Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that is a recommended treatment for post-traumatic stress disorder (PTSD), but remains controversial within the psychological community. It was devised by Francine Shapiro in 1987 and originally designed to alleviate the distress associated with traumatic memories such as PTSD.
EMDR involves focusing on traumatic memories in a manner similar to exposure therapy while engaging in side-to-side eye movements or other forms of bilateral stimulation.[1][2] It is also used for some other psychological conditions.[3][4]
There is debate about how the therapy works and whether it is more effective than other established treatments.[1][7] The eye movements have been criticized as having no scientific basis.[8] The founder promoted the therapy for the treatment of PTSD, and proponents employed untestable hypotheses to explain negative results in controlled studies.[9] EMDR has been characterized as a pseudoscientific purple hat therapy (i.e., only as effective as its underlying therapeutic methods without any contribution from its distinctive add-ons).[10][11]
Classification and technique
EMDR adds a number of non-scientific practices to exposure therapy.[8] EMDR is classified as one of the "power therapies" alongside thought field therapy, Emotional Freedom Techniques and others – so called because these therapies are marketed as being superior to established therapies which preceded them.[12]
EMDR is typically undertaken in a series of sessions with a trained therapist.[13] The number of sessions can vary depending on the progress made. A typical EMDR therapy session lasts from 60 to 90 minutes.[14]
Trauma and PTSD
The person being treated is asked to recall an image, phrase, and emotion that represent a level of distress related to a trigger while generating one of several types of bilateral sensory input, such as side-to-side eye movements or hand tapping.[15] 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."[16]
Training
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.[17][18] 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.[17] Such changes in definition and training for EMDR have been described as "ad hoc moves [made] when confronted by embarrassing data".[19]
A Cochrane systematic review comparing EMDR with other psychotherapies in the treatment of Chronic PTSD found EMDR to be just as effective as TF-CBT and more effective than the other non-TF-CBT psychotherapies.[24][25] 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.[24] A 2016 systematic review and meta-analysis found that the effect size of EMDR for PTSD is comparable to other evidence-based treatments, but that the strength of evidence was of a low quality,[26] indicating that the effect sizes achieved are associated with substantial uncertainty. A 2018 systematic review found moderate strength of evidence supporting the effectiveness of EMDR in reducing symptoms of PTSD and depression, as well as increasing the likelihood of patients losing their PTSD diagnosis.[27]
Many randomized trials of EMDR have been criticized for poor control groups,[28] small sample sizes,[29][4] and other methodological flaws.[4][24][30] It has been called a purple hat therapy because any effectiveness is provided by the underlying therapy (or the standard treatment), not from EMDR's distinctive features.[31][32]
There is some evidence that EMDR can be as effective as trauma focused cognitive behavioral therapy (TF-CBT) for treating PTSD, though concerns have been raised about the poor quality of the underlying studies.[4][24] In a 2021 systematic review of 13 studies, clients had mixed perceptions of the effectiveness of EMDR therapy.[33]
Medical guidelines
The World Health Organization's 2013 report on stress-related conditions found insufficient evidence to support EMDR for acute symptoms of traumatic stress.[34] Its 2023 guideline for mental, neurological and substance use disorders recommended EMDR with moderate evidence for adults and children in treating PTSD.[35]
As of 2017, the American Psychological Association "conditionally recommends" EMDR for the treatment of PTSD in adults, meaning its use is suggested rather than recommended.[6]
The UK National Institute for Health and Care Excellence's 2018 PTSD guidelines found low-to-very-low evidence of efficacy for EMDR in treating PTSD, but what was available justified recommending it for non combat-related trauma.[37][38]
A 2017 joint report from the US Departments of Veterans Affairs and Defense describes the evidence for EMDR in the treatment of PTSD as "strong."[39]
