Eye Movement Desensitization and Reprocessing
Abstract and Keywords
Since its inception in 1987, eye movement desensitization and reprocessing (EMDR) therapy has been the subject of lively debate and controversy, rigorous research both nationally and internationally, and is now used by licensed practitioners across six continents as an effective treatment of trauma symptoms and posttraumatic stress disorder (PTSD). The aim of this entry is to provide social work practitioners and researchers with a description of the treatment approach for adults and children, EMDR’s development and theoretical basis, a review of controversial issues, and an overview of the evidence of effectiveness of EMDR across trauma types and populations.
Keywords: eye movement desensitization and reprocessing, EMDR, trauma, treatment, PTSD, cross-reference suggestions, clinical and direct practice, mental and behavioral health, children and adolescents, international and global issues, race, ethnicity, and culture, research and evidence-based practice, populations and practice settings
Development of EMDR
As described in her book, Eye Movement Desensitization and Reprocessing, Francine Shapiro was out for a walk one spring day in 1987, when she noticed that some distressing thoughts she had been having had abruptly disappeared (Shapiro, 2001). This took her by surprise because she had not been consciously trying to stop the thoughts. Shapiro began paying attention to what happened on the emergence of disturbing thoughts and noticed that her eyes would move back and forth very quickly along a horizontal axis. She then decided to consciously pull up disturbing thoughts and make the eye movements of her own volition, which resulted in dissipation of the thoughts and a decrease of the negative charge that had been associated with them. Shapiro began trying this procedure on friends and associates in the psychology community, eventually working finger movements into the process when she noticed that people tended to have difficulty maintaining their own rapid eye movements with nothing on which to focus. Over a 6-month period, Shapiro developed the basic protocol that she initially named Eye Movement Desensitization (EMD).
In 1989, Shapiro’s first controlled study on EMD was published and reported positive effects in alleviating trauma symptoms related to combat trauma and childhood sexual, physical, and emotional abuse (Shapiro, 1989). Later, in 1990, Shapiro modified the name to Eye Movement Desensitization and Reprocessing (EMDR) on deciding that this title more accurately reflected the breadth of the effects of EMDR, which are thought to entail not only desensitization, but also the adaptive reprocessing of maladaptive stored traumatic memories (Shapiro, 2001).
The continued research, development, and dissemination of EMDR through the 1990s were accompanied by many achievements. In 1991, the EMDR Institute and the EMDR Network were developed, followed by publication of the first EMDR clinical journal, EMDR Networker, which would be followed in 2007 by the first edition of the Journal of EMDR Practice and Research, a peer-reviewed, quarterly publication on research, theory, and practice of EMDR. The incorporation of the EMDR Institute in 1993 would give rise to many national and international workshops and trainings. The EMDR Humanitarian Assistance Program (EMDR-HAP) was created in response to the tragedy of the 1995 Oklahoma City bombing and has gone on to provide support and disaster response trainings both nationally and internationally.
Congruent with EMDR’s ongoing roles in international disaster response support, EMDR Associations were formed in 1998 and 1999 in Australia, Canada, Europe, and Latin America. This growth trajectory has continued into the 21st century, resulting in productive research collaborations and seminal research contributions. For example, in addition to the first randomized controlled trials (RCTs) in veteran and civilian populations in the United States (United States: Boudewyns, Stwertka, Hyer, Albrecht, & Sperr, 1993; Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998; Wilson, Becker, & Tinker, 1995), the first meta-analysis to compare exposure therapy and EMDR was a collaboration between researchers in the United States and Canada (van Etten & Taylor, 1998). Other examples include a meta-analysis performed by collaborating Canadian and U.S. researchers (Maxfield & Hyer, 2002) and RCTs comparing cognitive behavioral therapies (CBT) and EMDR, which are authored not only in the United States, but in Australia and Scotland, United Kingdom (Ironson, Freund, Strauss & Williams, 2002; Lee, Gavriel, Drummond, Richards, & Greenwald, 2002; Power et al., 2002). The international presence of EMDR has not subtracted from ongoing growth in the United States as exemplified by the 2003 launch of EMDR-HAP nationwide trainings at nonprofit organizations in an effort to increase access to this evidence-based, trauma-focused treatment. Remarkably, by 2009, 54 countries across 6 continents had become host to licensed practitioners of EMDR (Maxfield, 2009). For a more detailed chronological history, see Maxfield, 2009.
EMDR Treatment Approach
Shapiro has described the process of EMDR as “an interactive, intrapsychic, cognitive, behavioral, body-oriented therapy” directed “to rapidly metabolize the dysfunctional residue from the past and transform it into something useful” (Shapiro, 1995, pp. 52–53). The breadth and flexibility inherent in this model has allowed practitioners from a variety of theoretical orientations (for example, psychodynamic, cognitive behavioral, and systemic approaches) to effectively employ EMDR from within the comfort of their familiar framework (Shapiro & Laliotis, 2011).
