Eye Movement Desensitization and Reprocessing (EMDR) Therapy

EMDR is a structured form of psychotherapy that is designed to reduce distress associated with traumatic memories or adverse life events. 

Dr Francine Shapiro is credited as being the originator and developer of EDMR. In 1987 Shapiro observed that when thinking about a disturbing event, her eyes started spontaneously moving back and forth. When she made these eye movements deliberately while concentrating on a variety of disturbing thoughts and memories, she found that the thoughts and images disappeared and lost their emotional charge. This personal experience kickstarted Shapiro’s development of and research into what is now known as EMDR therapy. 

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Who can Benefit from EMDR?

EMDR is best known as a trauma therapy designed to treat PTSD but has a number of applications including: 

• Distressing or adverse life events
• Severe anxiety and phobias
• Distress associated with both physical and mental illness
• Somatic disorders
• Grief 
• Addiction

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The Eight Phases of EMDR

EMDR consists of eight phases. The number of sessions devoted to each phase vary greatly from person to person.

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Phase 1 - History taking and assessment

• Rapport building and establishing goals for therapy (client needs a clear rationale for engaging in trauma/adverse memories work)
• History taking and assessment
• Assessing client suitability and readiness for EMDR therapy
• Treatment planning
• Mapping targets for reprocessing eg. establishing a trauma timeline

Phase 2 - Preparation and resourcing

• Establishing trust in the therapeutic relationship 
• Explanation of the theory and procedures of EDMR therapy
• Building coping strategies and resources that can be drawn upon both during and in between sessions eg. emotion regulation skills, calm place etc. 
• Setting up for an EMDR desentization session by establishing comfortable distance for bilateral stimulation, a cue word for calm place, and a stop signal

Phase 3 - Target assessment

• Establishing a target image or target trigger - ideally starting with the most distressing memory or trigger as other memories will lead back to this one
• Establishing a negative cognition (negative thought) about oneself strongly associated with the target eg. “I’m not enough”
• Establishing a positive cognition (positive thought) related to the negative cognition that the client would like to believe about themselves eg. “I’m enough”
• VoC (Validity Of positive Cognition) - rating the believability of the position cognition on a scale of 1 (feels completely untrue) to 7 (feels completely true). It is important to note that it is not about whether the cognition is intelellectually believable but whether it feels true to the individual
• SUD (Subjective Units of Distress) - rating how distressing the target is to the individual on a scale of 0 (not at all disturbing) to 10 (highest disturbance possible)
• Location of body sensations

Phase 4 - Desensitization

• Repeated sets of bilateral stimulation (with appropriate variations to reduce habituation) until the client’s SUD level is genuinely reduced to 0 or 1. This may span across many sessions
• Unblocking techniques utilised when processing gets stuck

Phase 5 - Installation

• Pairing the desensitised memory with an adaptive positive cognition eg. I did my best
• Sets of bilateral stimulation with the client simultaneously focusing on the desentised memory and the positive cognition, to achieve the greatest possible strengthening of the cognition (aiming for the positive cognition to feel true at a rating of 6 or 7 on the scale of 1-7)

Phase 6 - Body scan

• Mentally scanning the body whilst holding in mind the target memory and the positive cognition (not a typical body scan exercise)
• Further sets of bilateral stimulation to reprocess any residual distress and strengthen positive sensations

Phase 7 - Closure

• Occurs at the end of every session
• Debriefing the session
• If necessary, stabilising the client
• Providing information about what to expect in between sessions (if phase 4 desensitization occurred during the session, ongoing reprocessing is expected to occur for the following 24-48 hours in the form of thoughts, feelings, or body sensations popping up)
• Reiterating affect regulation skills

Phase 8 - Re-evaluation

• Occurs at the beginning of every session
• Re-accessing of previously reprocessed targets 
• Reviewing whether treatment gains have been maintained
• Assessing whether further reprocessing is required 

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Why does EMDR Work?

The Adaptive Information Processing (AIP) Model is the underlying explanatory model of EMDR therapy. The AIP posits that:

• The brain has an innate capacity to adaptively process information and integrate internal and external experiences
• Trauma can cause a disruption to the brain’s adaptive information processing system
• When this occurs, traumatic memories are maladaptively stored in isolated memory networks
• This can lead to mental illness and distress

It is thought that EMDR removes the ‘blockages’ that have been caused by trauma, allowing the brains natural healing process to resume. An example used to explain the AIP Model is the natural ability of the human finger to heal after a cut. However, if there is a splinter in the finger, the natural healing process is blocked. EMDR aims to remove the splinter (metaphorically) so that the normal healing processes of the brain can continue.

EMDR considers a distressing event successfully reprocessed if:

• The memory is recalled as a distant event (distancing)
• The memory no longer evokes significant distress (densenitization) 
• The meaning and beliefs linked to the memory shift to become more adaptive (reprocessing) 

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It is important to acknowledge that our understanding of how and why EMDR therapy works is largely a hypothesis at this stage.

It is believed that the bilateral (alternating from one side to the other) stimulation burdens the working memory while someone is connecting to and reprocessing a distressing memory. Something about the taxation of the working memory is theorised to contribute to the reduction in distress associated with the painful memories aka the ‘sting’ being taken out.

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What is the Evidence for EMDR?

Since Francine Shapiro’s initial pilot research in 1989, the results of more than 30 randomised control trials (RCTs) investigating the effectiveness of EMDR Therapy for the treatment of PTSD have been publised, providing evidence for EMDR as an effective trauma therapy (De Jong et al., 2019). Results from several meta-analyses have reported EMDR Therapy to be an efficient and effective treatment for PTSD (Lee & Cuijpers, 2013; Maxfield & Hyer, 2002; Rodenburg et al., 2009; Sack, Lempa & Lamprecht, 2001; Spector & Reed, 1999; van Etten & Taylor, 1998). 

It is important to note that EMDR studies have been criticised by some for having poor methodology (Cusack et al, 2016). The World Health Organisation’s (WHO) 2013 report on treating PTSD found “insufficient evidence” to support EMDR for acute symptoms, and the UK National Institute for Health and Care Excellence's 2018 report on the treatment of PTSD found low to very-low evidence of efficacy for EMDR in treating PTSD.

To date, EMDR Therapy has not been shown to be more effective than other evidence based PTSD treatment and as it is still a relatively new therapy and so it is hard to draw long-term conclusions about its effectiveness.

There is emerging evidence for EMDR Therapy for presenting issues other than PTSD but it is still in the early stages and more research is required (Matthijssen et al., 2020). 

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Limitations of EMDR

The biggest criticism of EMDR is that its underlying principals have been described as pseudoscience as they are unfalsifiable i.e. the hypotheses are vague and untestable. As detailed above, EMDR research has also been criticised for poor methodology.

EMDR Therapy is considered inappropriate for those vulnerable to dissociation or with dissociation disorders, unless the clinician is specially trained to deliver EMDR for those with dissociation. 

EMDR Therapy can actually have an adverse effect if delivered to soon after the distressing event i.e. when the person is in shock. However, this is true for all trauma therapies. Supportive therapy, rather than processing therapies, are more appropriate in the immediate aftermath of a traumatic or distressing event.

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