The Australian 2013 National Health and Medical Research Council guidelines recommends EMDR for the treatment of PTSD in adults with its highest grade of evidence, noting that "EMDR now includes most of the core elements of standard trauma-focussed CBT (TF-CBT)" and "the two variants of trauma-focussed therapy are not statistically different."[40]
The Institute of Medicine's 2008 report on the treatment of PTSD found insufficient evidence to recommend EMDR, and criticized many of the available studies for methodological flaws including allegiance bias and insufficient controls.[5]
The Dutch National Steering Committee on Mental Health Care has released multidisciplinary guidelines which describe "insufficient scientific evidence" to support EMDR in the acute period following a stressful event (2008),[41] but recommend EMDR's use in chronic PTSD (2003).[42][page needed]
Other conditions
EMDR has been tested on a variety of other mental health conditions with mixed results.[4]
A 2021 systematic review and meta-analysis found EMDR to have a moderate benefit in treating depression, but the number and quality of the studies were low.[3]
Positive effects have also been shown for certain anxiety disorders, but the number of studies was low and the risk of bias high.[4] The American Psychological Association describes EMDR as "ineffective" for the treatment of panic disorder.[43]
A 2023 systematic review of evidence found EMDR's effectiveness in treating mental health conditions of children and adolescents who have been sexually abused is limited.[46]
Possible mechanisms
Incomplete processing of experiences in trauma
Many proposals of EMDR efficacy share an assumption that, as Shapiro posited, when a traumatic or very negative event occurs, information processing of the experience in memory may be incomplete. The trauma causes a disruption of normal adaptive information processing, which results in unprocessed information being dysfunctionally held in memory networks.[47] 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."[16] This proposed mechanism has no known scientific basis.[8]
Other mechanisms
Several other possible mechanisms have been proposed:
EMDR may impact working memory.[48] If a patient performs bilateral stimulation task while remembering the trauma, the amount of information they can recall is thought to be reduced, making the resulting negative emotions less intense and more bearable.[49] This is seen by Robin Logie of the EMDR Association UK and Ireland as a "distancing effect". The client is then believed to re-evaluate the trauma and process it in a less-harmful environment.[50] This explanation is plausible, given research showing that memories are more modifiable once recalled.[51]
Horizontal eye movement is thought to trigger an "orienting response" in the brain, used in scanning the environment for threats and opportunities.[52]
The idea that eye movement prompts communication between the two sides of the brain. This idea is not grounded in accepted neuroscience.[51]
Bilateral stimulation, including eye movement
Bilateral stimulation is a generalization of the left and right repetitive eye movement technique first used by Shapiro. Alternative stimuli include auditory stimuli that alternate between left and right speakers or headphones and physical stimuli such as tapping of the therapist's hands or tapping devices.[2]
Most meta-analyses have found that the inclusion of bilateral eye-movements within EMDR makes little or no difference to its effect.[10][53][54] Meta-analyses have also described a high risk of allegiance bias in EMDR studies.[55] One 2013 meta-analysis with fewer exclusion criteria found a moderate effect.[56]
Pseudoscience
EMDR has been characterized as pseudoscience, because the underlying theory and primary therapeutic mechanism are unfalsifiable and non-scientific. EMDR's founder and other practitioners have used untestable hypotheses to explain studies which show no effect.[9] The results of the therapy are non-specific, especially if directed eye movements are irrelevant to the results. When these movements are removed, what remains is a broadly therapeutic interaction and deceptive marketing.[18][57] According to Yale neurologist Steven Novella:
[T]he false specificity of these treatments is a massive clinical distraction. Time and effort are wasted clinically in studying, perfecting, and using these methods, rather than focusing on the components of the interaction that actually work.[28]