EMDR treatment is implemented in eight phases within a three-pronged approach to address the following: (a) past traumatic experiences, (b) current triggers, and (c) future potential challenges (Shapiro, 2001). Together, the therapist and client work to identify pertinent experiences from the client’s past that are related to problems the client is presently experiencing; past event(s) are the focus of the first prong. Present triggers that are activating a trauma memory are subsequently identified and comprise the focus of the second prong. In the third prong, focus is shifted to the identification of future actions the client can take to adaptively respond to new life experiences.
The eight phases include the following: (a) history taking, (b) preparation, (c) assessment to determine targets for reprocessing of traumatic memories, (d) desensitization of the trauma memory during which attention is placed on cognitive, affective, and somatic elements of the memory, (e) installation of a positive cognition that is paired, in a sense, with the desensitized trauma memory, (f) body scan to attend to any residual disturbances associated with the trauma memory, (g) closure of the session, and (h) a final reevaluation of the session work at a later time (Shapiro, 2001).
In the first phase, the therapist obtains a thorough client history, preferably including the use of standardized assessment and diagnostic tools, in order to design the treatment plan. A comprehensive clinical evaluation in this phase allows the therapist to assess with the client indications and contraindications for the use of EMDR. Based on the client’s history and presenting issues, the therapist helps the client identify past events affecting current functioning, current triggers activating trauma memories, and potential future challenges and needs. Importantly, the treatment plan includes both positive and negative life experiences. Through this process as well as the work undertaken in phase two, the target memory or memories that will be addressed through EMDR are identified.
In the second phase, the client is prepared for EMDR and a therapeutic relationship is established. Preparation includes establishment of the client’s treatment goals and expectations, and psychoeducation on symptoms and diagnosis as well as on EMDR procedures. During this process, research findings on EMDR’s effectiveness are shared in a context relevant to the client. In addition, the therapist educates the client on possible negative reactions to the EMDR procedure and addresses client fears and any potential safety issues to ensure informed consent for treatment. The development of effective affect regulation and self-soothing skills through use of relaxation techniques—such as guided imagery among others is essential during this phase of treatment in order to ensure the client’s ability to stabilize following any distress experienced during, after, or in between sessions. Mastery of these skills is recognized as especially important for clients who have a history of complex trauma.
In the third phase, an assessment is performed to determine the target memory, associated components, and basal level of disturbance evoked by the target memory. Target components consist of the following: (a) presenting difficulty, (b) the memory associated with the presenting difficulty, (c) a mental image of the associated memory, (d) an identified current, negative self-belief that is associated with the memory (negative cognition), (e) an identified positive self-belief that will replace the negative one (positive cognition), (f) the emotions associated with the memory, and (g) the bodily location of any physical sensations associated with remembering the mental image that represents the traumatic memory. During this third phase, the level of disturbance evoked by the trauma memory is determined to establish a baseline rating of disturbance prior to the desensitization phase. The level of disturbance is rated by the client on a 10-point scale of subjective units of disturbance (SUD), ranging from “no disturbance” to “worst disturbance.”
Once the target traumatic memory has been determined, the client focuses on a mental image they consider as being most representative of the memory and identifies the negative cognition that resulted from the experience. The client then identifies a positive cognition with which the client would like to replace the negative cognition (this will occur later during the installation phase). At this time, the level at which the positive cognition feels true or valid to the client is assessed using the 7-point validity of cognition scale (VOC), which ranges from “feels completely false” to “feels completely true.” Following ascertainment of the VOC rating, the client is asked to visualize the image representing the traumatic event, hold in mind the negative cognition, and identify any emotions that come up. The client is then asked to rate the level of disturbance of the emotion(s) using the SUD scale. The level of disturbance is then checked periodically throughout the next and fourth phase, desensitization. Depending on the levels of the VOC and SUD, the therapist may decide to continue onto desensitization or remain in phase three until relevant alternative issues and components are identified that may be more problematic.
Desensitization comprises the fourth phase, which is focused on decreasing the client’s level of disturbance around the target memory. The objective in this phase is to reprocess the disturbing experience(s) to adaptive resolution, including weakening linkages to the disturbing experience, identifying and reprocessing any related disturbances, and increasing linkages to adaptive information or experiences. Activation of the target memory occurs when the therapist asks the client to hold the previously identified target memory components in mind during therapist-induced alternating bilateral stimulation. Bilateral stimulation can occur through the use of saccadic eye movements (visual), sounds from head phones (auditory), and hand taps or vibrations (tactile). During this process, the client is encouraged to “just notice” the experience or to “go with that” and to report what they observe regarding any of the target components (for example, the image, memory, thoughts, feelings, or body sensations). Each set of bilateral stimulation evokes a spontaneous move from an image to a body sensation, an emotion or insight, or a new image. Unlike trauma processing in gradual or prolonged exposure, the client does not need to describe a coherent narrative during the process of desensitization.
