EMDR for PTSD and anxiety.
Eye movement desensitization and reprocessing (EMDR) is a fairly new, nontraditional type of psychotherapy. It's growing in popularity, particularly for treating post-traumatic stress disorder (PTSD). PTSD often occurs after experiences such as military combat, physical assault, rape, or car accidents. Although research continues, EMDR remains controversial among some health care professionals.
At first glance, EMDR appears to approach psychological issues in an unusual way. It does not rely on talk therapy or medications. Instead, EMDR uses a patient's own rapid, rhythmic eye movements. These eye movements dampen the power of emotionally charged memories of past traumatic events.
What Can You Expect From EMDR?
If you suffer from PTSD, what can you expect during an EMDR treatment session -- which can last up to 90 minutes? Your therapist will move his or her fingers back and forth in front of your face and ask you to follow these hand motions with your eyes. At the same time, the EMDR therapist will have you recall a disturbing event. This will include the emotions and body sensations that go along with it.
Gradually, the therapist will guide you to shift your thoughts to more pleasant ones. Some therapists use alternatives to finger movements, such as hand or toe tapping or musical tones.
People who use the technique argue that EMDR can weaken the effect of negative emotions. Before and after each EMDR treatment, your therapist will ask you to rate your level of distress. The hope is that your disturbing memories will become less disabling.
Although most research into EMDR has examined its use in people with PTSD, EMDR is also used to treat many other psychological problems. They include:
- Panic attacks
- Eating disorders
- Anxiety, such as discomfort with public speaking or dental procedures
How Effective Is EMDR?
More than 20,000 practitioners have been trained to use EMDR since psychologist Francine Shapiro developed the technique in 1989. While walking through the woods one day, Shapiro happened to notice that her own negative emotions lessened as her eyes darted from side to side. Then, she found the same positive effect in patients.
EMDR appears to be a safe therapy, with no negative side effects. Still, despite its increasing use, mental health practitioners debate EMDR's effectiveness. Critics note that most EMDR studies have involved only small numbers of participants. Other researchers, though, have shown the treatment's effectiveness in published reports that consolidated data from several studies.
What Do the Guidelines Recommend?
Guidelines issued by more than one professional organization have recently boosted the credibility of EMDR. These guidelines define who may benefit from the treatment. For example:
The American Psychiatric Association (APA) has noted that EMDR is effective for treating symptoms of acute and chronic PTSD. According to the APA, EMDR may be particularly useful for people who have trouble talking about the traumatic events they've experienced. The APA guidelines note that other research is needed to tell whether improvements from EMDR can be sustained over time.
The Department of Veterans Affairs and the Department of Defense have jointly issued clinical practice guidelines. These guidelines "strongly recommended" EDMR for the treatment of PTSD in both military and non-military populations. They also note that this approach has been as effective as other psychological treatments in some studies, and less effective in others.
How Does EMDR Work?
Even the most enthusiastic supporters of EMDR have not agreed on how the therapy works. At this point, only theories exist. By inducing the recall of distressing events and diverting attention from their emotional consequences, EMDR in some respects borrows basic principles used in prolonged exposure therapy, the gold standard behavioral psychotherapeutic treatment of PTSD.
Some therapists believe that EMDR reduces anxiety. This allows patients to better take control of their upsetting thoughts. Others simply say that we don't yet understand how EMDR works. According to the APA guidelines, EMDR needs further study to more fully understand it
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Eye Movement Desensitization and Reprocessing (EMDR) - in more detail - review of literature
EMDR is a technique designed by Shapiro (1989, 1995) that has received considerable attention from practitioners and academics alike. Worldwide training institutes are well attended by clinicians seeking to learn about EMDR and its use in PTSD. Although Shapiro (1995) alleges that this technique is helpful for treating a range of disorders, its use is often directly associated with PTSD.
In the development of EMDR, Shapiro (1989) conducted a series of single-subject cases and open clinical trials, which suggested that this approach to treating the psychological effects of trauma exposure may promote recovery. From an operational perspective, the fundamentals of EMDR are (1) the evocation of trauma-relevant images and memories, (2) the psychological evaluation of the aversive qualities of these images/memories, (3) the identification (with or without therapist assistance) of an alternative cognitive appraisal of the image/memory, (4) examination of physiological reactions to the image/memory, (5) focusing on the idiographically determined positive appraisal of the image/memory, and (6) repeated sets of lateral eye movements while the patient is focusing on elements of the traumatic response or the alternative cognitive appraisal.
Examining the efficacy and effectiveness of EMDR is challenging. Its mechanism of action is not based on any contemporary theories of human behavior, learning, or cognitive science, although some discussion of Pavlovian neurophysiology is provided across publications (Shapiro, 1989, 1995). For this reason, it has been seriously criticized in the scientific literature (Herbert & Mueser, 1992; Keane, 1998; Lohr, Kleinknecht, Tolin, & Barrett, 1995; Lohr, Tolin, & Lilienfeld, 1998). Yet the absence of theory or a conceptual foundation is not sufficient to enable us to dismiss totally the preliminary findings on this technique. If there is efficacy, then serious scholars can assume responsibility for identifying the precise mechanism responsible for any effects observed. The question is therefore “Is there evidence for EMDR’s efficacy?”, and, more importantly, “Is EMDR more effective or efficient than tested techniques?”
