Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy developed by Francine Shapiro in the 1990s in which the person being treated is asked to recall distressing images; the therapist then directs the client in one type of bilateral sensory input, such as side-to-side eye movements or hand tapping. It is included in several evidence-based guidelines for the treatment of post-traumatic stress disorder (PTSD).

It has been controversial; critics have argued that the eye movements in EMDR do not add to its effectiveness and lack a falsifiable theory. While multiple meta-analyses have found it to be just as effective as trauma focused cognitive behavioral therapy for the treatment of PTSD, these findings are tentative given the low numbers in the studies, high risk rates of researcher bias and high dropout rates.

The person being treated is asked to recall distressing images while generating one of several types of bilateral sensory input, such as side-to-side eye movements or hand tapping. 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.”

A 1998 meta-analysis found that EMDR was as effective as exposure therapy and SSRIs.

A 2002 meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy.

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.

Two meta-analyses in 2006 found EMDR to be at least equivalent in effect size to specific exposure therapies.

A 2009 review of rape treatment outcomes concluded that EMDR had some efficacy. 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”.

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”.

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. 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.

Another 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. 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.”

The 2009 International Society for Traumatic Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults. Other guidelines recommending EMDR therapy – as well as CBT and exposure therapy – for treating trauma have included NICE starting in 2005, Australian Centre for Posttraumatic Mental Health in 2007, the Dutch National Steering Committee Guidelines Mental Health and Care in 2003, the American Psychiatric Association in 2004, the Departments of Veterans Affairs and Defense in 2010, SAMHSA in 2011, the International Society for Traumatic Stress Studies in 2009, and the World Health Organization in 2013.

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

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.

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.

There have been a number of proposed mechanisms including the Adaptive Information Processing (AIP) model.[unreliable medical source] In addition, 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.[unreliable medical source] A slowing of brain waves during the bilateral stimulation (eye movement) is somewhat similar to what occurs during sleep.[unreliable medical source]

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.”

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.

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. 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.

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. Shapiro developed EMDR therapy for post-traumatic stress disorder. She speculated that traumatic events “upset the excitatory/inhibitory balance in the brain, causing a pathological change in the neural elements”.

As early as 1999, EMDR was controversial within the psychological community, and 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. 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. Such changes in definition and training for EMDR have been described as “ad hoc moves [made] when confronted by embarrassing data”.

A 2000 review 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. 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), implying that “what is effective in EMDR is not new, and what is new is not effective” (McNally, 1999, p. 619).

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, and somatic disorders such as phantom limb pain.

What Can Go Wrong With Self-EMDR?

What Can Go Wrong?

    Although the most important consideration with Self-EMDR is safety, safety, safety – several reports have come in about problems.  Every one has been evaluated and removed.

Mary was a teenage mother, estranged from her family and living in a flat with her baby.  The child’s father did not like babies (“Dirty things”) and so departed with another lady.  Bravely, Mary battled on until, unexpectedly, the baby died of SIDS (Sudden Infant Death Syndrome).

Mary procured a copy of my book but reportedly was “unable to eliminate or substantially reduce the guilt and depression” within the suggested three or four one-hourly sessions.  She had allowed the grief process to run its course for two months, after moving back with her parents, before attempting self-EMDR.  Why the delay?  I recommend this because grief is part of a natural and necessary healing process.  To grieve is to heal, but unusually protracted grieving is unnecessary and undesirable.

Self-EMDR-sad_woman A brief E-mail conversation with the youngster and her mother was sufficient to establish the cause of Mary’s failure.  Once entranced and reliving the shock and desperate pain she had experienced when finding the baby’s body, Mary “bailed out”.  “I don’t like pain,” she said. “I’ve already had my share.”  I explained that, “If you are able to tolerate as little as 40 minutes of severe discomfort, once or even twice, you will be free of the tragedy for the rest of your life.  I promise.”  And so it was!  Mary rode the trauma down (from 10 out of 10 in terms of its intensity, to 9, to 9, to 9, to 6, to 5, to 3) over a period of 60 minutes.  At that point she was aware of a huge relief, but was feeling tired and called it off until the following day.

Accompanied by her fascinated – and hugely grateful – mother, the youngster did two more five-minute sets and called a halt when she could discern no further discomfort.  She could remember Baby’s death, and funeral, and the black hole she had carried in her heart for weeks afterwards, but the memory itself carried no pain. Self-EMDR-hope-despair

But, but… what if the trauma went down to only five out of 10 in intensity, and stayed there?  No problem.  Mary would simply do more five-minute sets during the next few  days until the discomfort did disappear.  Failure is not possible. 

    What other problems can we encounter?  I have had several complaints that were traced to people failing to focus, while in trance, on a single trauma.  Perhaps John is over-tired when starting his Self-EMDR.  His entranced mind drifts from the fact a junior member of the company has been promoted over his head (the principal trauma);  to the fact he feels jealous because his wife would rather spend time with the baby than with him;  to that awful noise in the car’s engine.  John is supposed to hold his focus on a single trauma or area of discomfort, and keep it there, set after set, as  the level of conflict falls away.  If he allows his attention to drift, it simply won’t happen.

In the rare event a Self-EMDR session is completely halted, possibly because… the smoke alarm starts screaming, or the power supply fails, a potentially unfortunate situation can unfold. Hours later, or on the following day, the painful emotions that were in the process of being drained, abruptly come bursting to the surface.  Although they, in turn, will recede without additional sets it can be a startling phenomenon. The obvious solution, of course, is to have another Self-EMDR session and finish draining the emotions once and for all.

Unfortunately the one problem area which is likely to capture every counselling and therapeutic modality in the world, also affects EMDR and Self-EMDR.

Because of their primal role, males tend to become aggressive when challenged (admittedly with plenty of exceptions).  As a result there is an inclination for John JoSelf-EMDR-sad_boynes to blame somebody else no matter what goes wrong;  even when he is obviously at  fault.  If he climbs out of bed on the wrong side, and you get in his face, he won’t even listen to your considered argument.  He’ll be too busy searching his mind for the last word, the coup de grace. 

But the woman is different, because the human coin has two sides.  She may lose an argument, because her emotions tell her that is better than damaging a relationship.  He is the warrior.  She is the nurturer.  The Israeli Defence Force tells us their female soldiers must not be exposed to certain pivotal combat situations.  She will seldom throw away her life because if she does her baby dies (again in primal terms) and there is no mother to look after the children.  On the other hand, John Jones can give himself the luxury of taking a bullet and simply rolling over and dying.  He has proved himself.  Nothing is more important.

Now for the focus:  The archetypal female will blame herself, because her role with the children demands nothing less.  A male will blame the child for keeping him awake night after night.  Eventually the youngster will occupy an unsafe environment.  In the same situation the mother will blame herself, and frequently walk away.  The child will always be in safe hands.

In the case of a severe conflict the male will defend himself by attacking.  The female (especially an adolescent girl) will attack herself, sometimes by cutting.  She blames herself.

It follows that a distraught women receiving EMDR or Self-EMDR is capable of holding so much self-loathing that she will (subconsciously/unconsciously/emotionally) inhibit the therapy from working without being aware of it;  irrespective of the modality or technique involved.

Heads up!

(1)  The above remarks are by definition a generalization, but I am convinced they are a robust generalization;

(2)  EMDR and Self-EMDR enable the woman’s self-loathing to be eliminated with a small handful of sessions, in a manner that is quite impossible with any other approach.

Self-EMDR-possible-impossible

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