If eye movements are the mechanism of bilateral stimulation used, the client is asked to bring up a mental image of the distressing event while holding in mind the identified cognitions and feelings and to visually track the therapist’s fingers, which move rhythmically (approximately 18 inches anterior to the client’s face or customized to client preference) back and forth, up and down, or diagonally. The rate of finger movement is rapid at about two back-and-forth movements per second. Directionality the number of movements vary based on the client’s needs, but a set is generally around 24–36 passes. After each set, the client reports any images, thoughts, or feelings that emerged during the set, as well as any change in the level of disturbance using the SUD scale. This process continues until all associated linkages or channels have been reprocessed and or little or no change has occurred, in which case the therapist typically repeats one or more sets of bilateral stimulation, targeting the same target memory and associated components. If processing becomes stalled, the therapist can use a cognitive interweave to introduce adaptive information. If the client experiences the emergence of any new material, the subsequent set(s) will target the new material. This process will be repeated, with each consecutive set of bilateral stimulation targeting the newly emerged material each time. The objective is to facilitate a decrease in the client’s level of disturbance associated with the original target memory; ideally, the SUD rating would reach 0 or 1 on the 10-point scale. If needed, the target memory or other trauma memories can be addressed during additional sessions. The implementation of reprocessing work (during the desensitization phase) is three-pronged in that past distressing experiences, current triggers, and potential future challenges are successively targeted in this phase.
Installation is the fifth phase and follows successful desensitization of the target memory. The client is asked whether the positive cognition (that is, a desired positive self-belief) identified in phase three still feels relevant or whether something else seems more appropriate. Sets of bilateral stimulation are used to install the positive cognition. Similar to taking a SUD rating during desensitization, a VOC rating (mentioned in phase three) is taken here. Installation is considered successful when the client rating of how true the positive cognition feels is a 6 or 7 on the 7-point VOC scale.
In the sixth phase, a body scan is performed wherein the client is asked to re-access the target image–memory along with the desired positive self-belief and to scan their body with the intention of noticing whether any positive or negative residual physical sensations from the target issue are present. Such residual physical sensations are considered to be a signal of unresolved components of the target memory warranting further processing, in which case, phases three through five are repeated until only positive or neutral physical sensations are present.
The seventh phase, closure, is conducted at the end of each EMDR session, regardless of whether desensitization was completed, and functions to ensure that the client feels stable enough to conduct daily activities following the session. In addition, the therapist confirms with the client that they feel capable of using relaxation techniques (such as guided imagery) to ameliorate distressing feelings that may occur in between sessions as processing continues. Clients are asked to maintain a log of any distressing cognitions, emotions, or physical sensations experienced between sessions.
In the eighth phase, the client is asked to reevaluate target memories that have already been reprocessed to assess whether treatment has been effective. The client log of new material is examined and discussed in the case that any new material emerged following the previous session. Attending to the three-pronged protocol, the therapist assesses for any residual distress related to past experiences, current triggers, or future challenges that still need to be targeted. Residual distress related to any of these areas would be targeted for treatment such that phases 3-8 are re-implemented.
Session length, pacing, and total number of sessions needed to accomplish meaningful change varies and should be tailored to client needs. According to some studies, clinically significant, stable changes have been achieved in as few as one to three sessions typically in cases of a client history with a single traumatic event, (Shapiro, 1996a,b, 2010). For clients with a history of complex trauma, treatment length is longer and varies on an individual basis. The EMDR International Association (2012) asserts that “EMDR treatment is not completed in any particular number of sessions. It is central to EMDR that positive results from its application derive from the interaction among the clinician, the therapeutic approach, and the client.” (EMDRIA’s Definition of EMDR, 2012). For adults and adolescents, the recommended session length is 90 minutes; the cumulative length of time that bilateral stimulation is occurring is several minutes.
EMDR is intended to be employed by experienced psychotherapists who have been formally trained in EMDR and is implemented following the establishment of a therapeutic alliance. It can be used along with other clinical approaches in which the therapist is experienced, but should be applied only to those target problems the therapist is already proficient in treating.
Theoretical Basis of EMDR and the AIP Model
Although EMDR was not originally born out of theory, which has been a source of much criticism, Shapiro developed the Adaptive Information Processing (AIP) model as a working hypothesis that provides a theoretical framework, explanation of symptom etiology, as well as explanation and prediction of EMDR treatment outcomes (EMDRIA, 2012; Schubert & Lee, 2009; Shapiro, 2001; Shapiro & Laliotis, 2011). The AIP model is viewed as the overarching framework that shapes case conceptualization, treatment planning, and implementation of the EMDR procedure (EMDRIA, 2012; Schubert & Lee, 2009; Shapiro & Laliotis, 2011). Briefly, the AIP model poses that there exists an intrinsic information processing system in human organisms that functions to integrate life experiences into extant memory networks, thus allowing for new learning.