Investigation into EMDR has been characterised by poor-quality studies, rather than tightly-controlled trials that could justify or falsify the mechanisms that have been proposed to support it. Novella writes that the research quantity nevertheless means that EMDR has claimed a place among accepted treatments and is "not likely going away anytime soon, even though it is a house of card built on nothing".[58]
EMDR has been characterised as a modern-day mesmerism, as the therapies have striking resemblances, from the sole inventor who devises the system while out walking, to the large business empire built on exaggerated claims. In the case of EMDR, these have included the suggestions that EMDR could drain violence from society and be useful in treating cancer and HIV/AIDS.[59] Psychology historian Luis Cordón has compared the popularity of EMDR to that of other cult-like pseudosciences, facilitated communication and thought field therapy.[60]
A parody website advertising "sudotherapy" created by a fictional "Fatima Shekel" appeared on the internet in the 1990s.[61][62][63] Proponents of EMDR described the website as libelous, since the website contained an image of a pair of shifting eyes following a cat named "Sudo", and "Fatima Shekel" has the same initials as EMDR's founder, Francine Shapiro.[63] However, no legal action took place against the website or its founders, who are likely protected by American First Amendment protections.[63]
In a workshop, Shapiro related how the idea of the therapy came to her while she was taking a walk in the woods, and discerned she had been able to cope better with disturbing thoughts when also experiencing saccadic eye movements.[64] Psychologist Gerald Rosen has expressed doubt about this description, saying that people are normally not aware of this type of eye movement.[64] Gerald Rosen and Bruce Grimley suggest that it is more likely that she developed EMDR out of her experience with neuro-linguistic programming.[65][66][67]
Fuelled by marketing hype, EMDR was taken up enthusiastically by therapists even while scientists remained skeptical.[60] By 2012 more than 60,000 therapists had been trained in its use.[31]
Society and culture
Sandra Bullock used EMDR following a home invasion by a stalker in 2014.[1]
^ abRodenburg R, Benjamin A, de Roos C, Meijer AM, Stams GJ (November 2009). "Efficacy of EMDR in children: a meta-analysis". Clinical Psychology Review. 29 (7): 599–606. doi:10.1016/j.cpr.2009.06.008. PMID19616353.
^ abcLohr JM, Gist R, Deacon B, Devilly GJ, Varker T (2015). "Chapter 10: Science- and Non-Science-Based Treatments for Trauma-Related Stress Disorders". In Lilienfeld SO, Lynn SJ, Lohr JM (eds.). Science and Pseudoscience in Clinical Psychology (2nd ed.). Routledge. p. 292. ISBN9781462517893. ...eye movements and other bilateral stimulation techniques appear to be unnecessary and do not uniquely contribute to clinical outcomes. The characteristic procedural feature of EMDR appears therapeutically inert, and the other aspects of this treatment (e.g., imaginal exposure, cognitive reappraisal, in vivo exposure) overlap substantially with those of exposure-based treatments for PTSD...EMDR offers few, if any, demonstrable advantages over competing evidence-based psychological treatments. Moreover, its theoretical model and purported primary active therapeutic ingredient are not scientifically supported.
^ abThyer BA, Pignotti MG (2015). "Chapter 4: Pseudoscience in Treating Adults Who Experienced Trauma". Science and Pseudoscience in Social Work Practice. Springer. p. 221. doi:10.1891/9780826177698.0004. ISBN9780826177681. Nevertheless, to date, given that there is no evidence that anything unique to EMDR is responsible for the positive outcomes in comparing it to no treatment and the florid manner in which it has been marketed, we are including it in this book... Another way in which EMDR qualifies as a pseudoscience is the manner in which it was developed and marketed... EMDR proponents have come up with ad hoc hypotheses to explain away unfavorable results that do not support its theory, which is one of the hallmark indicators of a pseudoscience... This type of post hoc explanation renders her theory unfalsifiable and thus places it outside the realm of science, because to qualify as scientific, a theory must be falsifiable.
^ abThyer BA, Pignotti MG (2015). "Chapter 4: Pseudoscience in Treating Adults Who Experienced Trauma". Science and Pseudoscience in Social Work Practice. Springer. pp. 106, 146. doi:10.1891/9780826177698.0004. ISBN9780826177681.
