Eye Movement Desensitisation 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 EMDR. 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.

Who can benefit from EMDR?

EMDR is best known as a trauma therapy developed to support people with PTSD, but it also has a number of other applications, including:

• Distressing or adverse life events
• Severe anxiety, panic, and phobias
• Depression
• Sleep problems
• Distress related to physical or mental health conditions
• Somatic (body-based) difficulties
• Grief
• Addictions

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 happens, traumatic memories can be stored in an unprocessed way, in isolated memory networks.
• This can lead to the memories being repeatedly activated in the present, leading to ongoing distress.

‍
It is thought that EMDR removes the 'blockages' that have been caused by trauma, allowing the brain's 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 natural healing processes of the brain can continue.

There is a good body of research supporting EMDR (see below), but it is important to acknowledge that our understanding of how and why EMDR therapy works in the brain is still largely a hypothesis.

The Process of Starting EMDR

EMDR can be a brief, focused therapy or part of a longer psychotherapy program. Before starting EMDR, your therapist will do a thorough assessment of your presenting concerns, the resources and skills you already have (e.g., in distress tolerance and emotion regulation), and any reasons EMDR might not be the right fit. Your therapist will talk with you about the approach/es that might suit you best, and whether and when EMDR may be a good fit.
‍
Please note that when starting EMDR, several sessions will be spent on “stabilisation” and assessment. The stabilisation phase involves building internal resources and skills to use throughout therapy, and creating safety within the therapeutic relationship.

The Eight Phases of EMDR

EMDR has eight phases. The number of sessions spent on each phase varies a lot from person to person.

Phase 1 - History taking and assessment

• Getting to know each other and setting goals for therapy (it helps to have a clear reason for doing work on trauma or adverse memories)
• History taking and assessment
• Working out together whether EMDR is a good fit for you, and whether now is the right time
• Planning therapy together
• Mapping the memories to work on (targets), for example by putting together a trauma timeline

Phase 2 - Preparation and resourcing

• Building trust in the therapeutic relationship
• Explaining the theory and procedures of EMDR therapy
• Building coping strategies and resources you can draw on both during and between sessions, for example emotion regulation skills or a calm place
• Setting up for desensitisation by finding a comfortable distance for bilateral stimulation, a cue word for your calm place, and a stop signal

Phase 3 - Target assessment

• Choosing a target image or trigger - often starting with the most distressing memory or trigger, as other memories tend to lead back to this one
• Identifying a negative cognition (an unhelpful belief about yourself) that is strongly linked to the target, for example “I’m not safe”
• Identifying a positive cognition (a belief about yourself you would like to hold instead), for example “I’m safe now”
• VoC (Validity of Cognition) - rating how true the positive cognition feels on a scale of 1 (feels completely untrue) to 7 (feels completely true). It isn’t about whether the belief makes sense intellectually, but whether it feels true to you
• SUD (Subjective Units of Distress) - rating how distressing the target feels on a scale of 0 (not at all disturbing) to 10 (the most disturbing possible)
• Noticing where you feel it in your body

Phase 4 - Desensitisation

• Repeated sets of bilateral stimulation (varied as needed so you don’t get used to them) until your SUD rating has genuinely come down to 0 or 1. This may take many sessions
• Unblocking techniques if processing gets stuck

Phase 5 - Installation

• Pairing the desensitised memory with a helpful positive cognition, for example “I did my best”
• Sets of bilateral stimulation while you hold both the memory and the positive cognition in mind, to strengthen the positive cognition as much as possible (aiming for it to feel true at a 6 or 7 on the 1-7 scale)

Phase 6 - Body scan

• Noticing your body while holding the target memory and the positive cognition in mind (this is different from a typical body scan exercise)
• Further sets of bilateral stimulation to process any leftover distress and strengthen positive sensations

Phase 7 - Closure

• Happens at the end of every session
• Debriefing the session
• Making sure you feel settled before you leave
• Talking about what to expect between sessions (if desensitisation happened in the session, processing often continues over the next 24-48 hours, and thoughts, feelings or body sensations may pop up)
• Going back over emotion regulation skills

Phase 8 - Re-evaluation

• Happens at the beginning of every session
• Revisiting targets that have already been processed
• Checking whether the changes have held
• Working out together whether further reprocessing is needed

What is an EMDR Session Like?

Eye movements, similar to those during REM sleep, will be recreated simply by asking you to watch the therapist's finger moving backwards and forwards across your visual field. Sometimes, other types of bilateral stimulation are used. The eye movements will last for a short while and then stop. You will then be asked to report back on the experiences you have had during each of these sets of eye movements. Experiences during a session may include changes in thoughts, images and feelings.

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. A meta-analysis of studies comparing EMDR with and without eye movements found an incremental benefit from the eye movements themselves (Lee & Cuijpers, 2013).

With repeated sets of eye movements, the memory tends to change in such a way that it loses its painful intensity and simply becomes a neutral memory of an event in the past. Other associated memories may also shift at the same time. This linking of related memories can lead to improvements in many areas of your life.

In EMDR, a distressing memory is considered successfully reprocessed when:

• The memory is recalled as a distant event (distancing)
• The memory no longer brings up significant distress (desensitisation)
• The meaning and beliefs linked to the memory shift and become more helpful (reprocessing)

What is the Evidence for EMDR?

Since Francine Shapiro's initial pilot research in 1989, the results of more than 30 randomised controlled trials (RCTs) investigating the effectiveness of EMDR Therapy for PTSD have been published, providing evidence for EMDR as an effective trauma therapy (de Jongh et al., 2019). Results from several meta-analyses have reported EMDR Therapy to be an efficient and effective therapy for PTSD (Maxfield & Hyer, 2002; Rodenburg et al., 2009; Sack, Lempa & Lamprecht, 2001; van Etten & Taylor, 1998).

Both the World Health Organisation (WHO) and the UK's National Institute for Health and Care Excellence (NICE) recommend EMDR for PTSD. The WHO's 2013 guidelines recommend trauma-focused CBT and EMDR as the psychotherapies of choice for PTSD in children, adolescents and adults.
‍
NICE's 2018 guideline recommends offering EMDR to adults with PTSD who present more than three months after a non-combat-related trauma, and considering it between one and three months after the trauma if the person prefers EMDR.

Limitations and Considerations of EMDR

All therapies have limitations. It is important to note that one major review rated the strength of the evidence for EMDR as low to moderate (Cusack et al., 2016). Some critics have also described EMDR’s underlying principles as pseudoscience, because the hypotheses are vague and hard to test (unfalsifiable). To date, EMDR Therapy has not been shown to be more effective than other evidence-based therapies for PTSD, and as it is still a relatively new therapy it is hard to draw long-term conclusions about its effectiveness.

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

EMDR isn’t the right fit for everyone. Strong thoughts and feelings linked to the trauma sometimes come up during sessions, so it’s important that you know this and feel willing to experience them. EMDR Therapy is used with caution for people who are prone to dissociation or who have a dissociative disorder. In that case, it is important that the clinician has specialised training in using EMDR with dissociation, and a longer stabilisation phase is needed.

The timing of EMDR Therapy is also important. EMDR Therapy can actually be unhelpful if started too soon after the distressing event, for example when the person is still in shock. However, this is true for all trauma therapies. Supportive therapy, rather than processing therapies, is more appropriate in the immediate aftermath of a traumatic or distressing event.

It is with these considerations in mind that your therapist will complete a thorough assessment with you before starting EMDR Therapy.

‍