During significantly distressing experiences, information may not be adequately processed or integrated due to an imbalanced neurobiological state (Shapiro, 2001). Insufficient trauma processing can result in maladaptive encoding of the memory, which is dysfunctionally stored in the neural network, similar to the fear network proposed by Foa and Kozak (1986) (EMDRIA, 2012; Schubert & Lee, 2009; Shapiro & Laliotis, 2011). Since the core elements of the distressing experience—external sensory stimuli such as images–sounds as well as internal sensory stimuli such as affect, thoughts, and body sensations—have not been adequately processed and integrated, present day stimuli resembling the original event can trigger the distressing material, compromise functioning, and potentially give rise to clinical mental disorders. The EMDR protocol aims to activate the neural network in which the inadequately processed memory is stored in order to reinitiate information processing to allow adaptive resolution of the traumatic memory (EMDRIA, 2012; Schubert & Lee, 2009; Shapiro & Laliotis, 2011). For a more extensive review of research on the AIP model as well as comparison with other models of posttraumatic stress disorder (PTSD), see Schubert and Lee (2009).
Applicability of EMDR across Populations
Similar to differentiation among trauma types, there is no current indication that individuals from distinct ethnic backgrounds differentially benefit from EMDR treatment. As previously indicated, practitioners from 54 countries across 6 continents have been trained in EMDR (Maxfield, 2009) and numerous studies conducted in different countries with different ethnic groups have consistently produced effective outcomes (e.g. Capezzani et al., 2013; de Roos, 2011; Diehle et al., 2014; Hogberg et al., 2007; Jaberghader et al., 2004; Nijdam et al., 2012; & Wanders et al., 2008). Studies conducted in the United States have predominately been comprised of Caucasians, with Hispanic and African American groups being the second and third most represented groups. A few U.S. studies also included Asian Pacific Islanders, Native Americans, and Alaskan Natives. Far too often studies fail to report the ethnic composition of their studies and none of the studies reviewed conducted comparative analysis of effectiveness by racial or ethnic background. Similarly comparative analysis of effectiveness by gender has not been examined, but studies comprised of single and mixed gender have demonstrated positive results for both male and female participants. Likewise, EMDR has been shown to be effective across a wide range of ages from as young as 6 and as old as 79.
EMDR Treatment in Children and Adolescents
While the literature on the use of EMDR with children and adolescents is sparse in comparison to that existing for adults, evidence is emerging on EMDR’s effectiveness in child and adolescent populations, notably for treatment of posttraumatic symptoms and PTSD (Adler-Tapia & Settle, 2009a; Ahmad, Larsson, & Sundelin-Wahlsten, 2007; deRoos, 2011; Field & Cottrell, 2011; Rodenburg, Benjamin, deRoos, Meijer, & Stams, 2009). Recently, the California Evidence-Based Clearinghouse for Child Welfare (CEBC) rated EMDR as a level 1 trauma-focused treatment for children indicating that it has a sound evidence base. The only other treatment modality to receive the level 1 rating was trauma-focused cognitive behavioral therapy (California Evidence-Based Clearinghouse for Child Welfare, 2013).
In addition to being trained in the basic EMDR protocol as well as in the advanced training in the use of EMDR with children, it is highly recommended that a clinician treating traumatized children also be trained in trauma treatment. Previous experience in working with both children and or or adolescents is also necessary. Treatment fidelity is important and the AIP model and eight phased, three-pronged approach of the full EMDR protocol are administered to children and adolescents with the understanding that accommodations for the developmental stage and the particular presenting problem will likely be necessary (Adler-Tapia, 2011; Adler-Tapia & Settle, 2009b). While the AIP model remains the guiding framework in the treatment of children and adolescents, creativity and play become very important throughout the eight phases and clinicians can incorporate developmentally appropriate techniques and strategies used in other treatment approaches, such as art and play therapy.
Adler-Tapia and Settle (2009b) have presented examples of developmentally appropriate creative modifications integrating other techniques into each of the eight phases of the EMDR protocol. For example, during the preparation phase, in addition to relaxation skills, recognition of emotions is taught. In the assessment phase, metaphor or fantasy can be used along with sand trays, play therapy, clay sculpting, and or or drawings to help children communicate their feelings and thoughts to facilitate identification of the target memory.
Relative to adults, reprocessing may proceed more quickly to a point of resolution in children, which is due to fewer years that children have lived potentially allowing for fewer adverse events to accumulate in association with presenting problems. Therefore, in the desensitization phase, shorter sets of eye movements (<24) are recommended. Also, to facilitate perdurance of engagement, the type of bilateral stimulation used can be varied. For example, the therapist might initially use a set of eye movements, switch to audio signals in the next round, and follow with hand taps in a subsequent round. Several fun modes of bilateral stimulation have been identified, such as having the child march, drum, or clap. Child-friendly forms of visual bilateral stimulation include substituting a puppet or stuffed animal for the therapist’s fingers. Between sets of bilateral stimulation, the child can give a verbal description of what she or he noticed or, alternatively, the child can sculpt clay, draw, or use a sand tray to communicate internal experiences.
