Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is a psychotherapy developed by Francine Shapiro that emphasizes disturbing memories as the cause of psychopathology.^[1][2] It is used to help with the symptoms of post traumatic stress disorder (PTSD).^[3] According to Shapiro, when a traumatic or distressing experience occurs, it may overwhelm normal coping mechanisms. The memory and associated stimuli are inadequately processed and stored in an isolated memory network.^[1]

EMDR therapy is better than no treatment and similar to cognitive behavioral therapy (CBT) in chronic PTSD.^[4][5]

The goal of EMDR is to reduce the long-lasting effects of distressing memories by developing more adaptive coping mechanisms. The therapy uses an eight-phase approach that includes having the patient recall distressing images while receiving one of several types of bilateral sensory input, such as side to side eye movements.^[6] EMDR was originally developed to treat adults with PTSD; however, it is also used to treat other conditions and children.^[7]

Medical uses

Two meta-analyses from 2013 found that EMDR therapy is better than no treatment and similar to cognitive behavioral therapy (CBT) in chronic PTSD.^[4][5] However, due to "very low" quality of evidence, significant rates of researcher bias, and some participant drop outs, the meta-analysts cautioned against interpreting the results of the studies which were analyzed.^[4] A 2007 review concluded that trauma-focused cognitive-behavioural therapy or EMDR are first-line psychological treatment for PTSD.^[8]

In one meta-analysis of PTSD, EMDR was reported to be as effective as exposure therapy and SSRIs.^[9] Two separate meta-analyses suggested that traditional exposure therapy and EMDR have equivalent effects immediately after treatment and at follow-up.^[10][11] A review of rape treatment outcomes concluded that EMDR had some efficacy.^[12] 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."^[13] Another review concluded EMDR to be of similar efficacy to other exposure therapies and more effective than SSRIs, problem-centered therapy, or 'treatment as usual.'^[14]

Position statements

The International Society of Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults.^[15] Some international guidelines recommended EMDR therapy — as well as CBT and exposure therapy — for treating trauma.^{[15][16][17][18]}

In 2013 the World Health Organization practice guidelines stated that trauma-focused CBT and EMDR therapy are the only psychotherapies recommended for children, adolescents, and adults with PTSD "referral for advanced treatments such as cognitive-behavioural therapy (CBT) or a new technique called eye movement desensitization and reprocessing (EMDR) should be considered for people suffering from PTSD. These techniques help people reduce vivid, unwanted, repeated recollections of traumatic events. More training and supervision is recommended to make these techniques more widely available."^[19]

In 1999, EMDR was a controversial therapy within the psychological community,^[20] and in 2000, its efficacy compared to other treatments and underlying mechanism was the subject of debate.^[21] However, since 2004, EMDR was recommended as an effective treatment for trauma in the Practice Guidelines of the American Psychiatric Association,^[22] the Departments of Veterans Affairs and Defense,^[23] SAMHSA,^[24] the International Society for Traumatic Stress Studies,^[25] and the World Health Organization.^[19]

Other applications

Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR therapy’s efficacy with other disorders, such as borderline personality disorder,^[26] and somatic disorders such as phantom limb pain.^[27][28]

Children

EMDR has been used effectively in the treatment of children who have experienced trauma and complex trauma.^[29] EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.^[30][31]

Approach

EMDR therapy consists of eight phases and each phase has its precise intentions.^[32][33]

Phase I History and Treatment Planning

The therapist conducts an initial evaluation of the client’s history and develops a general plan for treatment. This includes the problems which are the primary complaint of the client and a history of distressing memories which will become the targets for reprocessing.

Phase II Preparation

The therapist helps the client develop ways to cope with distressing emotions so that they are able to calm down and help themselves in between therapy sessions. Commonly this is done with guided imagery or other relaxation techniques.

Phase III Assessment

The therapist asks the client to visualize an image that represents the disturbing event. Along with it, the client describes a thought or negative cognition (NC) associated with the image. The client is 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 the PCs to be true using a 1–7 scale (completely false to completely true) called the Validity of Cognition (VOC) scale. The client is also asked to identify what emotions he or she feels. The client is then asked to rate his or her level of distress on a scale from 0–10, with 0 being no distress and 10 being the most distress they can imagine. This is the same as a Subjective Units of Distress scale (SUD) that is commonly used in cognitive behavioral therapy (CBT). Finally the client is asked to identify where in the body he or she is sensing the feelings.

