General Psychiatry

EMDR: A Rapidly Expanding Modality for Treating Mental Health Disorders

Avatar photoBatya Swift Yasgur, MA, LSW
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Therapist and client engaging in EMDR therapy (Eye Movement Desensitization and Reprocessing)
After 30 years, eye movement desensitization and reprocessing (EMDR) therapy continues to gain support as a beneficial treatment for a wide range of mental health conditions, especially post-traumatic stress disorder.

Eye movement desensitization and reprocessing (EMDR) therapy was first introduced in 1989,1 and has been described as “a relatively novel psychotherapy now well-established and recognized internationally as an empirically supported treatment for trauma,”2 garnering increasing attention, focus, and popularity as a promising treatment for posttraumatic stress disorder (PTSD).1 The modality was pioneered by Francine Shapiro, a psychologist who was walking through a park and noticed that certain saccadic eye movements reduced the intensity of disturbing thoughts. She then observed that bringing these eye movements under voluntary control while thinking about a distressing memory reduced the anxiety evoked by that memory.2

EMDR can be defined as “a comprehensive psychotherapeutic approach that emphasizes the role of the information processing system in the origin and treatment of mental health problems.”1 It posits that “current problems (excluding those caused by lack of information, physical injury, toxicity, and genetic factors) result from adverse life experiences that have been incompletely processed.”3

“EMDR is an evidence-based psychotherapy for the treatment of trauma,” according to Roger Solomon, PhD, psychologist based in Arlington, Virginia, specializing in trauma and grief, and a senior faculty member at the EMDR Institute.

Maladaptive Storage: The Adaptive Information Processing Model

EMDR is guided by the Adaptive Information Processing Model (AIP), which “suggests that inadequately processed memories of trauma and other adverse life experiences are the primary basis of psychopathology,” Dr Solomon told Psychiatry Advisor.

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“Trauma can be defined as any disturbing memory that is still distressing today,” he said.

Although traumas are often “big ‘T’ events, such as earthquakes, tsunamis, accidents, or assaults, something seemingly small but impactful—such as Mother’s angry look—can be taken in by a person’s system as a trauma,” he continued.

He explained that the brain has “a processing system that will process experiences, so that if there is some type of distressing experience, we will think, talk, and dream about it. Eventually, it will be integrated—meaning that we will remember the experience with appropriate emotion and retain useful information, so the experience will not intrude into present-day life and unnecessary emotion about it will be discarded.”

Experiences are turned into “physically encoded memories,” which are stored in associative neural networks that “provide the framework for a person’s interpretation of new experiences and significantly influence current perception, behavior, and emotions.”3

However, “a particularly intense memory can be too much to process, so that experiences gets stored in a state-specific excitatory form—in other words, that memory gets stuck, meaning maladaptively stored—and can be reawakened when a present-day problem triggers the past memory,” Dr Solomon said.

Traumatic re-triggering is classically associated with PTSD, with symptoms that include intrusive thoughts, hypervigilance, nightmares, and flashbacks.3 However, even adverse life experiences that do not meet formal criteria for PTSD can be “stored dysfunctionally, providing the basis for a wide variety of emotional, cognitive, behavioral, and somatic responses.”3

EMDR: An Eight-Phase Protocol

Dr Solomon reviewed the components of the EMDR protocol: client history, preparation, assessment,  desensitization, installation, body scan, closure, and reevaluation. The phases can be conducted over a long period of time or condensed into several days, depending on the severity and complexity of the trauma.

1. Client History

“We begin by taking a history of one of the past memories that underlie the present problems, assess the present-day triggers, and gather information to lay down a positive template for adaptive future behavior,” Dr Solomon said.

In addition, the first phase includes evaluating the client’s behavioral/emotional deficits, psychosocial education, and degree of stabilization needed for future functional behavior, as well as assessing client appropriateness and suitability for treatment. The therapist assesses individual and social functioning, questions current beliefs and/or bodily sensations, and guides clients to identify earlier events that contain the same responses.3

2. Preparation

During this phase, “we establish a therapeutic alliance and provide psychosocial education, which includes explaining the clinical symptoms and how current problems are the result of dysfunctionally stored memories, as well as explaining EMDR therapy procedures and what to expect,” Dr Solomon said.

Clients are also provided with affect regulation strategies, such as self-control methods that support stabilization and build a sense of personal self-mastery.

Suggesting that the client visualize a safe/calm place can assist in affect regulation and serve as a resource.