In the installation phase the therapist and child revisit the original sand tray work or drawing and determine how true the positive cognition currently feels. During the body scan, a magnifying glass can be used by the therapist to make the concept of scanning the body for any disturbances more concrete. During the closure phase, in order to achieve adequate affect regulation, relaxation skills developed in the preparation phase are employed. The same skills should serve as an out-of-session resource for both the child and parents. Between sessions, artwork, imagery, or drawing can be used to create containers in which painful thoughts, feelings, and memories can be placed. Drawing can also be used for conceptualization of potential future challenges in the third prong of the protocol. During the reevaluation phase, reintroduction of artwork or drawings developed in the course of treatment can be used to review treatment progress with the child.
Similar to other child-focused interventions, parental caregiver inclusion is important, beginning with psychoeducation on trauma, in both child and adolescent development, and the EMDR procedure. Parents and caregivers also serve as an informational resource on the child’s developmental and attachment history, traumatic experiences, and current symptoms or problems. As treatment proceeds, parents or caregivers can also provide valuable information on external signals of distress or indicators of improvement exhibited by the child (Adler-Tapia & Settle, 2009b). For a more comprehensive account of the use of EMDR in the treatment of children and adolescents see EMDR and the Art of Psychotherapy with Children (Adler-Tapia & Settle, 2008).
Controversy around EMDR
A substantial base of rigorous outcome studies has provided evidence of the effectiveness of EMDR in treating adult single-trauma PTSD. Despite this, some continue to view EMDR treatment as controversial. One reason is historically based, as EMDR proponents lauded its wide-ranging effectiveness in areas of psychopathology for which supportive research was scant. Another reason is that dramatic claims of effectiveness were initially made by its proponents, for example, the suggestion that a single session could eliminate PTSD and that EMDR was more effective than other existing trauma treatments. Evidence does indicate that one to three EMDR sessions can effectively reduce or eliminate symptoms of trauma or PTSD in some cases of single incident trauma. However, chronic or complex trauma generally requires longer treatment with any evidence-based trauma treatment, including EMDR (Edmond, Rubin & Wambach, 1999; Ironson et al., 2002; Jaberghaderi, Greenwald, Rubin, Dolatabadim & Zand, 2004). For example, in studies comparing EMDR and prolonged exposure, six to nine sessions resulted in comparable effectiveness outcomes (Ironson et al., 2002; Lee et al., 2002; Rothbaum, Astin & Marsteller, 2005). Notably, the Eye Movement Desensitization & Reprocessing International Association (2012) defines the length of treatment as being driven by client needs and circumstances rather than by a prescribed number of sessions.
EMDR has been depicted by some as a pseudoscientific movement suggesting that it is an imaginal exposure technique and that the dual attention stimulation component of the intervention is unnecessary and merely a treatment gimmick (Olatunji, Parker, & Lohr, 2005–2006). Detractors of EMDR have also denounced it for not having been developed out of theory and suggest that attempts at theoretical connections have been inconstant and speculative over time. The same critics have argued that proponents of EMDR continually change the criteria for judging fidelity to the model with outcome studies that produce findings they dislike (Rubin, 2003, 2004).
Evidence and Debate on Bilateral Stimulation
Although EMDR is comprised of various cognitive-behavioral techniques, bilateral stimulation is unique to the procedure and typically is employed in the form of eye movements. Bilateral stimulation can also be carried out tactilely with right and left alternating hand taps or auditorily with sounds that alternate between the right and left ears. These latter two modes can be useful when a client has vision difficulties or difficulties with dual concentration. Nevertheless, certain critics designate EMDR as a traditional cognitive-behavioral therapy with no added value resulting from bilateral stimulation (Nevid, Rathmus & Greene, 2008; Rosen, 1999). On the other hand, some proponents claim that EMDR is distinguished not only by the use of bilateral stimulation, but also by a distinct and methodical treatment sequence that incorporates multiple components considered effective in the majority of evidence-based trauma-focused treatments such as cognitive restructuring, some level of exposure, relaxation, and mindfulness (Lee & Cuijpers, 2013).
The most controversial remaining question may be that of whether bilateral stimulation is a necessary component of EMDR. Evidence from randomized experiments has shown that EMDR is as effective as and potentially more efficient than exposure therapy (van Etten & Taylor, 1998; Ironson et al., 2002; Lee et al., 2002; Power et al., 2002; Rothbaum et al., 2005; Taylor et al., 2003) and that bilateral stimulation enhances the effects of EMDR (Maxfield, Lake, & Hyer, 2004). In contrast, some studies have given rise to opposite conclusions causing some to question whether EMDR’s effectiveness can be ascribed solely to the element of imaginal exposure (Olatunji, Parker & Lohr, 2005–2006; Rothbaum, Astin, & Marsteller, 2005).
Lee and Cuijpers, (2013) recently conducted a meta-analysis of 14 clinical studies as well as 10 laboratory studies to examine the effect of bilateral eye movements during the EMDR procedure. The clinical experiments consisted of comparison of EMDR with and without eye movements. The result was a significant and moderate effect size for the additive effect of bilateral eye movements (Cohen’s d = 0.41). Similar experiments were conducted in laboratory studies wherein participants were asked to recall a distressing memory with eye movements and without eye movements. The use of eye movement resulted in a significant and large effect size (d = 0.74). The largest effect size resulted on a measure of vividness (d = 0.91) indicating that bilateral eye movements decreased the degree of vividness of the target memory. This finding has implications pertinent to the treatment of trauma symptoms such as flashbacks and intrusive images.
