Eye movement desensitization and reprocessing

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Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that was developed by Francine Shapiro^[1][2][3][4] to resolve the development of trauma-related disorders caused by exposure to distressing, traumatising, or negative life events, such as rape or military combat. According to Shapiro's theory,^[1][3][4]when a traumatic or distressing experience occurs, it may overwhelm usual cognitive and neurological coping mechanisms. The memory and associated stimuli of the event are inadequately processed, and are dysfunctionally stored in an isolated memory network. The goal of EMDR therapy is to process these distressing memories, reducing their lingering influence and allowing clients to develop more adaptive coping mechanisms.

Although some clinicians may use EMDR for other problems, its research support is primarily for disorders stemming from distressing life experiences,^[5] such as post-traumatic stress disorder (PTSD)^[6][7]. However, although EMDR is considered an efficacious treatment for PTSD,^{[6][8][7][9][10]} EMDR therapy remains somewhat controversial due to questions about its methods and theoretical foundations.^{[11][12][13][14][15]}

Approach

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EMDR integrates elements of effective psychodynamic, imaginal exposure, cognitive therapy, interpersonal, experiential, physiological and somatic therapies.^{[citation needed]} Distinguishing EMDR from other therapies, however, is the unique element of bilateral stimulation (e.g. eye movements, tones, or tapping) during each session.^{[citation needed]}

EMDR uses a structured eight-phase approach to address the past, present, and future aspects of a traumatic or distressing memory that has been dysfunctionally stored. The therapy process and procedures are according to Shapiro (2001)^[1]

Phase I

In the first sessions, the patient's history and an overall treatment plan are discussed. During this process the therapist identifies and clarifies potential targets for EMDR. Target refers to a disturbing issue, event, feeling, or memory for use as an initial focus for EMDR. Maladaptive beliefs are also identified (e.g., "I can't trust people" or "I can't protect myself.")

Phase II

Before beginning EMDR for the first time, it is recommended that the client identify a "safe place" -- an image or memory that elicits comfortable feelings and a positive sense of self. This safe place can be used later to bring closure to an incomplete session or to help a client tolerate a particularly upsetting session.

Phase III

In developing a target for EMDR, prior to beginning the eye movement, a snapshot image is identified that represents the target and the disturbance associated with it. Using that image is a way to help the client focus on the target, a negative cognition (NC) is identified – a negative statement about the self that feels especially true when the client focuses on the target image. A positive cognition (PC) is also identified – a positive self-statement that is preferable to the negative cognition.

Phase IV

The therapist asks the patient to focus simultaneously on the image, the negative cognition, and the disturbing emotion or body sensation. Then the therapist usually asks the client to follow a moving object with his or her eyes; the object moves alternately from side to side so that the client's eyes also move back and forth. After a set of eye movements, the client is asked to report briefly on what has come up; this may be a thought, a feeling, a physical sensation, an image, a memory, or a change in any one of the above. In the initial instructions to the client, the therapist asks him or her to focus on this thought, and begins a new set of eye movements. Under certain conditions, however, the therapist directs the client to focus on the original target memory or on some other image, thought, feeling, fantasy, physical sensation, or memory. From time to time the therapist may query the client about his or her current level of distress. The desensitization phase ends when the SUDS (Subjective Units of Disturbance Scale) has reached 0 or 1.

Phase V

The "Installation Phase": the therapist asks the client about the positive cognition, if it's still valid. After Phase IV, the view of the client on the event/ the initial snapshot image may have changed dramatically. Another PC may be needed. Then the client is asked to "hold together" the snapshot and the (new) PC. Also the therapist asks, "How valid does the PC feel, on a scale from 1 to 7?" New sets of eye movement are issued.

Phase VI

The body scan: the therapist asks if anywhere in the client's body any pain, stress or discomfort is felt. If so, the client is asked to concentrate on the sore knee or whatever may arise and new sets are issued.

Phase VII

Debriefing: the therapist gives appropriate info and support.

Phase VIII

Re-evaluation: At the beginning of the next session, the client reviews the week, discussing any new sensations or experiences. The level of disturbance arising from the experiences targeted in the previous session is assessed. An objective of this phase is to ensure the processing of all relevant historical events.

During the processing phases of EMDR, the client focuses on disturbing memory in multiple brief sets of about 15–30 seconds. Simultaneously, the client focuses on the dual attention stimulus (e.g., therapist-directed lateral eye movement, alternate hand-tapping, or bilateral auditory tones).^{[clarification needed]} Following each set of such dual attention, the client is asked what associative information was elicited during the procedure. This new material usually becomes the focus of the next set. This process of alternating dual attention and personal association is repeated many times during the session.^{[citation needed]}

When traumatic memory networks are activated, the client may re-experience aspects of the original event, often resulting in inappropriate overreactions.^{[citation needed]} This explains why people who have experienced or witnessed a traumatic incident may have recurring sensory flashbacks, thoughts, beliefs, or dreams.^{[citation needed]} An unprocessed memory of a traumatic event can retain high levels of sensory and emotional intensity, even though many years may have passed. The theory is that EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other semantic memory networks.^{[citation needed]} It is thought that the distressing memory is transformed^{[clarification needed]} when new connections are forged with more positive and realistic information.^{[citation needed]} This results in a transformation of the emotional, sensory, and cognitive components of the memory; when the memory is accessed, the individual is no longer distressed. Instead he/she recalls the incident with a new perspective, new insight, resolution of the cognitive distortions, elimination of emotional distress, and relief of related physiological arousal.^{[citation needed]}

