EMDR stands for Eye Movement Desensitization and Reprocessing therapy. EMDR is a specific type of psychotherapeutic intervention that utilizes lateral eye movements as a major component of its technique. Lateral eye movements consist of horizontal movements of the eyes within the visual plane (left to right or right to left). The technique was developed by psychotherapist Dr. Francine Shapiro.
In the 1980s, Dr. Shapiro had observed that patients, who were mostly being treated for issues associated with traumatic and stressful events, appeared to experience relief from their stress when they discussed their memories of the events while performing lateral eye movements. Dr. Shapiro refined the technique by adding various components of Cognitive Behavioral Therapy along with the eye movement technique. This resulted in a therapeutic intervention that Dr. Shapiro believed was superior to other interventions for the treatment of individuals with past history of exposure to traumatic stress. Eventually, the gain popularity, and numerous other therapists were trained by Shapiro and her associates.
Today, the technique enjoys moderate popularity as a potential treatment intervention that can be useful over numerous contexts. There is an EMDR International Association for EMDR professionals and researchers.
Basic Principles of EMDR and Its Uses
As mentioned above, EMDR was originally used in the treatment of individuals who had suffered some type of traumatic or stressful experience that resulted in issues with emotional adjustment. EMDR was initially used for the treatment of post-traumatic stress disorder (PTSD), adjustment disorders, and acute stress disorder. As the technique gained popularity, its supporters have made claims that it can also be used in the treatment of other issues, such as depression, anxiety disorders, and even substance use disorders.
An interesting facet of EMDR is that even though the technique is supposed to incorporate eye movements (EM), some therapists do not use this component. Eye movements typically involve the client following the therapist’s fingers as the therapist moves them back and forth across the visual field. However, the literature on EMDR clearly indicates that other techniques in place of the eye movement component result in the treatment being equally effective; other techniques may include the use of sounds, finger taps, or other types of attention-focusing techniques.
EMDR therapists also incorporate:
- The development of a solid therapeutic alliance or therapeutic relationship: The therapeutic alliance refers to the working bond between the therapist and the client. This alliance includes aspects of mutual respect, trust, and understanding. Research has indicated that the therapeutic alliance is an important factor in positive outcomes in any form of psychotherapy, and when the therapeutic alliance is weak, treatment outcomes are generally poorer.
- In-session activities and assigned homework: EMDR follows the lead of many other forms of psychotherapy, particularly Cognitive Behavioral Therapy, where the client and therapist work together to develop skills in therapy sessions and then the therapist assigns “homework ” for the client to complete. The homework typically involves using the skills practiced in the therapy sessions in real-world situations.
- Techniques from the behavioral paradigm of psychology: EMDR relies heavily on the use of techniques from the behavioral paradigm of psychology (often referred to as behaviorism). These techniques are not unique to EMDR, but used in numerous other types of therapy. Dr. Shapiro and her associates have simply applied them to EMDR.
- Techniques from the cognitive paradigm of psychology: The cognitive paradigm of psychology focuses on issues concerning cognition or thinking. The cognitive paradigm is interested in how attitudes and behaviors are connected, how beliefs are formed, how belief systems operate and affect behavior, and how changing belief systems results in behavioral change.
According to Dr. Shapiro, the eye movement component of EMDR is based on the notion that using saccadic eye movements, which are fast and jerky movements of the eyes that occur naturally when individuals focus on objects, results in the incorporation of an individual’s ability to reprocess their experiences and reduce their emotional stress. Dr. Shapiro and associates have developed several explanations for how this process works, based on neuroanatomy, although the explanations are often questionable.