Evidence of EMDR’s Effectiveness
Approximately 50 randomized, controlled studies along with several meta-analyses have provided substantial evidence of EMDR’s effectiveness (Bisson et al., 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005; Davidson & Parker, 2001; van Etten & Taylor, 1998; Seidler & Wagner, 2006). Notably, in 1998 the American Psychological Association (APA) Division 12 Task Force classified EMDR as an empirically validated treatment that is “probably efficacious” in treating civilian PTSD (Chambless et al., 1998). Only two other approaches were included in this classification at the time, exposure therapy and stress inoculation therapy. Since then, a host of comparative studies of EMDR have been conducted comparing EMDR to wait-list controls, nonspecific treatments for PTSD or trauma-focused treatments for PTSD. Findings indicate that EMDR is more effective than wait-list or nonspecific PTSD treatments and is at least as effective as other evidence-based trauma-focused PTSD treatments (reviewed in Schubert & Lee, 2009). In studies comparing EMDR and prolonged exposure, both treatments were found to be effective; however EMDR resulted in more rapid symptom abatement with results achieved in fewer sessions, required less homework (Ironson et al., 2002; Lee et al., 2002; Power et al., 2002), and had a lower dropout rate (van Etten & Taylor, 1998; Ironson et al., 2002; Rothbaum et al., 2005; Taylor et al., 2003). Taken together, the current state of evidence suggests that EMDR is comparably effective to other evidence-based trauma-focused treatment approaches and may be more efficient in achieving those comparable effects in a shorter length of time with less homework required of the client. Consequently, it may also be a more cost-effective treatment, particularly for insurance plans or agencies that only allow for a limited number of sessions.
In 1999, the International Society for Traumatic Stress Studies (ISTSS) recognized EMDR as an effective PTSD treatment in their treatment guidelines (Chemtob, Tolin, van der Kolk, & Pitman, 1999). By 2009, ISTSS gave EMDR an AHCPR level “A” rating for adult PTSD and a level “B” rating for children (Cohen, Berliner, & March, 2000). Since that time additional RCTs have been published on treating children with EMDR (de Roos, 2011). EMDR has been designated as an effective PTSD treatment by the Cochrane Database, the National Registry of Evidence Based Programs and Practices of the Substance Abuse and Mental Health Services Administration, the CEBC, the APA, the American Psychiatric Association, the Department of Veteran’s Affairs, and the Department of Defense. Internationally, EMDR has been recommended for treatment of PTSD in treatment guidelines in France, Ireland, Israel, the Netherlands, Sweden, and the United Kingdom. In 2013, the World Health Organization followed suit, endorsing EMDR for the treatment of PTSD in children and adults in their Guidelines for the Management of Conditions that are Specifically Related to Stress.
While there is comparatively less evidence on the effectiveness of EMDR treatment of trauma symptoms in child versus adult populations, the evidence base is growing and promising results are emerging. Evidence from several small-scale RCT studies, two systematic reviews, and a meta-analysis indicates that EMDR is effective at alleviating trauma symptoms in children. In a promising study that tested a brief course (three sessions) of EMDR in children (n = 32; ages 6–12) who had been through a hurricane compared to children in a wait-list control group, EMDR was found effective in decreasing symptoms of PTSD, anxiety, and depression (Chemtob, Nakashima & Carlson, 2002). Jeffres (2004) showed that up to five, hour-long EMDR sessions decreased PTSD symptoms in children (ages 8–12) who had experienced one or more traumatic events. In an RCT study of children (n = 33) with a PTSD diagnosis compared to a wait-list control group, children who had received EMDR treatment differed significantly on all outcome measures with the exception of one symptom cluster, hyperarousal (Ahmad et al., 2007). When children between 6 and 12 years old who had experienced a motor vehicle accident and exhibited PTSD symptoms (n = 27) were treated with EMDR, compared to a wait-list control group, a 25% reduction in PTSD symptoms resulted, while the wait-list group experienced no symptom reduction (Kemp, Drummond, & McDermott, 2010). While these results are promising, studies comparing EMDR to other evidence-based trauma treatments for children are still needed.
When EMDR was compared to CBT to treat 12–13-year-old Iranian girls (n = 14) who had been sexually abused, both treatments were effective in reducing PTSD symptoms and behavioral problems, however, results occurred more rapidly with EMDR (6.1 sessions) relative to CBT (11.6 sessions) (Jaberghaderi et al., 2004). In an RCT conducted in the Netherlands with an ethnically diverse sample, deRoos (2011) compared EMDR + parental counseling to CBT + parental counseling in 4–18-year-old children (n = 52) who had experienced a disaster. Both treatments were found to be effective in reducing symptoms of PTSD, depression, and anxiety. However, similar to findings in adults, symptom relief in the EMDR group occurred in fewer sessions (three versus four). Notably, deRoos was a codeveloper of the CBT intervention used in the aforementioned study, therefore, if bias were to be a concern, presumably it would have been toward the CBT treatment condition.