Carlson, Chemtob, Rusnak, Hedlund, and Muraoka (1998) compared EMDR to biofeedback-assisted relaxation training and to routine clinical care. In this randomized clinical trial with combat veterans, the authors reported that at the 180-day follow-up, the group receiving EMDR showed greater clinical improvement than either of the two comparison groups on self-report, psychometric, and clinician-rated measures of PTSD.
Wilson, Becker, and Tinker (1995) reported on the treatment of traumatic memories in a heterogeneous sample of individuals recruited through newspaper advertisements and other means. Half of their subjects received EMDR, while the remaining half were placed on a waiting list. Of the 80 subjects in this study, fewer than half reached DSM criteria for PTSD. Following three 90-minute sessions of EMDR, the treated group demonstrated a greater reduction on psychometric measures and clinician ratings of symptoms than did the wait-list subjects.
Rothbaum (1997) utilized EMDR in a sample of female rape survivors with PTSD. She found strong treatment effects when the active treatment was compared to a wait-list comparison group. Similarly, Chemtob, Nakashima, Hamada, and Carlson (in press) found that EMDR was an effective treatment for PTSD in children who survived Hurricane Iniki on the island of Kauai in the state of Hawaii. This study also compared EMDR to a waitlist comparison group.
In an HMO setting, Marcus, Marquis, and Sakai (1997) found that EMDR was more effective than standard psychological care among individuals with PTSD due to diverse traumatic events. These findings are impressive because the study was conducted in a clinical setting, where control over the patient characteristics and therapist behavior (particularly for the experimental treatment) is difficult to attain.
Devilly, Spence, and Rapee (1998) compared EMDR to a similar type of treatment but without the eye movements in the treatment of combat-related PTSD in Australian Vietnam veterans. Each of these treatments was also compared to a supportive treatment comparison. The results of this study indicated that both active treatment groups improved equally; there was no apparent benefit to the inclusion in this treatment package of the eye movements per se. Pitman et al. (1996) also found no differences between EMDR with the eye movements and EMDR without the eye movements in the treatment of combat-related PTSD among American Vietnam veterans. These studies contribute to the growing skepticism about the value of the eye movement processes in achieving the outcomes observed to date in using EMDR with PTSD.
Other studies on EMDR’s efficacy have been less encouraging. Projects by Boudewyns, Stwertka, Hyer, Albrecht, and Sperr (1993), Jensen (1994), and Vaughan et al. (1994) found only modest effects for EMDR. These studies all have significant methodological limitations, but they are comparable in quality and design to many of those projects providing the empirical support for this technique. One study by Renfrey and Spates (1994) found no differences between a group that received the eye movements and a similar group that didn’t, contributing to the mounting evidence challenging their role in the treatment.
In summary, much work needs to be done before research will firmly support the use of EMDR in the treatment of PTSD. To date, there is not a single study supporting EMDR (as espoused by its developer) as a treatment superior to any of the existing treatments for PTSD, such as exposure therapy, AMT, or cognitive therapy. Such studies would provide needed evidence in the debate about the ultimate contribution of EMDR to the scientific and clinical literature (Chemtob, Tolin, van der Kolk, & Pitman, 2000; Lohr et al., 1998). Unlike the various forms of exposure therapy, which have a long tradition of ameliorating a range of anxiety-mediated clinical problems and which are embedded in the rich conceptual tradition of experimental psychology, EMDR falters seriously at the theoretical level. Needed are basic studies to examine the effects of eye movements (or other laterally alternating stimuli); small-scale, well-controlled efficacy studies that meet contemporary standards for treatment outcome research; and the formulation of a testable theory for the technique. Implicit in this latter recommendation are the development of a conceptual model of PTSD, and an explanation of how EMDR attempts to correct either the deficits or excesses involved in this disabling psychological condition.
To conclude the review of EMDR, it may be valuable to specify the possible strengths of this technique. First, EMDR does share some components of exposure therapy and cognitive therapy. These overlapping components should be identified and operationalized to promote our ability to study the approach more fully. Second, the technique builds assessment into the ongoing therapy process. Third, EMDR suggests that instructions to modify images and alter cognitive self-statements may be a reasonable treatment objective for patients with PTSD. Fourth, proponents of this technique have always noted the need for empirical documentation to support their approach.
If there is a fundamental weakness of EMDR, it stems from a distinct lack of integration with existing psychological models of psychopathology and psychotherapy. Although all existing models of PTSD clearly have their own limitations, it is incumbent upon the proponents of EMDR to hypothesize how their view of the problems associated with PTSD differs from others; how the theoretical mechanisms of their technique derive from behavioral theory and/or cognitive neuroscience; and how this technique functions to allay specific targeted symptoms or to create alternative cognitive structures of the traumatic event, and thus contributes to our understanding of this multidimensional disorder.