Eye movement desensitization and reprocessing

Medical uses

Two meta-analyses from 2013 found that EMDR therapy is better than no treatment and similar in efficacy to cognitive behavioral therapy (CBT) in chronic PTSD. However, due to "very low" quality of evidence, significant rates of researcher bias, and some participant drop outs, the meta-analysts cautioned against interpreting the results of the studies which were analyzed. A 2007 review concluded that trauma-focused cognitive-behavioral therapy or EMDR are first-line psychological treatment for PTSD.

In one meta-analysis of PTSD, EMDR was reported to be as effective as exposure therapy and SSRIs. Two separate meta-analyses suggested that traditional exposure therapy and EMDR have equivalent effects immediately after treatment and at follow-up. A review of rape treatment outcomes concluded that EMDR had some efficacy. Another meta-analysis concluded that all "bona fide" treatments were equally effective, but there was some debate regarding the study's selection of which treatments were "bona fide." Another review concluded EMDR to be of similar efficacy to other exposure therapies and more effective than SSRIs, problem-centered therapy, or 'treatment as usual.'

Position statements

The International Society for Traumatic Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults. Some international guidelines recommended EMDR therapy — as well as CBT and exposure therapy — for treating trauma.

In 2013 the World Health Organization practice guidelines stated that trauma-focused CBT and EMDR therapy are the only psychotherapies recommended for children, adolescents, and adults with PTSD: "referral for advanced treatments such as cognitive-behavioural therapy (CBT) or a new technique called eye movement desensitization and reprocessing (EMDR) should be considered for people suffering from PTSD. These techniques help people reduce vivid, unwanted, repeated recollections of traumatic events. More training and supervision is recommended to make these techniques more widely available."

In 1999, EMDR was a controversial therapy within the psychological community, and in 2000, its efficacy compared to other treatments and underlying mechanism was the subject of debate. However, since 2004, EMDR has been recommended as an effective treatment for trauma in the Practice Guidelines of the American Psychiatric Association, the Departments of Veterans Affairs and Defense, SAMHSA, the International Society for Traumatic Stress Studies, the National Institute for Health and Care Excellence and the World Health Organization.

Other applications

Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR therapy’s efficacy with other disorders, such as borderline personality disorder, and somatic disorders such as phantom limb pain.

Children

EMDR has been used effectively in the treatment of children who have experienced trauma and complex trauma. EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.

History

EMDR therapy was first developed by Francine Shapiro upon noticing that certain eye movements reduced the intensity of disturbing thought. She then conducted a scientific study with trauma victims in 1988 and the research was published in the Journal of Traumatic Stress in 1989

Shapiro noted that, when she was experiencing a disturbing thought, her eyes were involuntarily moving rapidly. She noticed further that, when she brought her eye movements under voluntary control while thinking a traumatic thought, anxiety was reduced. Shapiro developed EMDR therapy for posttraumatic stress disorder. She speculated that traumatic events "upset the excitatory/inhibitory balance in the brain, causing a pathological change in the neural elements".

EMDR therapy uses a structured eight-phase approach to address the past, present, and future aspects of a traumatic or distressing memory. The therapy process and procedures are guided by the Adaptive Information Processing model.

Controversy

EMDR has generated a great deal of controversy since its inception in 1989. Shapiro was criticised for repeatedly increasing the length and expense of training and certification, allegedly in response to the results of controlled trials that cast doubt on EMDR's efficacy. A 2002 review disputed the two articles and similar statements, stating that “scientific debate has begun to degenerate into slurs, innuendo, and ad hominem attacks”.

In 2000, Herbert et al. argued that the eye movements did not play a central role, that the mechanisms of eye movements were speculative, and that the theory leading to the practice was not falsifiable and therefore not amenable to scientific inquiry. As discussed in 2013 by Richard McNally, one of the earliest and foremost critics: "Shapiro’s (1995) Eye Movement Desensitization and Reprocessing (EMDR) provoked lively debate when it first appeared on the scene in the late 1980s.... Skeptics questioned whether the defining ingredient, bilateral eye movement, possessed any therapeutic efficacy beyond the imaginal exposure component of EMDR.... A 2001 meta-analysis suggested that EMDR with the eye movements was no more efficacious than EMDR without the eye movements (Davidson & Parker, 2001), implying that "what is effective in EMDR is not new, and what is new is not effective" (McNally, 1999, p.619). A 2013 meta-analysis concluded, 'the eye movements do have an additional value in EMDR treatments'. However, the authors of this analysis addressed several limitations with this study by stating, "This study has several limitations. The most important one is that the quality of included studies was not optimal. This may have distorted the outcomes of the studies and our meta-analysis. Apart from ensuring adequate checks on treatment quality, there were other serious methodological problems with the studies in the therapy context".

Likewise, Salkovskis in 2002 reported that the eye movement is irrelevant, and that the effectiveness of EMDR was solely due to its having properties similar to CBT, such as desensitization and exposure. However, the 2013 World Health Organization practice guidelines drew clear distinctions in contrasting CBT and EMDR therapy procedures: "This therapy [EMDR] is based on the idea that negative thoughts, feelings and behaviours are the result of unprocessed memories. The treatment involves standardized procedures that include focusing simultaneously on (a) spontaneous associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Like CBT with a trauma focus, EMDR aims to reduce subjective distress and strengthen adaptive beliefs related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework".

Although one early meta-analysis conducted in 2002 concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy, other researchers using meta-analysis had found EMDR to be at least equivalent in effect size to specific exposure therapies.

The working mechanisms that underlie the effectiveness of the eye movements in EMDR therapy are still under investigation and there is as yet no definitive finding. The consensus regarding the underlying biological mechanisms involve the two that have received the most attention and research support: (1) taxing working memory and (2) orienting response/REM sleep.