3. Assessment

Clients are not required to provide detailed descriptions of the traumatic/adverse event, but they must be able to share enough information for the clinician to understand what the memory is (eg, “My brother molested me”). During this phase, “the memory to be treated is accessed and its aspects delineated by briefly identifying its cognitive, affective, and somatic manifestations.”3 Accomplishing this involves addressing 4 domains, which are used to assess the memory and initiate processing during the next phase:

  • Pictorial: eliciting the mental image of the most disturbing part of the event
  • Cognitive: negative beliefs, such as sense of responsibility (“I did something wrong”) or lack of safety or choices
  • Affective: present-day negative emotions associated with the trauma
  • Somatic: the perceived locations of the attendant physical sensations3

4. Desensitization and Processing

During this phase, the memories of the past experiences and present-day triggers are processed using dual-attention bilateral stimulation (eg, eye movements, tapping, or auditory tones), which are applied while the individual is attending to the accessed memories. Eye movements are the recommended first-line approach.3

Dual-attention stimulation initiates a rapid associative process facilitated by EMDR procedures resulting in the emergence of insights, as well as new images, thoughts, feelings, and/or sensations.3

5. Installation

During this phase, the client’s most desired self-belief is identified and strengthened. While undergoing dual attention stimulation, clients are asked to focus on the positive cognition and the event to strengthen the adaptive connection between the memory and the belief, Dr Solomon said.

He provided an example. “A soldier who had been in an explosion might have had the belief ‘I’m going to die.’ We seek to have him reach a positive cognition—‘I survived.’ And we measure on a scale of 1-7 how true the phrase ‘I survived’ feels. Cognitively, the client might know that he is alive and rate that phrase ‘7.’  But emotionally, in the gut, the client does not feel he will survive, and gives that phrase a rating of ‘2.’” The goal is to have the client answer “7,” and feel it on every level: pictorial, cognitive, affective, and somatic.

6. Body Scan

Bilateral stimulation is continued, and the provider assists the client in identifying disturbing physical sensations, with the end result being that the adaptive information links into the memory network and the soldier can say, “‘I’m alive, I survived’ and feel it on a bodily level,” Dr Solomon stated.

The processing is considered complete when all negative somatic responses have been eliminated.3

7. Closure

The experience and stability of the client are evaluated at the end of each session, incorporating affect-change procedures to return clients to equilibrium if necessary. Clients are also educated about what to expect between sessions and are asked to keep a log, indicating trigger, image, cognition, emotion, and physical sensation and to use the calming procedures they have been taught, if necessary.3

8. Reevaluation

During this phase, clients are assessed regarding their psychological state and what may have emerged since processing, with interpersonal issues being addressed, when relevant, “to ensure adaptive integration within the larger social context.”3 The memory is also accessed to investigate whether the treatment effects have been maintained and any new perspective have emerged that might need to be addressed.

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Mechanism of Action

There are several hypotheses regarding the therapeutic effects of EMDR, Dr Solomon said.

One is that the benefits result from a shift in brain state. The bilateral stimulation (eg, eye movements) seems to produce a chain of associations, which allows adaptive information to link to the memory networks holding the maladaptive stored information, allowing integration to occur. The distressing memory is no longer held in isolation, but integrated into the wider memory network. 3

In particular, the rapid eye movements are similar to those that occur during rapid eye movement sleep, which serve to integrate episodic memory into existing semantic memory networks, eliminate the associated negative affect, and develop understanding and insight.2,3

“REM sleep mechanisms process disturbing experiences,” Dr Solomon explained. “The eye movements used in EMDR produce slow waves similar to what happens in sleep, which may push trauma through the nervous system if it is ‘stuck’ there.”2

Another theory is that bilateral stimulation interferes with working memory,2 he said. “When the person brings up the memory through bilateral stimulation, it interferes with the working memory, so that negative images start to fade and negative emotions start to subside. This may account for many of the clinical effects.”

In addition, he suggested, bilateral stimulation may assist with reconsolidation of the memory.

“Each time a memory is activated, there is the potential for the memory to be stored in a new way, which is what seems to happen with EMDR.”

The concept of reconsolidation “distinguishes EMDR therapy from exposure-based, trauma-focused [cognitive behavioral therapy], in which the underlying mechanisms are hypothesized to be habituation and extinction that leave the original memory intact while creating a new memory during the therapeutic process.”3

While exposure-based trauma-focused cognitive behavioral therapy (CBT) causes extinction, shorter exposures such as those used in EMDR lead to memory reconsolidation. Extinction does not necessarily eliminate or replace previous associations. Instead, it results in new learning that competes with the old information.3 In contrast, EMDR allows for a significantly greater amount of positive recall compared with exposure therapy.3

EMDR has been found to be equivalent in efficacy to CBT in addressing symptoms of panic, PTSD, and low self-esteem.4-6 It has been found effective in the treatment of a variety of disorders beyond PTSD, including psychosis, chronic pain, phantom limb pain, anxiety, substance abuse, and eating disorders.7-9

“These findings support the AIP tenet that the unprocessed memory contains the negative emotions and physical sensations experienced at the time of the traumatic events,” and that the outcome of effective EMDR is that the “processed memory becomes stored without the dysfunctional affect and sensations.”3

Working With Children and Adolescents

EMDR has been successfully used in children and adolescents with PTSD. A meta-analysis of 8 studies (n=295 patients) found EMDR to be superior to waitlist/placebo conditions and found that it also showed comparable efficacy to CBT in reducing posttraumatic and anxiety symptoms. The researchers concluded that the results of their meta-analysis “suggest that EMDR could be a promising psychotherapeutic approach for the treatment of PTSD and anxiety symptoms in children and adolescents.”10

“I have found that EMDR works well with children and adolescents, if used with age-appropriate modifications,” Dr Solomon observed. “In fact, it may be even more efficient with kids and it appears to work faster than with adults.”11

Contraindications to EMDR

However, EMDR has some contraindications, Dr Solomon noted.

