Eye movement desensitization and reprocessing


Eye movement desensitization and reprocessing 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. According to the 2013 World Health Organization practice guideline: "This therapy 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 spontaneous associations of traumatic images, thoughts, emotions and bodily sensations and bilateral stimulation that is most commonly in the form of repeated eye movements."
EMDR is included in several evidence-based guidelines for the treatment of post-traumatic stress disorder. As of 2020, the American Psychological Association lists EMDR as an evidence-based treatment for PTSD 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.

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. 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 further noted that her anxiety was reduced when she brought her eye movements under voluntary control while thinking a traumatic thought. 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".

Delivery

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

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. The 2013 World Health Organization practice guideline says that "Like cognitive behavioral therapy 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 detailed descriptions of the event, direct challenging of beliefs, extended exposure, or homework."

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.
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. The American Psychological Association "conditionally recommends" EMDR for the treatment of PTSD.

Children

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, and superior to waitlist or placebo.

Other conditions

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

Depression

Studies have indicated EMDR effectiveness in depression. 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."

Anxiety related disorders

Small studies have found EMDR to be effective with GAD, OCD, other anxiety disorders, and distress due to body image issues.

Other conditions

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

Reviews

A 2013 overall literature review covered research up to that time. 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."

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.
A 2013 meta-analysis focused on two mechanisms: taxing working memory and orienting response/REM sleep.
It may be that several mechanisms are at work in EMDR.

Questions about bilateral stimulation (eye movement)

A small 1996 study found that the eye movements employed in EMDR did not add to its effectiveness. A 2000 review argued that the eye movements did not play a central role, and that the mechanisms of eye movements were speculative. A 2001 meta-analysis suggested that EMDR with the eye movements was no more efficacious than EMDR without the 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. 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. 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.
Bilateral stimulation has been found to have effects on memory, mental health and emotions, and on the level of connectedness and the symmetry of activation of the brain hemispheres.

Criticisms

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

Effectiveness and theoretical basis

Concerns have included effectiveness and the importance of the eye movement component of EMDR.

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. According to Yale neurologist Steven Novella:

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. 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" 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 when confronted by embarrassing data".