^Fasce, Angelo (22 December 2017). "What do we mean when we speak of pseudoscience? The development of a demarcation criterion based on the analysis of twenty-one previous attempts [¿Qué queremos decir cuando hablamos de pseudociencia? El desarrollo de un criterio de demarcación basado en el análisis de veintiún intentos anteriores]". Disputatio: Philosophical Research Bulletin. 6 (7): 459–488. doi:10.5281/ZENODO.1433737. ISSN2254-0601. a technique that avoids [criteria] 1 and 3 but not 2 [and is therefore a pseudoscience based on the classification method described on the previous page]
^Rosquist J (2012). Exposure Treatments for Anxiety Disorders: A Practitioner's Guide to Concepts, Methods, and Evidence-Based Practice. Routledge. p. 92. ISBN9781136915772.
^"Post-Traumatic Stress Disorder". National Institute for Health and Care Excellence. 2018-12-05. Retrieved 2021-12-03. 1.6.20 EMDR for adults should: be based on a validated manual; typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple traumas; be delivered by trained practitioners with ongoing supervision; be delivered in a phased manner and include psychoeducation about reactions to trauma, managing distressing memories and situations, identifying and treating target memories (often visual images), and promoting alternative positive beliefs about the self; use repeated in-session bilateral stimulation (normally with eye movements) for specific target memories until the memories are no longer distressing; include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions.
^Feske U (June 1998). "Eye Movement Desensitization and Reprocessing Treatment for Posttraumatic Stress Disorder". Clinical Psychology: Science and Practice. 5 (2): 171–181. doi:10.1111/j.1468-2850.1998.tb00142.x. ISSN0969-5893.
^ abHerbert JD, Lilienfeld SO, Lohr JM, Montgomery RW, O'Donohue WT, Rosen GM, Tolin DF (November 2000). "Science and pseudoscience in the development of eye movement desensitization and reprocessing: implications for clinical psychology". Clinical Psychology Review. 20 (8): 945–971. doi:10.1016/s0272-7358(99)00017-3. PMID11098395. S2CID14519988.
^Hasandedić-Đapo L (February 2021). "How Psychologists Experience and Perceive EMDR?". Psychiatria Danubina. 33 (Suppl 1): 18–23. PMID33638952.
^Adler-Tapia R, Settle C (2008). EMDR and The Art of Psychotherapy With Children. New York: Springer Publishing Co. p. 228. ISBN978-0-8261-1117-3.
^Scott CV, Briere J (2006). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks, CA: Sage Publications. p. 312. ISBN978-0-7619-2921-5.
^Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ (June 2013). "Meta-analysis of the efficacy of treatments for posttraumatic stress disorder". The Journal of Clinical Psychiatry. 74 (6): e541 –e550. doi:10.4088/JCP.12r08225. PMID23842024. S2CID23087402.
^ abArkowitz H, Lilienfeld SO (1 August 2012). "EMDR: Taking a Closer Look". Scientific American. Retrieved 21 March 2023.
^Rosquist (2005). Exposure Treatments for Anxiety Disorders: A Practitioner's Guide to Concepts, Methods, and Evidence-Based Practice. Routledge. p. 94. ISBN9781136915772.
^Shipley G, Wilde S, Hudson M (April 2021). "What do clients say about their experiences of Eye Movement Desensitisation and Reprocessing therapy? A systematic review of the literature". European Journal of Trauma & Dissociation. 6 (2): 100226. doi:10.1016/j.ejtd.2021.100226. ISSN2468-7499. S2CID235544895.
^Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. World Health Organization. 2023. ISBN9789240084278.
^Dutch National Steering Committee Guidelines Mental Health and Care (2003). Guidelines for the diagnosis treatment and management of adult clients with an anxiety disorder (Report). Utrecht, Netherlands: The Dutch Institute for Healthcare Improvement.