Phase IV Desensitization

During the reprocessing phases of EMDR therapy, 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 consists of focusing on the trauma while the clinician initiates lateral eye movement or another stimulus such as a pulsing light held in each hand, or tapping on the knees.^[34] 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 or another aspect of the memory may be guided by the clinician. This process of personal association is repeated many times during the session.^[34] This process continues until the client no longer feels as distressed when thinking of the target memory.

Phase V Installation

The therapist asks the client to focus on the event along with the PC developed in phase III. The client is asked to hold in mind the memory with the positive thought as the therapist continues with the bilateral stimulation. When the client feels he or she is certain the PC is fully believed and that belief is as strong as possible, 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 when thinking about the target memory and the PC. While thinking about the event and the positive belief the client is asked to scan over his or her body entirely, searching for tension, tightness or other unusual physical sensation. Any negative sensations are targeted and then diminished, using the same bilateral stimulation technique from phases IV and V. The PCs should be incorporated emotionally as well as intellectually. Phase VI is complete when the client is able to think and speak about the event along with the PC without feeling any physical or emotional discomfort.

Phase VII Closure

Not all traumatic events will be resolved completely within one session. If the client is significantly distressed the therapist will guide the client through relaxation techniques that are designed to bring about emotional stability and tranquility. The client will also be asked to use these same techniques for experiences that might arise between sessions such as strong emotions, unwanted imagery, and negative thoughts. The client may be encouraged to keep a brief log 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.

History

EMDR therapy was first developed by Francine Shapiro upon noticing that certain eye movements reduced the intensity of disturbing thought. She then conducted a scientific study with trauma victims in 1988 and the research was published in the Journal of Traumatic Stress in 1989^[35]

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.^[36] Shapiro developed EMDR therapy for posttraumatic stress disorder. She speculated that traumatic events "upset the excitatory/inhibitory balance in the brain, causing a pathological change in the neural elements".^[36]

EMDR therapy 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 guided by the Adaptive Information Processing model.^[37]

Controversy

EMDR has generated a great deal of controversy since its inception in 1989. Shapiro was criticised 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.^[20][21] A 2002 review disputed the two articles and similar statements, stating that “scientific debate has begun to degenerate into slurs, innuendo, and ad hominem attacks”.^[38]

In 2000, Herbert et al. argued that the eye movements did not play a central role, that the mechanisms of eye movements were speculative, and that the theory leading to the practice was not falsifiable and therefore not amenable to scientific inquiry.^[21] As discussed in 2013 by Richard McNally, one of the earliest and foremost critics: "Shapiro’s (1995) Eye Movement Desensitization and Reprocessing (EMDR) provoked lively debate when it first appeared on the scene in the late 1980s.... Skeptics questioned whether the defining ingredient, bilateral eye movement, possessed any therapeutic efficacy beyond the imaginal exposure component of EMDR.... A 2001 meta-analysis suggested that EMDR with the eye movements was no more efficacious than EMDR without the eye movements (Davidson & Parker, 2001),^[39] implying that "what is effective in EMDR is not new, and what is new is not effective" (McNally, 1999, p.619).^[40][41] A 2013 meta-analysis concluded, 'the eye movements do have an additional value in EMDR treatments'.^[41][42] However, the authors of this analysis addressed several limitations with this study by stating, "This study has several limitations. The most important one is 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".^[42]

Likewise, Salkovskis in 2002 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.^[43] However, the 2013 World Health Organization practice guidelines drew clear distinctions in contrasting CBT and EMDR therapy procedures: "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. Like 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".^[44]

Although one early meta-analysis conducted in 2002 concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy,^[45] other researchers using meta-analysis had found EMDR to be at least equivalent in effect size to specific exposure therapies.^[46][47]

The working mechanisms that underlie the effectiveness of the eye movements in EMDR therapy are still under investigation and there is as yet no definitive finding. The consensus regarding the underlying biological mechanisms involve the two that have received the most attention and research support: (1) taxing working memory and (2) orienting response/REM sleep.^[48]

Notes