Rodenburg and associates (2009) performed a meta-analysis that included seven EMDR RCTs with traumatized children wherein types of trauma varied. Results indicated an overall significant medium effect size (d = .56), which led to the conclusion that EMDR is an effective treatment for trauma symptoms in children and adolescents. A systematic review of EMDR treatment efficacy in studies of children and adolescents was performed by Adler-Tapia and Settle (2009a). A total of 19 studies met the inclusion criteria with four studies comprising RCTs with children experiencing posttraumatic symptoms or PTSD (these studies were included in the aforementioned meta-analysis as well). Results of the systematic review led Adler-Tapia and Settle (2009b) to conclude that EMDR shows promise for treating childhood and adolescent trauma symptoms while its efficacy with behavioral problems and disorders remains to be established.
Evidence for the AIP Model
Much of the debate around the necessity and contribution of bilateral stimulation in the effectiveness of EMDR stems from the need for a theoretical model that presents a more compelling explanation of the mechanisms underlying EMDR. The current theoretical model is the Adaptive Information Processing (AIP) model. The AIP model postulates four hypotheses on the mechanisms underlying EMDR, each having some degree of empirical support: (a) orienting response, (b) REM-like state, (c) increased hemispheric communication, and (d) working memory (reviewed in Schubert & Lee, 2009).
Support for the activation of an orienting response comes from evidence showing that eye movements induce a relaxation response that decreases stress level, which makes processing the trauma memory more bearable for the client (Elsofsson, von Sche’ele, Theorell, & Sondergaard, 2008; Sack et al., 2008 as cited in Schubert & Lee, 2009). In addition, the eye movement component of EMDR has been found to generate a physiological response pattern resembling a “REM-like state” that “through repeated orienting responses, may ‘push-start’ memory processing in the brain by inducing a physiological and neurological state that is akin to REM sleep that aids in the transfer and integration of memories” (Schubert & Lee, 2009, p. 126). Based on evidence that saccadic eye movements in the horizontal direction cause improved episodic memory retrieval, it has also been hypothesized that horizontal eye movements increase communication between the left and right hemispheres of the brain so that recall of the traumatic memory is strengthened while arousal is not (Christman, Garvey, Propper, & Phaneuf, 2003; also reviewed in Schubert & Lee, 2009).
The working memory hypothesis posits that the dual attention aspect of EMDR directs the client’s attention simultaneously to an external stimulus of bilateral stimulation of any form and an internal stimulus composed of the trauma memory, thereby taxing attentional capacity. In the context of the EMDR procedure, dual attention during the desensitization phase wherein trauma processing occurs would cause “the quality of the [trauma] image [to deteriorate], presumably because it gets pushed out of working memory and integrated into long-term memory, where the memory then becomes less vivid and less emotional” (Schubert & Lee, 2009, p. 127).
Neurobiological studies conducted pre- and post-EMDR delivery have begun to elucidate the relationship between changes in brain function and EMDR efficacy (Lansing, Amen, Hanks, & Rudy, 2005; Nardo et al., 2010; Pagani et al., 2007; Sack, Hoffman, Wizelman, & Lempa, 2008 as cited in Pagani et al., 2012). Quite compelling is the evidence for mechanisms underlying EMDR efficacy as elucidated by the first study (Pagani et al., 2012) to analyze real-time cortical neuronal firing throughout delivery of a psychotherapeutic intervention. Pagani et al., (2012) examined neuronal response during the desensitization phase of the EMDR protocol using electroencephalography (EEG). They performed functional mapping of the different areas most active during target memory recall (verbalizing the target memory) and reprocessing with bilateral eye movements. Comparing treatment group to controls, they found significant differences in post-treatment psychological symptom severity and these pre- to post-symptom reductions correlated with changes in functional connectivity as measured by EEG. Pagani et al. (2012) found that EMDR treatment resulted in a functional shift from emotion centers in limbic regions to higher order cognitive, integrative cortical regions. This provides strong neurobiological evidence of the efficacy of EMDR and a window into the underlying mechanism (see Pagani et al., 2012 for further details).
Although the mechanisms underlying EMDR are not yet fully understood, an abundance of empirical evidence has been published that supports the efficacy of EMDR for the treatment of PTSD symptoms in traumatized adults. Additionally, the evidence supporting the efficacy of EMDR in treating traumatized children is mounting.
Types of Trauma Treatable with EMDR
EMDR has been found to be effective in treating trauma symptoms generated by a wide array of both single incident and chronic complex traumas in civilian populations. Although some EMDR studies have focused on a specific type of trauma (natural disaster or motor vehicle accident), most have included samples with a broad mixture of trauma types such as childhood physical or sexual abuse, sexual assault, domestic violence, life-threatening injury or medical event, traumatic loss of someone close, witnessing homicide or death of someone close, and rape of a spouse. None of the studies reviewed examined differential effectiveness by trauma type, but consistent positive outcomes have been found across a large number of studies with a variety of trauma types included. In addition, one RCT found EMDR to be effective in treating what are referred to as “small t traumas” (for example, humiliation in childhood and relationship difficulties) as opposed to major life-threatening events (Cvetek, 2008).
