Eye Movement Desensitization and Reprocessing Therapy (abbreviated as EMDR) is a form of psychotherapy that combines both behavioral therapy techniques and cognitive behavioral techniques with the utilization of lateral eye movements.
EMDR was developed by Dr. Francine Shapiro, a psychotherapist, in the 1980s. She had observed that her clients who were in psychotherapy for issues related to trauma reported relief from their stress as they discussed their recollections of stressful events while engaging in lateral eye movements. Lateral eye movements consist of horizontal movements of the eyes from right to left and then left to right as the individual follows the therapist’s fingers, which the therapist waives horizontally across the client’s visual plane.
Shapiro’s technique gained popularity with therapists. As she refined the technique, she applied it to the treatment of other issues, such as depression, anxiety, and even substance abuse. EMDR has achieved a sort of cult status within the field of clinical psychology. There are journals that specialize in research for EMDR as well as an international organization devoted to the technique. Nonetheless, the technique has generated moderate controversy in the field of clinical psychology.
Principles of EMDR
The first basic principle of EMDR is that the client reflects on their emotionally charged or upsetting experiences while they follow the therapist’s hands back and forth across their visual field. This is the lateral eye movement component of EMDR. Dr. Shapiro has been asked in numerous contexts how this lateral eye movement is supposed to work, and she has explained that use of saccadic eye movements helps to reprocess emotionally laden experiences.
Saccadic eye movements consist of jerky and fast movements of the eyes that occur whenever an individual attempts to focus on an object. Dr. Schapiro and her group have posited numerous neuroanatomical exhalations of why these movements help individuals to process emotionally laden memories or experiences; however, many of these explanations are questionable at best. Essentially, the use of the lateral eye movements is the only original application used in EMDR.
EMDR borrows heavily from other forms of psychotherapy and from overall general principles derived from research that have been found to increase the effectiveness of therapy. These specific techniques and principles include:
- Focus on the therapeutic alliance (relationship) as the mechanism of change: The therapeutic alliance has been studied extensively by researchers who consistently identify that a positive therapeutic alliance is essential to successful outcomes in psychotherapy. The therapeutic alliance is the working bond or relationship between the client and the therapist. A positive therapeutic alliance includes both the therapist and client’s mutual respect of each another, trust in one another, and the therapist trying to understand the client from the client’s point of view. EMDR therapists use a positive therapeutic alliance to effect change. Developing a positive therapeutic alliance has been a principal that has been used extensively by psychotherapists since the time of Sigmund Freud, and its use is not specific to EMDR.
- Numerous activities, which are learned and practiced in therapy sessions: EMDR is what is often termed an “action-oriented” type of psychotherapy. Clients in EMDR therapy are not passive; they are actively involved in the session. The client is expected to practice and refine techniques in the therapy sessions.
- Extensive use of homework: Therapists also assign homework projects for the client to complete and discuss in the next session. Homework sessions typically involve more practice of the skills and techniques that have been learned in the session. Homework involves practicing these techniques in the real world and then later discussing the results with the therapist to refine them. EMDR therapists were not the first therapists to assign homework.
- The use of exposure techniques: Exposure therapy is a behavioral therapeutic technique that was developed by behavioral psychologists. The technique quite simply involves exposing individuals to anxiety-provoking or stressful stimuli, images, memories, etc. The technique works on the assumption that repeated exposures to these situations allows the individual to habituate, and over time, the distress, anxiety, discomfort associated with the stimulus will dissipate.
This technique has been used in numerous contexts by professional therapists who are trained in applying the technique safely. In addition, cognitive therapists have used exposure techniques extensively by having individuals imagine or recollect past traumatic events, anxiety-provoking situations, feared outcomes, etc. Cognitive-behavioral therapists often use exposure techniques in conjunction with relaxation training. When individuals are trained in muscle relaxation and diaphragmatic breathing, they can tolerate any anticipated stress or discomfort associated with exposure more effectively.
EMDR uses exposure techniques and stress management techniques, such as relaxation training, heavily. Exposure is a technique that is a component of numerous cognitive-behavioral therapeutic interventions, and it has been around far longer than EMDR.
- Systematic desensitization: Systematic desensitization is a specialized exposure technique where individuals develop a ranking of potentially stressful or anxiety-provoking situations, from the least to most distressing. Starting with the least stressful or anxiety-provoking situation, the therapist uses exposure to inoculate the individual against the stress or anxiety associated with that style in a hierarchy until the individual can tolerate the most severe or stressful memory, anxiety-provoking event, etc. Systematic desensitization is often used in conjunction with progressive muscle relaxation and diaphragmatic breathing techniques to foster a relaxed state. This application has been used extensively for decades by behavioral therapists, cognitive therapists, and cognitive-behavioral therapists, so it is not unique to EMDR.
- The use of cognitive-restructuring techniques: Cognitive-restructuring techniques come from the cognitive paradigm in psychology and have been instrumental in the success of Cognitive Behavioral Therapy. These techniques begin with the identification of irrational beliefs, attitudes, or expectations that are held by the client (e.g., “Everyone must like me.”). Then, the therapist and client challenge these in order to determine their validity. Most often, dysfunctional cognitive structures are found to be inconsistent with reality. Cognitive restructuring involves changing belief systems, attitudes, expectations, etc., to be functional and consistent with the real world.