When the distressing or traumatic event is an isolated, single incident (e.g., a traffic accident), approximately three sessions are necessary for comprehensive treatment.^{[citation needed]} When multiple traumatic events contribute to a health problem—such as physical, sexual, or emotional abuse, parental neglect, severe illness, accident, injury, or health-related trauma that result in chronic impairment to health and well-being, or combat trauma, the time to heal may be longer,^{[16][unreliable medical source?]} and complex, multiple trauma may require many more sessions for the treatment to be complete and robust.^{[citation needed]}

Although EMDR is established as an evidence-based treatment for PTSD^{[6][8][7][9][10]} there are two main perspectives on EMDR therapy. First, Shapiro^[1] proposed that although a number of different processes underlie EMDR, the eye movements add to the therapy's effectiveness by evoking neurological and physiological changes that may aid in the processing of the trauma memories being treated. The other perspective is that the eye movements are an unnecessary epiphenomenon, and that EMDR is simply a form of desensitization.^[11]

EMDR also uses a three-pronged approach, to address past, present and future aspects of the targeted memory.^{[citation needed]}

Empirical evidence and comparison

In a 2007 review of 33 randomised controlled trials of various psychological treatments for PTSD, EMDR was rated as an effective method, not significantly different in effect from Trauma-Focused CBT (Cognitive Behavioral Therapy) or SM (Stress Management) treatments.^[17] EMDR did significantly better than other therapies, according to patient self-reports.^[17] The International Society of Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults.^[10] A number of international guidelines include EMDR as a recommended treatment for trauma.^{[8][7][9][10]}

Research on the application of EMDR therapy continues, and several meta-analyses have been performed to further evaluate its efficacy in the treatment of PTSD. In one meta-analysis of PTSD, EMDR was reported to be as effective as exposure therapy and SSRIs.^[18] Two separate meta-analyses suggested that traditional exposure therapy and EMDR have equivalent effects both immediately after treatment and at follow-up.^[19][20] A 2007 meta-analysis of 38 randomized controlled trials for PTSD treatment suggested that the first-line psychological treatment for PTSD should be Trauma-Focused CBT (Cognitive Behavioral Therapy) or EMDR.^[21] A review of rape treatment outcomes concluded that EMDR had some efficacy.^[22] Another 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".^[23] A comparative review concluded EMDR to be of similar efficacy to other exposure therapies and more effective than SSRIs, problem-centred therapy, or treatment as usual.^[24]

Other applications

Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR’s efficacy with other anxiety disorders as well as numerous reports of diverse clinical applications.

Depression

EMDR can work on a multitude of problems that are less complex than PTSD.^{[citation needed]} One of these is uncomplicated depression. The EMDR Casebook by Philip Manfield documents case studies in which EMDR was used. In the case about uncomplicated depression, Manfield was able to help his client, George, resolve several childhood issues that have plagued his adult life. Moreover, EMDR can work for postpartum depression.^{[citation needed]} By having the client target a distinctive memory and work through it with a series of eye movements, the client is then able to achieve a positive cognition.^{[25][unreliable medical source?]}

In children

EMDR has been used effectivley in the treatment of children who have experienced trauma and complex trauma^{[26][27][4][28][29]} .

EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder,^{[30] [3][4]} emotional dysregulation, and in the treatment of children exposed to chronic early maltreatment that is related to attachment disorder^[31].

Controversy over mechanisms and effectiveness

The working mechanisms that underlie the effectiveness of EMDR, and whether the eye movement component in EMDR contributes to its clinical effectiveness are still points of uncertainty and contentious debate.^[13][14][15]

EMDR has generated a great deal of controversy since its inception in 1989. Critics of EMDR argue that the eye movements do not play a central role, that the mechanisms of eye movements are speculative, and that the theory leading to the practice is not falsifiable and therefore not amenable to scientific inquiry.^[12]

Although one meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy,^[32] several other researchers using meta-analysis have found EMDR to be at least equivalent in effect size to specific exposure therapies.^{[18][19][20][21]}

Exposure

Despite the treatment procedures being quite different between EMDR and traditional exposure therapy, some authors^[8][33] continue to argue that the main effective component in EMDR is exposure.

The exposure that occurs in EMDR should, according to the assumptions of emotional processing theory,^[34] sensitise rather than desensitise and decrease the fear and distress associated with traumatic memories. However, EMDR is effective, therefore processes other than imaginal exposure must play a role in the effectiveness of EMDR in the treatment of PTSD.^{[original research?]}

Eye movements

An early critical review and meta-analysis that looked at the contribution of eye movement to treatment effectiveness in EMDR concluded that eye movement is not necessary to the treatment effect.^[11][35] Salkovskis (2002) reported that the eye movement is irrelevant and that the effectiveness of the procedure is solely due to its having properties similar to cognitive behavioral therapies, such as desensitization and exposure.^[36]

Effect of eye movement on memory, cognitive processes, and physiology

Although a wide range of researchers^[who?] have proposed various models and theories^{[clarification needed]} to explain the effect of eye movement, and the possible role that eye movement may play in the process of EMDR, to date, no single model or theory exists that can explain all of the above mentioned findings. Further research is therefore required in this area.

See also

• Neuroplasticity

References

External links

• EMDR Institute