Eye movement desensitization and reprocessing

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 movements 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" redirects here. For the materials characterisation technique, see Electrically detected magnetic resonance.

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 upon noticing that certain eye movements reduced the intensity of a 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.[7] 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.[8]

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.[9] 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".[9]

Delivery

Shapiro over time developed an eight-stage process for EMDR, with various additions being made to the core EMDR practice itself.[10] EMDR is typically undertaken in a series of sessions with a trained therapist.[11] The number of sessions can vary depending on the progress made. A typical EMDR therapy session lasts from 60-90 minutes.[12] However self-administration also occurs.[13][14][15]

Medical uses

Trauma and PTSD

The person being treated is asked to recall distressing images while generating one of several types of bilateral stimulation|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 1998 meta-analysis found that EMDR was as effective as exposure therapy and SSRIs.[19]
  • A 2002 meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy.[20]
  • 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.[21][22]
  • Two meta-analyses in 2006 found EMDR to be at least equivalent in effect size to specific exposure therapies.[16][22]
  • A 2009 review of rape treatment outcomes concluded that EMDR had some efficacy.[23] 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".[24]
  • 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".[25]
  • 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][26] 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 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.[27][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 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:

Despite these limitations, the results of this meta-analysis aid us in concluding that EMDR may be effective in the treatment of PTSD in the short term and possibly have comparable effects as other treatments. However, the quality of studies is too low to draw definite conclusions. Further, it is evident that the long-term effects of EMDR are unclear and that there is certainly not enough evidence to advise its use in patients with mental health problems other than PTSD.[18]

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.[28] Other guidelines recommending EMDR therapy – as well as CBT and exposure therapy – for treating trauma have included NICE starting in 2005,[29][4][30] Australian Centre for Posttraumatic Mental Health in 2007,[31] the Dutch National Steering Committee Guidelines Mental Health and Care in 2003,[32] the American Psychiatric Association in 2004,[33] the Departments of Veterans Affairs and Defense in 2010,[34] SAMHSA in 2011,[35] the International Society for Traumatic Stress Studies in 2009,[36] 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.[37]

Children

EMDR is included in a 2009 practice guideline for helping children who have experienced trauma.[38] EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.[39][40]

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.[41]

Other conditions

Several small studies have indicated EMDR efficacy for other mental health conditions,[42] but more research is needed.[18]

Depression

Studies have indicated EMDR effectiveness in depression.[43][44] 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."[45]

Small studies have found EMDR to be effective with GAD,[46] OCD,[42] other anxiety disorders,[47] and distress due to body image issues.[48]

Other conditions

EMDR may have application for psychosis when co-morbid with trauma,[42] Other studies have investigated EMDR therapy’s efficacy with borderline personality disorder,[49] and somatic disorders such as phantom limb pain.[50][51] EMDR has also been found to improve stress management symptoms.[52] EMDR has been found to reduce suicide ideation,[53] and help low self-esteem.[54] Other studies focus on effectiveness in substance craving[55] and pain management.[56] EMDR may help people with autism who suffer from exposure to distressing events.[57]

Reviews

A 2013 overall literature review covered research up to that time.[58] 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]

Mechanism

Possible mechanisms

The proposed mechanisms that underlie eye movements in EMDR therapy are still under investigation and there is as yet no definitive finding.

  • Many proposals 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.[59] 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] Proposed mechanisms posit that EMDR can assist to successfully alleviate clinical complaints by processing the components of the contributing distressing memories.[60] Doing EMDR allows the client to access and reprocess negative memories (leading to decreased psychological arousal associated with the memory).[61] This is sometimes known as the Adaptive Information Processing (AIP) model.[62][63] The mechanism by which EMDR achieves this effect is unknown.
    • One proposal is that EDMR achieves this effect through impacting working memory.[64] The proposal is that the degradation in working memory causes a distancing effect, enabling the client to 'stand back' from the trauma. This enables the client to re-evaluate the trauma and their understanding of it, because they can re-experience it whilst not feeling overwhelmed by it.[42] This effect may be achieved by bilateral stimulation. 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.[65]
    • Bilateral stimulation (BLS) may have other effects (see below).
    • Another proposal is that EMDR enables ‘dual attention’ (recalling the trauma whilst keeping ‘one foot in the present’ assisted by BLS), allowing the brain to access the dysfunctionally stored experience and stimulate the innate processing system, allowing it to transform the information to an adaptive resolution.[42]
    • Other commentators compare EMDR to the effects of sleep, and posit that traumatic experiences are processed during sleep. A slowing of brain waves has been seen during bilateral stimulation (eye movement), somewhat similar to what occurs during sleep.[66] A possibly related finding is that brain waves during EMDR treatment shows changes in brain activity, specifically the limbic system showed its highest level of activity prior to commencing EMDR treatment.[67]
    • An earlier suggestion was that horizontal eye movement triggers an evolutionary 'orienting approach' in the brain, used in scanning the environment for threats and opportunities.[68]
  • Another approach is that trauma can be overcome or mastered, and that EMDR facilitates a form of mindfulness or other form of mastery over the trauma.[42]

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.[42]

Questions about eye movement and bilateral stimulation

Bilateral stimulation is a generalization of the left and right repetitive eye movement technique first used by Shapiro. These 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.[69] 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. A small 1996 study found that the eye movements employed in EMDR did not add to its effectiveness.[70] A 2000 review found that the eye movements did not play a central role, and that the mechanisms of eye movements were speculative.[71] A 2001 meta-analysis suggested that EMDR with the eye movements was no more efficacious than EMDR without the eye movements (Davidson & Parker, 2001).[27][72][73] 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.[74] However 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.[68] 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][42] As of 2020, the most recent and robust experiments call into question the consistency and generalizability of the technique.[75]

Criticisms

As early as 1999, EMDR was controversial within the psychological community,[76] and it has continued to be so.[77]

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,

Yet not a shred of good evidence exists that EMDR is superior to exposure-based treatments that behavior and cognitive-behavior therapists have been administering routinely for decades. Paraphrasing British writer and critic Samuel Johnson, Harvard University psychologist Richard McNally nicely summed up the case for EMDR: “What is effective in EMDR is not new, and what is new is not effective.”[78]

Pseudoscience

Skeptics of the therapy argue 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.[71][20] According to Yale neurologist Steven Novella:

[T]he false specificity of these treatments is a massive clinical distraction. Time and effort are wasted clinically in studying, perfecting, and using these methods, rather than focusing on the components of the interaction that actually work.[79]

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.[80][71] 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.[80] Such changes in definition and training for EMDR have been described as "ad hoc moves [made] when confronted by embarrassing data".[81]

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