Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro that emphasizes the role of distressing memories in some mental health disorders, particularly posttraumatic stress disorder (PTSD).[1] It is an evidence-based therapy used to help with the symptoms of PTSD.[2][3] It is thought that 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 as effective as cognitive behavioral therapy (CBT) in chronic PTSD.[4][5] However, after decades of research, controversy persists as to whether the novel eye movement element is an active ingredient in improved patient outcomes.

The goal of EMDR is to reduce the long-lasting effects of distressing memories by engaging the brain's natural adaptive information processing mechanisms, thereby relieving present symptoms. 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 trauma and PTSD in children and adolescents.[7]

Medical uses

Two meta-analyses from 2013 found that EMDR therapy is better than no treatment and similar in efficacy 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]

In one meta-analysis of PTSD, EMDR was reported to be as effective as exposure therapy and SSRIs.[8] Two separate meta-analyses suggested that traditional exposure therapy and EMDR have equivalent effects immediately after treatment and at follow-up.[9][10] A review of rape treatment outcomes concluded that EMDR had some efficacy.[11] 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."[12] 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.'[13]

A 2013 meta-analysis concluded, 'the eye movements do have an additional value in EMDR treatments'.[14][15] 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".[15]

Although one early meta-analysis conducted in 2002 concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy,[16] other researchers using meta-analysis had found EMDR to be at least equivalent in effect size to specific exposure therapies.[17][18]

Position statements

The International Society for Traumatic Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults.[19] Some international guidelines recommended EMDR therapy — as well as CBT and exposure therapy — for treating trauma.[19][20][21][22]

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."[23]

In 1999, EMDR was a controversial therapy within the psychological community,[24] and in 2000, its efficacy compared to other treatments and underlying mechanism was the subject of debate.[25] However, since 2004, EMDR has been recommended as an effective treatment for trauma in the Practice Guidelines of the American Psychiatric Association,[26] the Departments of Veterans Affairs and Defense,[27] SAMHSA,[28] the International Society for Traumatic Stress Studies,[29] the National Institute for Health and Care Excellence[30] and the World Health Organization.[23]

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,[31] and somatic disorders such as phantom limb pain.[32][33]

Children

EMDR has been used effectively in the treatment of children who have experienced trauma and complex trauma.[34] EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.[35][36]

Mechanism

The proposed mechanisms that underlie 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.[37]

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.[38]

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".[39]

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[40]

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.[41] 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".[41]

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.[42]

Society and culture

Training

Shapiro was 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.[24][25] 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 control 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.[24] Such changes in definition and training for EMDR have been described as “ad hoc moves [made] when confronted by embarrassing data” [43]

Debate

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”.[44] This came after Hebert et al. (2000) similarly accused EMDR proponents of undertaking ad hominem attacks against EMDR critics by questioning their training or competence and/or suggesting they had ulterior motives for their criticisms.[25]

The same 2000 article by 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. It went on to refer to EMDR as “pseudoscience”, citing non-falsifiability as one of several hallmarks of pseudoscience that EMDR met. Others included failure to “draw or build on existing scientific concepts, but instead purport[ing] to create entirely novel paradigms” and having “the primary goal of … persuasion and promotion, rather than truth seeking through the corrective skepticism of the scientific enterprise”.[25] 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),[45] implying that "what is effective in EMDR is not new, and what is new is not effective" (McNally, 1999, p.619).[46][14] It is also worth noting that although the primary controversy in EMDR has centered on the necessity of the eye-movement component, Davidson and Parker’s (2001) meta-analysis also found no difference between EMDR and control groups in which "EMDR procedures were used except that a single aspect other than eye movements was changed.”[47]

