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 patient in one type of bilateral sensory input, such as side-to-side eye movements or hand tapping.[1] It is included in several evidence-based guidelines for the treatment of post-traumatic stress disorder (PTSD).[2][3][4]

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

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."[3]

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 variety of exposure therapy.[6] A 2003 analysis in the professional journal Traumatology reports that EMDR has been controversial.[7] Several studies have found that the eye movements employed in EMDR do not add to its effectiveness.[8] Additionally, commentators have attacked EMDR as pseudoscience, claiming that it is not falsifiable.[9][10] While multiple meta-analyses have found EMDR to be 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.[11][12]

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.[13] 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.[14]

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.[15] 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".[15]

Delivery

EMDR is typically undertaken in a series of sessions with a trained therapist.[16] However self-administration also occurs.[17]

Medical uses

Trauma and PTSD

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.[1][2] 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."[3]

Evidence

A 1998 meta-analysis found that EMDR was as effective as exposure therapy and SSRIs.[18]

A 2002 meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy.[9]

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.[19][20]

Two meta-analyses in 2006 found EMDR to be at least equivalent in effect size to specific exposure therapies.[21][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.[12][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.[12]

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.[27][11] 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."[11]

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).[3] 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

EMDR has been found to have use for OCD, for psychosis when co-morbid with trauma,[42] for suicide ideation,[43] and for low self-esteem.[44] A small study found EMDR was effective with GAD.[45] A number of studies have investigated EMDR therapy’s efficacy with other disorders, such as borderline personality disorder,[46] and somatic disorders such as phantom limb pain.[47][48] A 2013 literature review covered research up to that time.[49]

Mechanism

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

There have been a number of proposed mechanisms.

  • The Adaptive Information Processing (AIP) model,[50] posits that trauma causes a disruption of normal adaptive information processing, which results in unprocessed information being dysfunctionally held in memory networks.[51] 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."[3] The hypothesis is that doing EMDR allows the client to access and reprocess negative memories (leading to decreased psychological arousal associated with the memory).[52]
  • Others posit that the bilateral stimulation causes a degradation of working memory. Horizontal eye movements have been shown to tend to tax working memory.[53] In support of the working memory account, analogue studies have found that other taxing tasks during recall also reduce vividness and/or emotionality of negative memories.[54] 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]
  • Others 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.[55] 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.[56]
  • Other possible mechanisms are that EMDR facilitates a form of mindfulness, or a form of mastery over the trauma.[42]

A 2013 meta-analysis focused on the two mechanisms that have received the most attention and research support: (1) taxing working memory and (2) orienting response/REM sleep.[57]

It may be that several mechanisms are at work in EMDR.[42]

Questions about eye movement

A 2000 review argued that the eye movements did not play a central role, and that the mechanisms of eye movements were speculative.[58] 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][59][60] 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.[61]

However 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.[62][42]

Controversy

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.[63][58] 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.[63] Such changes in definition and training for EMDR have been described as "ad hoc moves [made] when confronted by embarrassing data".[64]

A 2000 review argued 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.[58] 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.

References
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