping children who have experienced trauma.[39] EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.[40][41]
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.[42]
Other conditions
Several small studies have indicated EMDR efficacy for other mental health conditions,[43] but more research is needed.[18]
Depression
Studies have indicated EMDR effectiveness in depression.[44][45] 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."[46]
Small studies have found EMDR to be effective with GAD,[47] OCD,[43] other anxiety disorders,[48] and distress due to body image issues.[49]
Other conditions
EMDR may have application for psychosis when co-morbid with trauma,[43] Other studies have investigated EMDR therapy’s efficacy with borderline personality disorder,[50] and somatic disorders such as phantom limb pain.[51][52] EMDR has also been found to improve stress management symptoms.[53] EMDR has been found to reduce suicide ideation,[54] and help low self-esteem.[55] Other studies focus on effectiveness in substance craving[56] and pain management.[57] EMDR may help people with autism who suffer from exposure to distressing events.[58]
Reviews
- A 2020 review found EMDR "is a safe and economical therapeutic option."[59]
- 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."[18]
- A 2013 overall literature review covered research up to that time.[60]
Mechanism
Possible mechanisms
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.[61] 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."[2]
EMDR allowing correct processing of memories
EMDR is posited to help in the correct processing of the components of the contributing distressing memories.[62][63] EMDR may allow the client to access and reprocess negative memories (leading to decreased psychological arousal associated with the memory).[64] This is sometimes known as the Adaptive Information Processing (AIP) model.[65][66][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 impacts working memory.[67] By having the patient perform a bilateral stimulation task while retrieving memories of trauma, the amount of information they can retrieve about the trauma is limited, and thus the resulting negative emotions are less intense.[68] This is seen by some as causing a distancing effect which enables the client to 'stand back' from the trauma. The client is enabled to re-evaluate the trauma and their understanding of it, and thus process it correctly, because they can re-experience it whilst not feeling overwhelmed by it.[43]
- EMDR enables ‘dual attention’ (recalling the trauma whilst keeping ‘one foot in the present’ assisted by bilateral stimulation). This allows the brain to access the dysfunctionally stored experience and stimulate the innate processing system, allowing it to transform the information to an adaptive resolution.[43]
- 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.[69] These changes may cause EMDRs efficacy.[70][71]
- EMDR efficacy has been linked to the Zeigarnik effect (i.e. better memory for interrupted rather than completed tasks).[72]
- Horizontal eye movement triggers an evolutionary 'orienting response' in the brain, used in scanning the environment for threats and opportunities.[73]
- EMDR gives an effect similar to the effects of sleep,[74] and posit that traumatic experiences are processed during sleep.
- Trauma can be overcome or mastered, and EMDR facilitates a form of mindfulness or other form of mastery over the trauma.[43]
A 2013 meta-analysis focused on two mechanisms: (1) taxing working memory and (2) orienting response/REM sleep.[16]
It may be that several mechanisms are at work in EMDR.[43]
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.[75] 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.
Research results and opinions have been mixed on the effectiveness and importance of the technique;
- 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.[76]
- A 2020 review questioned the consistency and generalizability of the technique.[77]
- 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.[16][43]
- 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.[73]
- 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.[78]
- A 2001 meta-analysis suggested that EMDR with the eye movements was no more efficacious than EMDR without the eye movements (Davidson & Parker, 2001).[19][79][80]
- A 2000 review found that the eye movements did not play a central role, and that the mechanisms of eye movements were speculative.[81]
- A small 1996 study found that the eye movements employed in EMDR did not add to its effectiveness.[82]
Francine Shapiro noticed that eye movements appeared to decrease the negative emotion associated with her own distressing memories.[83][84][85] Bilateral stimulation seems to cause dissipation of emotions.[86][87]
Criticisms
EMDR has historically been controversial within the psychological community.[88][89]
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,
Client perceptions of effectiveness are also mixed.[91]
Pseudoscience
Skeptics of the therapy argued that EMDR is a 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.[81][26] According to Yale neurologist Steven Novella:
Excessive training
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.[93][81] 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.[93] 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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