The eye movement aspect of the technique is only one component of the full treatment. The full treatment borrows from other aspects of previously established psychotherapy procedures (e.g., Cognitive Behavioral Therapy) that have sufficient empirical evidence to support their use without the use of the eye movement reprocessing technique developed by Shapiro. The specific techniques that are part of the EMDR protocol that were in effect long before the development of EMDR include:
- Exposure therapy: Exposure therapy is a technique derived from behavioral psychology. Exposure techniques are simple in their application. They were originally designed to address issues with anxiety and can also be used to address issues associated with the experience of stressful or traumatic events. The technique at its most basic level is to simply “expose” someone to an anxiety-provoking situation or stimulus or to have them re-experience the traumatic event. This produces extreme discomfort at first, but this discomfort will peak and then subside. Over repeated exposures, the individual develops a sort of “inoculation” to the anxiety-provoking or stressful event or stimulus.
Exposure techniques often have individuals imagine the situation or object that results in their distress as opposed to actually confronting them with the actual object or situation. This use of imagery is also borrowed from other therapeutic paradigms.
- Systematic desensitization and relaxation: Systematic desensitization develops a hierarchy of situations that produce anxiety or stress. Via exposure therapy, the client is then exposed to situations that produce the least amount of stress and then gradually to situations up the hierarchical list that produce more anxiety. Systematic desensitization and other exposure techniques are also used in conjunction with stress management training techniques, such as progressive muscle relaxation and diaphragmatic breathing.
By inducing a state of relaxation in an individual and then applying the systematic desensitization or exposure technique, the individual experiences decreased stress and learns to control their anxiety or emotional discomfort. These techniques were in effect long before the development of EMDR and come from the cognitive and behavioral paradigms of psychology.
- Cognitive restructuring: Cognitive restructuring is a technique that comes from cognitive therapy and has been incorporated into cognitive-behavioral techniques. It is one of the most popular techniques used today.
Cognitive restructuring helps clients to conceptualize attitudes, beliefs, feelings, and thoughts in a different and more rational or functional manner. This technique is based on the principle that many aspects of psychopathology, dysfunctional behavior, emotional distress, etc., can be traced back to certain beliefs and expectations that people have about themselves, the world in general (including other people), and the future. When individuals confront these dysfunctional or irrational beliefs and test them, they often find them to have little merit.
Therapists using cognitive restructuring techniques help individuals alter these attitudes and beliefs to more realistic and functional ones. This is a technique that is heavily used in EMDR sessions and was not developed by Dr. Shapiro.
- The use of other well-established principles and protocols: As mentioned above, EMDR utilizes other principles and components of psychotherapy that have been previously demonstrated to be significant contributors to positive therapeutic outcomes, such as the use of homework assignments, concentrating on the therapeutic alliance, the use of empathy, being genuine with the client, and demonstrating unconditional positive regard for the client regardless of their situation. These techniques are not specific to EMDR and were not developed by Dr. Shapiro.
How Does EMDR Work?
EMDR adopts an action-oriented approach to therapy. Even though the therapist is interested in the client’s history, the focus of the treatment is on how the person is currently functioning in their environment. There is some variation in the delivery of EMDR from therapist to therapist, but the recommended approach (the classic EMDR approach) operates over eight major steps in the delivery of the treatment. These eight steps or phases are outlined below.
- Collecting information regarding the history of the client: In the first phase of the treatment process, the therapist will gather information regarding the client’s history and background. This type of information gathering may often continue throughout the entire eight phases of treatment, but typically in the first two sessions, the therapist attempts to get as much information about the client as possible.
The therapist often attempts to identify specific therapeutic “targets,” which are aspects of the individual’s experience that will be addressed in therapy. Targets include things like past stressful events, factors that might interfere with successful treatment, stimuli that provoke anxiety or stress in the individual, and other issues. The development of an initial treatment plan also occurs in the first phase.
- Preparation for treatment: In the second phase, the therapy concentrates on the development of the therapeutic alliance. The therapist explains the philosophy and goals of EMDR, and instructs the client in techniques that can be used to address issues with stress, such as progressive muscle relaxation, diaphragmatic breathing, and the use of imagery. Giving the client tools they can use immediately fosters the therapeutic alliance.