References

  1. 1 2 Shapiro, Francine; Laliotis, Deany (12 October 2010). "EMDR and the adaptive information processing model: Integrative treatment and case conceptualization". Clinical Social Work Journal. 39 (2): 191–200. doi:10.1007/s10615-010-0300-7.
  2. ↑ Schnyder, Ulrich; Cloitre, Marylène (2015-02-14). Evidence Based Treatments for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians. Springer. ISBN 9783319071091. Retrieved 2016-12-07.
  3. ↑ Horton, Hilary (June 2011). "Dealing with self distress". Occupational Health. 63 (6): 20–22.
  4. 1 2 3 Bisson J, Roberts NP, Andrew M, Cooper R, Lewis C (2013). "Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults". Cochrane Database of Systematic Reviews. 12: CD003388. PMID 24338345. doi:10.1002/14651858.CD003388.pub4.
  5. 1 2 Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ (2013). "Meta-analysis of the efficacy of treatments for posttraumatic stress disorder". Journal of Clinical Psychiatry. 74 (6): e541–550. PMID 23842024. doi:10.4088/JCP.12r08225.
  6. ↑ Feske, Ulrike (1998). "Eye movement desensitization and reprocessing treatment for posttraumatic stress disorder". Clinical Psychology: Science and Practice. 5 (2): 171–181. doi:10.1111/j.1468-2850.1998.tb00142.x.
  7. ↑ Greyber, Laura; Catherine Dulmus; Maria Cristalli (17 June 2012). "Eye movement desensitization reprocessing, posttraumatic stress disorder, and trauma: A review of randomized controlled trials with children and adolescents". Child Adolescent Social Work Journal. 29 (5): 409–425. doi:10.1007/s10560-012-0266-0.
  8. ↑ Van Etten M. L.; Taylor, S (1998). "Comparative efficacy of treatments for post-traumatic stress disorder: a meta-analysis". Clinical Psychology & Psychotherapy. 5 (3): 126–144. doi:10.1002/(SICI)1099-0879(199809)5:3<126::AID-CPP153>3.0.CO;2-H.
  9. ↑ Bradley, R.; Greene, J.; Russ, E.; Dutra, L.; Westen, D. (2005). "A multidimensional meta-analysis of psychotherapy for PTSD". The American Journal of Psychiatry. 162 (2): 214–227. PMID 15677582. doi:10.1176/appi.ajp.162.2.214.
  10. ↑ Seidler, GH; Wagner, FE (November 2006). "Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study.". Psychological Medicine. 36 (11): 1515–22. PMID 16740177. doi:10.1017/s0033291706007963.
  11. ↑ Vickerman, K. A.; Margolin, G. (2009). "Rape treatment outcome research: Empirical findings and state of the literature". Clinical Psychology Review. 29 (5): 431–448. PMC 2773678 Freely accessible. PMID 19442425. doi:10.1016/j.cpr.2009.04.004.
  12. ↑ Ehlers, A.; Bisson, J.; Clark, D.; Creamer, M.; Pilling, S.; Richards, D.; Schnurr, P.; Turner, S.; Yule, W. (2010). "Do all psychological treatments really work the same in posttraumatic stress disorder?". Clinical Psychology Review. 30 (2): 269–276. PMC 2852651 Freely accessible. PMID 20051310. doi:10.1016/j.cpr.2009.12.001.
  13. ↑ Cloitre M (January 2009). "Effective psychotherapies for posttraumatic stress disorder: a review and critique". CNS Spectrums. 14 (1 Suppl 1): 32–43. PMID 19169192.
  14. 1 2 McNally, R. (Fall 2013). "The evolving conceptualization and treatment of PTSD: A very brief history". American Psychological Association Newsletter-Trauma Psychology: 7–11. p.9 http://traumapsychnews.com/wp-content/uploads/2016/01/newsletter_2013_fall.pdf
  15. 1 2 Lee CW, Cuijpers P (2013). "A meta-analysis of the contribution of eye movements in processing emotional memories". Journal of Behavior Therapy and Experimental Psychiatry. 44 (2): 231–239. PMID 23266601. doi:10.1016/j.jbtep.2012.11.001.
  16. ↑ Devilly GJ (Fall–Winter 2002). "Eye movement desensitization and reprocessing: a chronology of its development and scientific standing" (PDF). The Scientific Review of Mental Health Practice. 1 (2): 132.
  17. ↑ Lee CW, Cuijpers P (2013). "A meta-analysis of the contribution of eye movements in processing emotional memories". Journal of Behavior Therapy and Experimental Psychiatry. 44 (2): 231–239. PMID 23266601. doi:10.1016/j.jbtep.2012.11.001.
  18. ↑ Seidler GH, Wagner FE (2006). "Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study". Psychological Medicine. 36 (11): 1515–1522. PMID 16740177. doi:10.1017/S0033291706007963.
  19. 1 2 Foa EB; Keane TM; Friedman MJ (2009). "Effective treatments for PTST: Practice guidelines of the International Society for Traumatic Stress Studies". New York: Guilford Press.
  20. ↑ National Institute for Clinical Excellence (2005). "Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care". London: NICE Guidelines.
