Using EMDR Therapy for PTSD and Abuse
Shapiro had noticed that lateral movements of the eyes were associated with reduced emotional responses to particular types of unsettling or disturbing thoughts or memories. She began to experiment with individuals who had experienced some particularly devastating trauma in their lives, and who had adjustment issues or were diagnosed with a formal post-traumatic stress disorder (PTSD diagnosis). She began to refine the technique of using lateral eye movements to help individuals process the effects of trauma.
During the EMDR procedure, the therapist has the client reflect on particular aspects of traumatic experiences that are associated with the most stress/emotional reaction while the client follows the hand motions of the therapist with their eyes. The therapist typically moves their fingers back and forth in front of the visual field of the client during this procedure, and the client, using only their eyes, follows this movement.
The eye movements are broken down into saccadic eye movements, which are quick, jerky movements of the eye that redirect a person’s line of sight in order to fix their vision on a moving object. Proponents of EMDR, such as Shapiro and her followers, claim that inducing these movements while reflecting on past traumatic experiences helps individuals to reprocess the experience and curbs the emotional response even if it is severe. However, EMDR also incorporates a number of other principles from behavioral therapy and Cognitive Behavioral Therapy.
Who is Qualified to Perform EMDR?
Because the formal process of EMDR treatment is rather lengthy and complicated, only therapists who are specifically trained in the technique and certified to perform it should be using EMDR.
Thus, there are two major qualifications:
The individual should be licensed by the state to perform therapy.
The individual should have specific training and certification in EMDR.
EMDR Borrows Principles from Established ParadigmsEMDR was originally designed to treat the experience of trauma that results in difficulties with emotional adjustment in individuals. The American Psychiatric Association lists a number of disorders under the overall heading of Trauma and Stressor Related Disorders in the DSM–5, the latest version of the diagnostic manual. EMDR was intended originally to help in the treatment of PTSD, adjustment disorders, and acute stress disorder, which are still listed in the diagnostic manual. The proponents of EMDR have also gone on to claim that it is useful in treating a number of other different psychological problems/disorders that have components of anxiety, depression, and maladjustment to them.
Although the EM in EMDR represents the notion of eye movements, not every therapist using the EMDR technique incorporates the eye movement component. Sometimes, the therapist simply tabs their finger, uses sound, or uses some other technique instead of the eye movement component in conjunction with the overall EMDR treatment package. As will be revealed later on, this is a problem for the theoretical foundations of this particular technique.
EMDR does include the following components in its overall treatment package that have empirical validation for their usage:
Session assignments and homework: The majority of cognitive and behavioral therapies require that clients in therapy complete certain practice assignments during the therapy sessions and that they complete assigned homework given to them by the therapist. The principle of giving homework for clients to practice newly develop skills in an effort to deal with some type of emotional issue has a long history in psychotherapy.
The notion of developing a strong therapeutic alliance: EMDR practitioners attempt to develop a strong working alliance between the client and the therapist as a main contributor to the success of the treatment. This is a longstanding aspect of successful therapy that dates far back in the history of psychotherapy.
The notion of exposure treatment: As part of the reprocessing component of EMDR, individuals are required to reflect on aspects of their traumatic experience that are particularly distressing for them. The process of this type of reflection, especially when individuals are instructed to visualize, try and hear aspects of the experience, and involve all the senses, is borrowed from a behavioral psychology therapeutic technique known as exposure therapy. Exposure therapy has a long history of use, with behavioral therapy and Cognitive Behavioral Therapy, to assist individuals who have experienced traumatic events to desensitize themselves emotionally to those events. The basic premise behind exposure therapy is that when people feel anxious, fearful, etc. as a result of some particular stimulus, having them re-experience the stimulus/event or remain in the presence of the stimulus eventually results in their anxiety peeking and then leveling off. Repeating this process of exposing a person either directly or through mental imagery results in the individual’s anxiety levels steadily decreasing to the point where recalling the experience no longer produces any significant distress. Individuals can also be taught breathing and relaxation during exposure to facilitate the process. A major component of EMDR is to have the person recollect important aspects of the traumatic event while undergoing the eye movement component of the treatment.
The notion of cognitive restructuring: Cognitive restructuring is a technique that is borrowed from Cognitive Behavioral Therapy (CBT), one of the most popular therapeutic paradigms used by therapists today. Cognitive restructuring involves re-conceptualizing one’s attitudes, thoughts, belief systems, etc. in a manner that is more functional and realistic. CBT works on the notion that many dysfunctional behaviors, such as substance abuse or psychological disorders like depression, are fueled by an irrational and dysfunctional belief system. CBT identifies these core irrational beliefs and, through a therapeutic process, helps the individual restructure them so they are more in line with reality. Part of the process of EMDR is for the therapist to help the client develop a different attitude and value system regarding aspects of their traumatic experience. This is done in conjunction with the exposure technique and eye movement component.
A Brief Outline of the Process Used in EMDR
During the overall EMDR procedure, the therapist focuses on the individual’s current situation and attempts to understand the history of the individual; however, the focus is not on the past as much as a focus of the treatment concerns itself with how the individual is reacting currently in the world. The actual delivery of EMDR can vary from treatment provider to treatment provider; however, in its classic presentation, the delivery of EMDR is accomplished over eight major steps or phases. These phases will be very briefly explained here. The eight phases are:
Phase I – History and background of the client and the preparation of an individualized treatment plan: Most often this phase will occur over the first two sessions, but most therapists continue to gather information regarding the history and background the client throughout the entire process. In this phase of treatment, the therapist and client will define the specific “targets” to be addressed in therapy. These can include traumatic events or other presenting problems.