- Assessment: Even though the assessment of the client has already begun, the formal assessment process becomes the focus of the sessions in this phase. Targets to be addressed in treatment are identified, and the emotional aspects of the targets on the client’s functioning are evaluated and discussed. The client and therapist discuss how to address specific issues with stress, anxiety, and other emotional reactions. The client and therapist rate the client’s current level of stress associated with specific targets and discuss how to address stressful reactions.
- Desensitization: In this phase, the actual process of using the EMDR techniques occurs. Positive feelings/images are used to replace the distressful feelings associated with targets during the treatment (exposure and cognitive restructuring).
- Installation: This phase involves continued treatment with a focus on inserting more positive feelings regarding stress-provoking issues.
- Body scan: After going through formal EMDR treatment protocol, the client and therapist go back and reevaluate the results in this phase. They try to identify any remaining stress, tension, or distress associated with the identified targets. If any distress remains, phases 4-6 can be repeated.
- Closure: The client’s progress is reassessed to ensure they have responded to treatment and are satisfied with the results.
- Reevaluation: In the final phase, the entire course of therapy is evaluated, the treatment plan is reviewed, the goals of the treatment are reviewed, and if any other issues need to be addressed, the client and therapist go back and address them. Once the goals of therapy have been completed and the client is satisfied, the therapy can be terminated.
As can be surmised from the above description, the classic approach to delivering EMDR is organized and systematic, and attempts to ensure that the client is treated with respect, concern, and care. The treatment is evaluated, reevaluated, and reevaluated again by both the client and therapist.
Because EMDR involves a very lengthy and intensive process, therapists need specific training in the techniques. Certified EMDR therapists must be licensed in their state to practice psychotherapy. The individual must complete certain educational requirements, have specific training experiences that can be documented, and pass a formal examination. After these stipulations are complete, the person must complete specific training and become certified in EMDR therapy.
Is EMDR Effective?
Dr. Shapiro and her associates have numerous followers, and many therapists trained in EMDR are convinced that the technique is effective. However, numerous issues have been voiced about the technique.
The first issue associated with determining whether EMDR is a valid therapeutic technique has to do with the eye movement component. As stated, not all therapists use the eye movement component, and there is actually research that has demonstrated that the eye movement component of EMDR adds no effectiveness to the other already established techniques, such as exposure, the use of imagery, cognitive restructuring, etc. According to Science and Pseudoscience in Clinical Psychology, the research that has indicated that the eye movement component is not necessary suggests that any effects associated with the technique are due to standard behavioral and cognitive-behavioral treatments.
If the eye movement component of EMDR has no clinical utility, in research terms, this means that the technique offers no incremental validity to therapeutic techniques that are already being practiced; essentially, the eye movement component of EMDR adds nothing to already established therapeutic interventions. That basically means that EMDR is a therapeutic technique that represents “old wine in new bottles.” Because therapists often charge higher fees for the use of EMDR compared to traditional Cognitive Behavioral Therapy, this notion is concerning.
Several independent sources have claimed that the effects of EMDR as touted by its supporters are limited to anecdotal evidence or research with poor methodologies and often represent placebo effects. Several other sources have gone on to report that the eye movement component of the treatment has no clinical utility. These include standard studies and meta-analytic studies as well as an article in Scientific American.
The Cochrane Review reported findings based on review of the research associated with the use of EMDR and found that EMDR is generally equivalent to other forms of treatment used for the same issue. This is consistent with the notion that EMDR does not offer significant incremental validity to other treatment modalities. Again, considering that treatment with EMDR is often more expensive than traditional treatments, it makes EMDR’s use for treating stress, substance abuse, depression, anxiety, etc., far less attractive.
The good news is that studies that test the effectiveness of EMDR against having no treatment at all indicate that the results from EMDR are significantly more positive than no treatment. This means that even though the technique may not offer anything unique to existing treatments, it most likely does not increase the risk of detrimental effects. However, based on the overall body of research, it appears that the effects of EMDR are due to its incorporation of numerous techniques from other therapeutic paradigms and not due to its use of eye movements.