  21. ↑ Australian Centre for Posttraumatic Mental Health. (2007). Australian guidelines for the treatment of adults with acute stress disorder and post traumatic stress disorder. Melbourne, Victoria: ACPTMH. ISBN 978-0-9752246-6-3.
  22. ↑ Dutch National Steering Committee Guidelines Mental Health and Care (2003). "Guidelines for the diagnosis treatment and management of adult clients with an anxiety disorder". Utrecht, Netherlands: The Dutch Institute for Healthcare Improvement (CBO).
  23. 1 2 World Health Organization (2013). Guidelines for the management of conditions that are specifically related to stress. Geneva, who.int
  24. 1 2 3 Rosen, Gerald M; Mcnally, Richard J; Lilienfeld, Scott O (1999). "Eye Movement Magic: Eye Movement Desensitization and Reprocessing". Skeptic. 7 (4).
  25. 1 2 3 4 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. PMID 11098395. doi:10.1016/s0272-7358(99)00017-3.
  26. ↑ American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines.
  27. ↑ Department of Veterans Affairs & Department of Defense (2010). VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense
  28. ↑ SAMHSA’s National Registry of Evidence-based Programs and Practices (2011)
  29. ↑ Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies New York: Guilford Press.
  30. ↑ National Institute for Health and Care Excellence (2016). Post-traumatic stress disorder overview: Interventions for symptoms present for more than 3 months after a trauma
  31. ↑ Brown S, Shapiro F (October 2006). "EMDR in the treatment of borderline personality disorder". Clinical Case Studies. 5 (5): 403–420. doi:10.1177/1534650104271773.
  32. ↑ De Roos C, Veenstra AC, De Jongh A, den Hollander-Gijsman ME, van der Wee NJ, Zitman FG, van Rood YR (2010). "Treatment of chronic phantom limb pain using a trauma-focused psychological approach". Pain Research & Management. 15 (2): 65–71. PMC 2886995 Freely accessible. PMID 20458374.
  33. ↑ Wilensky M (2006). "Eye movement desensitization and reprocessing (EMDR) as a treatment for phantom limb pain" (PDF). Journal of Brief Therapy. 5 (1): 31–44.
  34. ↑ Foa B; Keane TM; Friedman MJ Cohen JA (eds.) (2009). Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York: Guilford Press. ISBN 978-1-60623-001-5.
  35. ↑ Adler-Tapia R; Settle C (2008). EMDR and The Art of Psychotherapy With Children. New York: Springer Publishing Co. ISBN 978-0-8261-1117-3.
  36. ↑ Scott CV; Briere J (2006). Principles of trauma therapy : a guide to symptoms, evaluation, and treatment. Thousand Oaks, California: Sage Publications. p. 312. ISBN 0-7619-2921-5.
  37. ↑ Lee CW; Cuijpers P (2013). "A meta-analysis of the contribution of eye movements in processing emotional memories". Journal of Behavior Therapy and Experimental Psychiatry. 44 (2): 231–239. PMID 23266601. doi:10.1016/j.jbtep.2012.11.001.
  38. ↑ 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. PMID 11915816. doi:10.1136/ebmh.5.1.13.
  39. ↑ "Guidelines for the management of conditions that are specifically related to stress". Geneva: World Health Organization. 2013. PMID 24049868.
  40. ↑ Glaser, Tom. "How was EMDR Developed?". Retrieved 8 March 2013.
  41. 1 2 Shapiro, F (1989). "Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories". Journal of Traumatic Stress. 2 (2): 199–223. doi:10.1002/jts.2490020207.
  42. ↑ Schnyder, Ulrich; Cloitre, Marylène (2015-02-14). Evidence Based Treatments for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians. Springer. ISBN 9783319071091. Retrieved 2015-04-20.
  43. ↑ McNally, R. J. "The demise of pseudoscience". The Scientific Review of Mental Health Practice. 2 (2): 97–101.
  44. ↑ Perkins, B. R.; Rouanzoin, C. C. (2002). "A critical evaluation of current views regarding eye movement desensitization and reprocessing (EMDR): Clarifying points of confusion". Journal of clinical psychology. 58 (1): 77–97. doi:10.1002/jclp.1130.
  45. ↑ Davidson PR, Parker KC (April 2001). "Eye movement desensitization and reprocessing (EMDR): a meta-analysis". Journal of Consulting and Clinical Psychology. 69 (2): 305–16. PMID 11393607. doi:10.1037/0022-006x.69.2.305.
  46. ↑ McNally, R. J. (1999). "On eye movements and animal magnetism: A reply to Greenwald's defense of EMDR". Journal of Anxiety Disorders. 13 (6): 617–620. doi:10.1016/S0887-6185(99)00020-1.
  47. ↑ Davidson PR, Parker KC (April 2001). "Eye movement desensitization and reprocessing (EMDR): a meta-analysis". Journal of Consulting and Clinical Psychology. 69 (2): 305–16. PMID 11393607. doi:10.1037/0022-006x.69.2.305.
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