Phase II – Treatment preparation: During this phase, the treatment alliance is developed, and the therapist explains EMDR to the client. The therapist will instruct the client in some specific techniques that can help them to deal with the effects of trauma. These techniques are typically breathing, relaxation, and other practices that can help to deal with stress.
Phase III – Assessment phase: This phase can be quite lengthy and involves quite a bit of interaction between the client and therapist. Typically, various targets are identified, and their emotional effects on the client are evaluated. The client and therapist work together to develop more functional approaches to existing emotional reactions. Then, the client and therapist work together to develop methods of rating current feelings of stress and alternative desired approaches to dealing with stress.
Phase IV – Desensitization stage: During this stage, the actual work of using the eye movement desensitization technique is paired with reevaluating both the traumatic events and their emotional experiences. In addition, positive emotions are inserted with recollections of past experience that resulted in distress (during phases III-VI, most of the exposure and cognitive restructuring occur).
Phase V – The installation phase: During this phase, more reprocessing is done to instill positive feelings regarding the client’s perception of past events as well as the client’s own efficacy in dealing with everyday experiences.
Phase VI – Body scan: During this phase, the therapist and client go back and try to evaluate any remaining tension related to stress that is associated with the targets identified in the early sessions and reprocessed over the course of treatment. Any remaining tension is dealt with. Phase VII – Closure: During this phase, the client’s reactions are reassessed to make sure they have responded to the treatment, and the client feels better as a result of the treatment.
Phase VIII – Reevaluation: During the final phase, the therapist and client reevaluate the entire process to make sure that the goals of treatment have been reached and that the techniques for coping are working well. If any issues need to be addressed, the therapy returns to the appropriate stage and works through them. If the goals of the therapy have been met, the treatment is terminated.
The Status of EMDR
EMDR has a number of very devoted followers, and there are a number of publications, websites, therapists, and even a journal devoted to it. However, EMDR is also a therapy that has a number of detractors.
As mentioned above, one of the first issues that many researchers and psychologists point out concerning EMDR is that the eye movement component of the treatment adds nothing to the effectiveness of the treatment. These critics assert that EMDR simply repackages already established treatments under a different name and at a different, and often more expensive, price level.
As it turns out, there is a good deal of independent research that has supported the notion that the eye movement component used in EMDR offers no incremental validity to the already established techniques of exposure therapy, cognitive restructuring, developing the therapeutic alliance, etc. Incremental validity refers to the notion that specific components of a certain type of therapy or new types of therapy add more value to already existing components used to treat certain disorders. If someone develops a new therapeutic technique, then the accepted protocol to judge the value of the new technique is that the new technique should add something different and more effective than the already existing techniques or it is not a valid form of treatment. This is especially true when the new form of treatment is packaged as something special and often comes with a higher price tag than existing forms of an intervention. The research suggests that the eye movement component of EMDR adds nothing useful to the already established techniques that the therapy incorporates.
While EMDR utilizes techniques that have been shown to have validity in treating stress and trauma victims, the eye movement component that differentiates EMDR from other forms of treatment appears to offer little additional benefit. Moreover, as mentioned above, the eye movement component of the treatment is sometimes replaced with other activities, such as finger tapping. The results indicate that the treatment remains equivalently effective in these cases. This also suggests that the eye movement component of EMDR adds little to the already established techniques used in the procedure. Thus, there is an ethical issue regarding packaging EMDR as something different, as therapists might charge higher rates for administering EMDR then they might for other forms of treatment.
The second major issue with EMDR is one that reinforces the above issue. First, it is relatively well established that EMDR treatment produces benefits in individuals compared to individuals who receive no treatment at all. While some may consider this evidence that EMDR is an effective form of treatment, it is important to note that even individuals who receive placebo treatments will often fare better than individuals who receive no treatment at all. By definition, a placebo is some type of substance or intervention that has no therapeutic effect for the issue being addressed. Placebos are used in certain types of research designs to determine the effectiveness of a particular intervention beyond expectations of getting well and beyond undefined issues that affect subjective perceptions. Thus, research demonstrating that EMDR is better than doing nothing does little to support the notion that is it an effective treatment or that it adds something different.
Supporters of EMDR point to a number of studies that demonstrated its effectiveness in treating emotional trauma. The Cochrane Review, a prestigious research source, reviewed the available research findings regarding EMDR and concluded that treatment with EMDR was generally equivalent to other forms of the therapy that do not include the eye movement component for trauma- and stressor-related disorders. There are two ways to look at this finding:
- Individuals who provide EMDR treatment cite that this is evidence that the technique is effective.
- Critics of EMDR point to the fact that since EMDR uses empirically validated aspects of Cognitive Behavioral Therapy, the results of the Cochrane review simply reinforce the notion that the eye movement component used in EMDR offers no incremental validity.
EMDR is a form of treatment that was initially used to help individuals with trauma-related issues and disorders to readjust to the effects of these experiences.
The technique has gained popularity and been used to address other psychological disorders.
While research supports the notion that EMDR is superior to no treatment at all and that it is generally equivalent to other forms of treatment for trauma-related issues, there remains serious concerns regarding its actual utility as a separate form of treatment.
Nonetheless, individuals who choose to get EMDR will most likely not experience any harmful or detrimental effects of the treatment (other than perhaps the treatment being more expensive than equivalent forms of treatment). Some individuals may find the treatment approach and the intensive level of intimacy with the therapist to be advantageous to their needs. Thus, while the use of EMDR raises some professional and ethical concerns in the therapy community, there is no reason to believe that it is harmful or that it cannot be used to assist individuals who have serious emotional effects as a result of experiencing some sort of trauma. As always, individuals are free to engage in any form of treatment that they feel is best for them and to decide whether or not to remain in treatment if it is not beneficial to their needs.