Despite the overwhelming evidence for the efficacy of EMDR in treating trauma symptoms in adult civilians, a recent meta-analysis found that EMDR RCTs with the military population do not provide sufficient evidence of EMDR effectiveness in this population (Verstrael, van der Wurff, & Vermetten, 2013). Their analysis revealed nonsignificant medium and small effects for primary and secondary measures of PTSD symptoms, respectively. The differential effectiveness in civilian versus military populations is not unique to EMDR and has been found in the majority of RCTs of trauma-focused therapies (Foa, Keane, Friedman, & Cohen, 2009, p. 5). As discussed by Verstrael and colleagues (2013) and Foa and associates (2009), some have posited that these findings could be due to a decreased treatment response as a result of combat PTSD being distinct from civilian PTSD with respect to the longer duration and higher frequency of traumatic events associated with combat. Verstrael et al. (2013) point out, however, that the majority of experimental findings are incongruent with this notion (see also Albright & Thyer, 2010 as cited in Verstrael et al., 2013).
Foa and colleagues (2009, p. 5) reviewed studies on veterans in both Veterans’ Affairs (VA) and non-VA settings as well as veterans who underwent treatment for traumatic events not associated with combat and concluded that existing evidence did not indicate that PTSD resulting from particular types of trauma is distinctly treatment resistant. Verstrael and colleagues (2013) concluded that drawing final conclusions from the current evidence base seems premature, as only four studies with a total of 60 EMDR treatment participants, met the design criteria to make it into their meta-analysis. Further, only one out of the four studies analyzed (Jensen, 1994) found EMDR to be ineffective and this was one in which only two sessions were administered (Verstrael et al., 2013). Although there are currently no published studies of EMDR on the treatment of military sexual trauma, the evidence for EMDR effectiveness in treating single and multiple incident sexual trauma is sufficiently robust to suggest that it would be an appropriate treatment option for this population.
Over the past 25 years there has been a significant number of studies conducted examining the effectiveness of EMDR. Substantial evidence of EMDR effectiveness has mounted as a result of approximately 50 randomized controlled trials and several meta-analyses. The current evidence base indicates that EMDR is comparably effective to other evidence-based trauma-focused treatment approaches and may be more efficient in that comparable results have been achieved in a shorter length of time with less homework required of the client.
Widespread national and international practice and research using EMDR have shown it to be an effective treatment for trauma symptoms resulting from a wide array of both single incident and chronic complex traumas across populations ranging in age, gender, and ethnic backgrounds. Recent neurobiological studies have begun to uncover relationships between changes in brain function and EMDR efficacy. More research is needed to fully elucidate the underlying mechanism of EMDR. Additionally, promising implications have arose as a result of ongoing research that seeks to identify the parameters of effectiveness of EMDR for other clinical applications that are being explored in practice: eating disorders, substance abuse, borderline personality disorders, somatic disorders, and psychosis (van den Berg & van der Gaag, 2012; Mosquera & Gonzalez-Vazquez, 2012; de Roos et al., 2010; Schneider, Hofmann, Rost, & Shapiro, 2008).
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Resources for Further Education
EMDR bibliography from 1989 through 2005. http://www.trauma-pages.com/s/emdr-refs.php.
EMDR International Association. http://www.emdria.org.
EMDR Network. http://www.emdrnetwork.org.
EMDR Research Foundation. http://www.EMDRRESEARCHFOUNDATION.org
“EMDR: Taking a Closer Look.” http://www.sciam.com/article.cfm?id=emdr-taking-a-closer-look.
“EMDR Treatment: Less Than Meets the Eye?” http://www.quackwatch.com/01QuackeryRelatedTopics/emdr.html.
Francine Shapiro Library-EMDR Bibliographyhttp://emdr.nku.edu/
EMDR Humanitarian Assistance Projecthttp://www.emdrhap.org/content/about-hap/
This one hour webinar features Dr. Francine Shapiro, originator of EMDR Psychotherapy, introducing the basics of EMDR therapy and providing an overview of treatment. Both the theoretical foundation and recent research findings are explored. The entire webinar can be viewed online or downloaded at: http://www.emdr.com/general-information/webinar1.html
VA/DoD PTSD Clinical Practice Guidelines (2010), which offer recommendations for the treatment of PTSD and gives EMDR its highest (“A”) rating. Complete guidelines are at: http://www.healthquality.va.gov/guidelines/MH/ptsd/cpg_PTSD-FULL-201011612.pdf
PTSD Pocket Guide (2013): http://www.healthquality.va.gov/guidelines/MH/ptsd/PTSDPocketGuide23May2013v1.pdf