Eye Movement Desensitization and Reprocessing (EMDR) Therapy

Eye movement desensitization and reprocessing (EMDR) therapy is a treatment tool that combines cognitive-behavioral therapeutic techniques (imaginal exposure and rehearsed alternative interpretations of imagined traumatic events) with the utilization of some form of bilateral stimulation, such as back-and-forth eye movements or rhythmic tones and taps.^1,2 EMDR therapy was first introduced in 1989 by the psychologist Francine Shapiro, when it was part of a randomized controlled trial evaluating the effects of the procedure in treating trauma victims.¹

EMDR is guided by the model of Adaptive Information Processing, which considers symptoms of PTSD and certain other mental health issues to arise from disturbing experiences that continue to exert a negative impact because the distressing memory has not been adequately processed.³ EMDR focuses on these memories with the intention of altering the way in which they are stored in the brain, with the hope of better managing the distress that they would otherwise elicit. Dr. Shapiro’s clinical observations suggest that by having people focus on traumatic memories while undergoing bilateral stimulation, the vividness and maladaptive emotional impact of the memory may be reduced.³

The EMDR Treatment Process

EMDR is conducted as one-on-one therapy and typically is administered once or twice per week for a total of 6-12 sessions.³  Though there may be variations in the treatment process utilized by individual therapists, the standard EMDR protocol is structured around eight phases:^1,4

1. Patient history: In this initial phase of treatment, the therapist must assess and gather information from the patient/client in order to better understand the client and the issues that brought the client to therapy. This information-gathering process will continue all the way through the treatment, but it is the focus of the first sessions (typically the first two appointments). Therapists aim to get a complete history of the individual and to identify targets or specific areas of the person’s experience that will need to be formally addressed in the treatment (e.g., past stressful events, things that currently provoke or trigger anxiety in the person, and any roadblocks to meeting future needs, etc.). A pertinent medical history, including any current physical issues, will also be taken at this stage.
2. Preparation: In the second phase, the therapist begins by explaining the goals of the treatment and allows the client to practice the involved techniques (i.e., eye movements or other bilateral stimulation techniques like tapping or auditory tones). The therapist also instructs the client in ways to manage affective changes or other negative symptoms to arise during the treatment exercises and, in doing so, providing them with a sense of personal control.
3. Assessment or evaluation of the primary aspects of the memory: The therapist and client work together to identify the target memory(s) that the treatment will focus on as well as the thoughts, emotions, and physical sensations associated with these targets. Negative cognitions associated with the specific targets are identified, as well as suitable positive cognition(s) to replace these.
4. Desensitization: In this phase, the client begins incorporating the techniques of eye movements or other bilateral stimulation techniques learned in the prep stage as they recollect stressful memories, anxiety-provoking events, etc. The client will be asked to report on whatever new insights, emotions, physical sensations, or other thoughts emerge in association with these memories. These may then be considered during additional bilateral stimulation exercises. The process may continue as the distress of the original memory subsides.
5. Installation: This step concentrates on calling to mind the previously-identified positive cognition (from phase 3) to be newly-associated with the original experience. Additional bilateral accompanies a cognitive restructuring as positive cognitions become associated with past memories that had previously been stressful, anxiety-provoking, etc.
6. Body scan: After addressing all the targets and using the EMDR method, the therapist and client evaluate the results of the therapy. Any lingering negative or unpleasant sensations—such as stress, anxiety, tension—that remain associated with the original experience are identified, and the client and therapist return to step 4 and re-complete the process until it disappears. Any positive sensations may conversely be reinforced using brief periods of bilateral stimulation.
7. Closure or debriefing: The therapist and client reassess the client’s progress to make sure the client is satisfied with the outcome of the treatment and all goals have been met. If the target memory was not fully processed during one session, techniques will be prescribed (e.g., guided imagery or self-control techniques) to stabilize the client and ensure safety until additional sessions may take place
8. Re-assessment: Treatment effects and maintenance of therapeutic outcomes are evaluated. If any areas need further intervention, the therapist and client go back to the appropriate stage and go through the process again. At the point that the client is satisfied with their progress in treatment, additional sessions may not be needed.

EMDR Controversy—The Eye Movement Debate

Though its proponents in the larger psychotherapeutic community will argue that it is an empirically backed treatment method, and perhaps more efficient than many other standard PTSD treatments, the approach has not been universally embraced.⁵ Several issues have been raised about EMDR and its unique implementation of bilateral stimulation.

The issue that is perhaps most often considered to be a “red flag” by many professional psychologists is that the eye movement component of EMDR is not necessary.

It is debated whether the eye movement component of the technique offers any incremental clinical utility to other already empirically validated techniques from the cognitive and behavioral schools of psychotherapy. In other words, though EMDR may be successfully used to manage PTSD and other conditions, it may not be any more effective than exposure therapy and other cognitive focused therapeutic interventions. The American Society of Addiction Medicine points to several studies that indicate that, despite more than a decade of research, evidence has not emerged to support the saccadic eye movement feature being relevant to EMDR treatment outcomes.² As mentioned, some of the therapists who practice EMDR do not even use the eye movement component but instead use other types of bilateral stimulation techniques, such as finger taps and sounds.

Much of the research suggests that EMDR is certainly no worse than already established treatments, but it might not add much that is unique to techniques that have been used and developed by other paradigms. This being said, it’s possible that some individuals may become more involved in therapies that use different or unique approaches, and may experience more satisfaction as a result of the overall approach used by EMDR therapists and its concentration on the relationship between the client and therapist.

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References

1. Shapiro, F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. The Permanente journal, 18(1), 71–77.
2. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
3. American Psychological Association. (2017). Clinical Practice Guideline for the Treatment of PTSD—Eye Movement Desensitization and Reprocessing Therapy.
4. Navarro PN, Lindin-Romero R, Guardioloa-Wanden-Berghe R, Moreno-Alcazar A, Valiente-Gomez A, Lupo W, Garcia F, Fernandez I, Perez V, Amann BL. (2015). 25 years of EMDR: The EMDR therapy protocol, hypotheses of its mechanism of action and a systematic review of its efficacy in the treatment of post-traumatic stress disorder. Rev Psiquiatr Salud Ment (Barc.). 2018; 11(2):101-114.
5. Society of Clinical Psychology—Division 12, American Psychological Association. (n.d). Eye Movement Desensitization and Reprocessing for Post-Traumatic Stress Disorder.