Eye movement desensitization and reprocessing (EMDR) is a treatment method for traumatic memories and their psychological consequences. The effectiveness of the method in the treatment of post-traumatic stress disorder (PTSD) has been scientifically proven. EMDR was developed in 1987 by the American psychologist Francine Shapiro, who discovered a connection between spontaneous rapid eye movements and the reduction of disturbing emotions. In the following years, this discovery was refined into a systematic psychotherapeutic treatment method, EMDR [1]. At City Psychological Services we provide emdr therapy in London to help patients with ptsd and other mental health issues
Shapiro’s model has as its starting point that psychological traumatization means a disturbance and imbalance in the psychological and biological processes that normally cause experiences and associated memories to be processed. There is an assumption that the individual has a self-healing ability, which usually integrates traumatic memories in a more normalized form. In more serious events, traumatic memories – at least partially – do not seem to be integrated into a wider network. This can lead to a distortion in perception, feelings and reactions to stimuli associated with the original event.
EMDR follows a structured program
EMDR treatment follows a structured treatment protocol [2]. The patient is encouraged to identify different aspects of the traumatic memory: images and beliefs, affective and physiological response elements, negative self-representations, and an alternative, desired positive self-representation. Rating scales are used to be able to follow the processing process.
Then the processing takes place. The patient is asked to focus on the disturbing image, the negative thought and the bodily sensations associated with the memory. At the same time, the therapist moves his hand back and forth in front of the patient’s face while the patient follows the movement of the hand with his eyes. Alternatives to eye movements are sound signals or tactile stimulation. After approx. 30–40 seconds, the stimulation is stopped, and the patient can tell about the thoughts, memories, feelings or bodily sensations that have been activated.
The process is repeated until the anxiety level has been maximally reduced. This part of the treatment is often the most intensive, but equally important is the subsequent one, where a more adequate self-referential self-concept associated with the trauma is established and residual bodily reactions are processed. The patient is prepared for the processing to continue between treatment sessions. The patient is encouraged to keep a diary of feelings, thoughts and dreams related to the trauma and to use self-control techniques for anxiety and tension reduction.
Hypotheses about mechanisms of action
EMDR therapy is now an internationally accepted treatment method for PTSD [3-9]. The British National Institute of Clinical Excellence (NICE) determined in 2005 that EMDR can be recommended for PTSD treatment [10]. In the same year, an SBU report arrived at corresponding recommendations [11].
However, it has not yet been possible to fully explain exactly how the method works. One explanation put forward is that the EMDR methodology could »trick« the CNS into releasing the fixation on maladaptive reaction patterns that are no longer functional [12]. Alternating bilateral stimulation, such as eye movements, sound or touch, appears to be able to create a state of »mindfulness« – a relaxed state in the information processing system. This could create conditions for new thoughts and perspectives and facilitate the processing of the traumatic memories [13]. The EMDR treatment appears to activate networks of associated memories, which supports the hypothesis that active processes involve information processing rather than a pure exposure effect [14].
Some findings suggest that EMDR has both neurobiological and psychological effects. Through studies with positron emission tomography (SPECT), van der Kolk and colleagues have shown that three treatments with EMDR seem to be able to correct the marked asymmetry in traumatized people. This was noticed in the form of increased activation in Broca’s area and through increased bilateral activation of the posterior central sulcus, which is stated to facilitate a more realistic differentiation between real and perceived threat and reduce overexcitement [15].
Others have found that the eye movements in EMDR lead to reduced skin conductance, lower heart rate and increased body temperature [16, 17]. In a study from 2003, it was found that, contrary to the assumption that it can create false memory images, eye movements instead increase the retrieval of the episodic memory [18]. Which individual component is active in the EMDR treatment has not yet been clarified. The importance of bilateral stimulation to facilitate information processing has been questioned by several authors [19, 20].
Intended for PTSD and acute stress disorders
EMDR is a method that has been developed for the treatment of primarily PTSD and acute stress disorders, but the method can also be applied to the treatment of other disturbing traumatic memories. In the case of multiple traumatization and complex PTSD, EMDR can be part of the treatment, where perhaps most of the treatment time is spent on psychologically stabilizing the patient before trauma processing can take place.
EMDR has also been shown to be effective for traumatized children and adolescents [21-27].
EMDR compared to other methods
Pharmacological treatment for PTSD includes antidepressants and anti-anxiety preparations. A meta-study comparing pharmacotherapy and psychotherapy found that psychotherapy appeared to be slightly more effective as a treatment method for PTSD [28]. Compared to cognitive behavioral therapy, EMDR has comparable treatment effects on adult populations. In several studies, EMDR has been shown to require fewer treatment hours and is better tolerated than other treatment options [29-33]. Other comparative studies have shown more equivalent results or an advantage for CBT methods [34, 35].
In a treatment study by Power et al [36], 105 patients with PTSD were randomly assigned to EMDR, CBT, or wait list. In the active treatment groups, ten treatment sessions were given over ten weeks. The patients were assessed by blinded assessors during and after treatment and after 15 months. Both treatment groups improved, a result that persisted at 15 months, with a slight advantage for EMDR. In a well-controlled study by Rothbaum et al [37], also with independent blinded raters, three groups of adult female rape victims with PTSD were compared. One group received EMDR treatment, another extended exposure, and a third group constituted a waitlist control group. Both treatment groups improved, a result that persisted at a six-month follow-up.
No side effects reported
No negative side effects were reported in the studies reviewed. It has been commented that EMDR activates less anxiety than other therapies that include exposure, due to the fact that the exposure is dosed through the patient’s thoughts rather than through confrontation with disturbing images.
Costs and cost-effectiveness
The effectiveness of EMDR has been shown to be good in several studies. Not unexpectedly, effectiveness is greatest for patients with circumscribed trauma. The cost of EMDR treatment is mainly in the hourly rate charged by a trained EMDR therapist. Treatment mostly takes place in outpatient care. The length of treatment varies with the severity of the problem. In the case of limited PTSD in a patient with an otherwise intact personality, 6–10 treatments may be sufficient, but for severely traumatized patients the treatment time is often considerably longer. The treatment session is estimated at 90 minutes.
Training in EMDR requires that the therapist has qualified prior knowledge (licensed psychologist, licensed psychotherapist or psychiatrist with basic psychotherapy training). In order to be certified as an EMDR therapist, experience of at least 50 EMDR treatments with at least 20 clients and supervision by an approved supervisor is required.