“Clients have to be able to access memories that may be very disturbing and stay present, with one foot in the past, experiencing memory, and one foot in the present, attending to what’s going on in the therapy room,” he said.

In cases of significant dissociation, EMDR can be utilized, but the client may “need a longer period of stabilization and building up affect tolerance and integrative capacity,” he continued.12

“This is why we only teach EMDR to mental health professionals who can perform an assessment and determine if the client is ready for EMDR and, if not, who have the education and skills to help the client build up affective regulation and integrative capacity to process memories,” Dr Solomon emphasized.

EMDR was once thought to be contraindicated in psychosis, but recent research has suggested that it might have utility and be practiced safely in this population,7,13 as well as in bipolar disorder, unipolar depression, substance abuse, and chronic pain.7,14,15

Dr Solomon noted that psychiatrists can complete training and provide EMDR to their patients directly, or can work collaboratively with a trained EMDR therapist, while they prescribe and oversee pharmacotherapy, when relevant, and possibly engage the client in other therapies.

The research supporting EMDR is substantial, and future research will continue to establish the validity of this approach and expand its potential applications.

The EMDR Institute (https://www.emdr.com) provides training to medical and mental health practitioners, as well as a list for clients seeking this modality.

Dr Francine Shapiro, the originator of EMDR, passed away on June 16, 2019.

References

  1. Shapiro F. Eye movement desensitization: a new treatment for post-traumatic stress disorder. J Behav Ther Exp Psychiatry. 1989;20(3):211-217.
  2. Landin-Romero R, Moreno-Alcazar A, Pagani M, Amann BL. How does eye movement desensitization and reprocessing therapy work? A systematic review on suggested mechanisms of action. Front Psychol. 2018;9:1395.
  3. Shapiro F, Solomon R. Eye movement desensitization and reprocessing therapy. In: Gold, AN (ed.) APA Handbook of Trauma Psychology: Trauma Practice. Washington, DC: American Psychological Association Press, 2017.
  4. Horst F, Den Oudsten B, Zijlstra W, de Jongh A, Lobbestael J, De Vries J. Cognitive behavioral therapy vs. eye movement desensitization and reprocessing for treating panic disorder: A randomized controlled trial. Front Psychol. 2017;8:1409.
  5. Seidler GH, Wagner FE. Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychol Med. 2006;36(11):1515-1522.
  6. Griffioen BT, van der Vegt AA, de Groot IW, de Jongh A. The effect of EMDR and CBT on low self-esteem in a general psychiatric population: A randomized controlled trial. Front Psychol. 2017;8:1910.
  7. Valiente-Gómez A, Moreno-Alcázar A, Treen D, et al. EMDR beyond PTSD: A systematic literature review. Front Psychol. 2017;8:1668.  doi:10.3389/fpsyg.2017.01668
  8. Niraj S, Niraj G. Phantom limb pain and its psychologic management: a critical review. Pain Manag Nurs. 2014;15(1):349-364.
  9. Bloomgarden A, Calogero RM. A randomized experimental test of the efficacy of EMDR treatment on negative body image in eating disorder inpatients. Eat Disord. 2008;16(5):418-427.
  10. Moreno-Alcázar A, Treen D, Valiente-Gómez A, et al. Efficacy of eye movement desensitization and reprocessing in children and adolescent with post-traumatic stress disorder: a meta-analysis of randomized controlled trials. Front Psychol. 2017;8:1750.
  11. Verardo AR, Cioccolanti D. Traumatic experiences and EMDR in childhood and adolescence: a review of the scientific literature on efficacy studies. Clinical Neuropsychiatry. 2017;14(5):313-320.
  12. Van der Hart O, Nijenhuis ERS, Solomon R. Dissociation of the personality in complex trauma-related disorders and EMDR: theoretical considerations. J EMDR Pract Res. 2010;4:76-92.
  13. Croes CF, van Grunsven R, Staring AB, van den Berg DP, de Jongh A, van der Gaag M. Imagery in psychosis: EMDR as a new intervention in the treatment of delusions and auditory hallucinations]. Tijdschr Psychiatr. 2014;56(9):568-576.
  14. Gerhardt A, Leisner S, Hartmann M, et al. Eye movement desensitization and reprocessing vs. treatment-as-usual for non-specific chronic back pain patients with psychological trauma: a randomized controlled pilot study. Front Psychiatry. 2016;7:201.
  15. Carletto S, Oliva F, Barnato M, et al. EMDR as add-on treatment for psychiatric and traumatic symptoms in patients with substance use disorder. Front Psychol. 2018;8:2333.