^Recommended Guidelines: A General Guide to EMDR's Use in the Dissociative Disorders (authored by the EMDR Dissociative Disorders Task Force and published in Shapiro, 1995, 2001)
^p. 159, Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision, International Society for the Study of Trauma and Dissociation. 3 Mar 2011
^Solomon RM, Shapiro F (November 2008). "EMDR and the Adaptive Information Processing ModelPotential Mechanisms of Change". Journal of EMDR Practice and Research. 2 (4): 315–325. doi:10.1891/1933-3196.2.4.315. S2CID7109228.
^van den Hout MA, Engelhard IM, Beetsma D, Slofstra C, Hornsveld H, Houtveen J, Leer A (December 2011). "EMDR and mindfulness. Eye movements and attentional breathing tax working memory and reduce vividness and emotionality of aversive ideation". Journal of Behavior Therapy and Experimental Psychiatry. 42 (4): 423–431. doi:10.1016/j.jbtep.2011.03.004. PMID21570931.
^Chen L, Zhang G, Hu M, Liang X (June 2015). "Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: systematic review and meta-analysis". The Journal of Nervous and Mental Disease. 203 (6): 443–451. doi:10.1097/NMD.0000000000000306. PMID25974059. S2CID34850645.
^ abPatihis L, Cruz CS, McNally R (2020). "Eye Movement Desensitization and Reprocessing (EMDR)". In Zeigler-Hill V, Shackelford TR (eds.). Encyclopedia of Personality and Individual Differences. Springer. doi:10.1007/978-3-319-24612-3_895.
^Jeffries FW, Davis P (May 2013). "What is the role of eye movements in eye movement desensitization and reprocessing (EMDR) for post-traumatic stress disorder (PTSD)? a review". Behavioural and Cognitive Psychotherapy. 41 (3): 290–300. doi:10.1017/S1352465812000793. PMID23102050. S2CID33309479.
^Rodenburg R, Benjamin A, de Roos C, Meijer AM, Stams GJ (November 2009). "Efficacy of EMDR in children: a meta-analysis". Clinical Psychology Review. 29 (7): 599–606. doi:10.1016/j.cpr.2009.06.008. PMID19616353. p. [page needed]: Results indicate efficacy of EMDR when effect sizes are based on comparisons between the EMDR and the non-established trauma treatment or the no-treatment control groups, and the incremental efficacy when effect sizes are based on comparisons between the EMDR and the established (CBT) trauma treatment.
^Cuijpers P, Veen SC, Sijbrandij M, Yoder W, Cristea IA (May 2020). "Eye movement desensitization and reprocessing for mental health problems: a systematic review and meta-analysis". Cognitive Behaviour Therapy. 49 (3): 165–180. doi:10.1080/16506073.2019.1703801. eISSN1651-2316. PMID32043428. S2CID202289231. p. [page needed]: EMDR was found to be significantly more effective than other therapies in the treatment of PTSD. However, these results are not convincing for a number of reasons. First, there were few studies with low risk of bias. Furthermore, studies with low risk of bias did not point at a significant difference between EMDR and other therapies. The difference between studies with low risk of bias and those with at least some risk of bias was significant and we found considerable indications for researcher allegiance. Because studies with low risk of bias found no difference between EMDR and other therapies, we conclude that there is not enough evidence to decide about the comparative effects of EMDR.
^ abCordón LA, ed. (2005). "Eye movement desensitization and reprocessing". Popular psychology: An encyclopedia. Greenwood Press. pp. 81–82.
^de Jongh A, ten Broeke E (February 2007). "A course in pseudoscience"(PDF). De Psycholoog: 87–91. Retrieved 15 April 2023.
^McNally RJ (2001). "emdr en mesmerisme". DTH Magazine (in Dutch). 3 (21). Retrieved 15 April 2023.
^ abcThyer BA, Pignotti MG (2015). "Chapter 1: Characteristics of Science and Pseudoscience in Social Work Practice". Science and Pseudoscience in Social Work Practice. Springer. doi:10.1891/9780826177698.0004. ISBN9780826177681.