- Others: EMDR borrows liberally from the cognitive and behavioral schools of psychotherapy and incorporates numerous techniques from these schools into its own protocol. Using techniques from other paradigms is acceptable; however, simply borrowing techniques from other paradigms and claiming that these techniques are specific or unique to EMDR is a kind of therapeutic plagiarism.
The Formal Treatment Process in EMDR
EMDR uses an approach that immediately gets both the therapist and the client involved in the treatment. Variations in the treatment process will occur from therapist the therapist, but there is an overall recommended approach that involves eight phases or steps in the treatment.
- In the initial phase of treatment, the therapist must assess and gather information from the client in order to understand the client and the issues that brought the client to therapy. This information-gathering process will continue all the way through the treatment, but it is the focus of the first sessions (typically the first two appointments). Therapists aim to get a complete history of the individual and to identify targets or specific areas of the person’s experience that will need to be formally addressed in the treatment (e.g., past stressful events, things that provoke anxiety in the person, factors or characteristics of the person that may interfere with treatment progress, etc.).
- In the second phase, the therapist begins to focus on creating a positive therapeutic alliance by explaining the goals of the treatment and the philosophy of the treatment, and by providing the client with tools that can be used immediately, such as the development of stress management through progressive muscle relaxation and/or breathing techniques and the use of mental imagery.
- The therapist and client work together to identify the targets that the treatment will focus on and the emotions associated with these targets. They discuss how to deal with anxiety, stress, and other negative emotions as the therapy progresses; they develop a rating scale to rate the stress associated with the specific targets that will be treated in therapy; and they identify the specific goals of the therapy.
- In this phase, the actual implementation of EMDR is used. The client focuses on the therapist’s fingers as they use stress management tools while they recollect stressful memories, anxiety-provoking events, etc. Cognitive-restructuring techniques are also implemented.
- This step concentrates on inserting positive feelings in the individual, particularly inserting positive feelings associated with past memories that may have been stressful, anxiety-provoking, etc.; this is a form of cognitive restructuring.
- After addressing all the targets and using the EMDR method, the therapist and client evaluate the results of the therapy. Any stress, anxiety, tension, etc., that remains and is associated with the targets is identified, and the client and therapist return to step 4 and recomplete the process.
- The process of closure begins. The therapist and client reassess the client’s progress to make sure the client is satisfied with the outcome of the treatment and all goals have been met.
- A comprehensive review of the treatment, goals, treatment plan, and results occurs. If any areas need further intervention, the therapist and client go back to the appropriate stage and go through the process again. If the client is satisfied with their progress in treatment, the therapy is terminated.
Qualifications to Practice EMDR
EMDR is a recognized form of psychotherapy. In order to practice EMDR professionally, an individual must have a license to perform psychotherapy within the state, and complete specific and intensive training that leads to certification in EMDR interventions.
Competent practice of EMDR cannot be learned through reading articles or books. It requires that an individual be formally trained by an individual certified in EMDR who is qualified to train others.
Issues with EMDR
As mentioned above, EMDR practitioners are fully convinced that the technique is a valid and unique approach to the treatment of stress, trauma, anxiety, and numerous other issues. The therapists are often devoted to the technique and to the principles originally developed by Dr. Shapiro. However, there have been numerous concerns associated with this technique.
The first issue that is often considered to be a “red flag” by many professional psychologists is that the eye movement component of EMDR is not necessary.
Some of the therapists who practice EMDR do not even use the eye movement component but instead use other types of attention-grabbing techniques, such as finger taps, sounds, or other attention-focusing techniques with equivalent success to therapists who use the eye movement component. Thus, it is unclear if the eye movement component of the technique offers any incremental clinical utility to other already empirically validated techniques from the cognitive and behavioral schools of psychotherapy.
The text Science and Pseudoscience in Clinical Psychology, a book that attempts to differentiate empirically validated techniques in clinical psychology from techniques that are not empirically validated, reviewed the research regarding the effectiveness of EMDR and concluded that the eye movement component is not necessary, and the success of the EMDR therapy technique is primarily due to the use of cognitive and behavioral components. Numerous other sources, including meta-analytic research and the journal Scientific American, have come to the same conclusion.
A 2013 study in the prestigious Cochrane Review found that EMDR is superior to no treatment at all for trauma- and stressor-related disorders, and overall, its treatment success is comparable and equivalent in its effectiveness to other cognitive-behavioral forms of treatment used to address these issues. These findings suggest that the EMDR technique offers no incremental validity over the other already established interventions that it incorporates and that the eye movement component adds very little, if anything at all, to the therapy; incremental validity refers to the notion that a new type of technique increases the effectiveness of already established techniques. Thus, it appears that the effectiveness of EMDR is primarily due to its use of established cognitive and behavioral principles.
These types of findings suggest that EMDR is certainly no worse than already established treatments, but it also adds little that is unique to techniques that have been used and developed by other paradigms. This could be an important consideration when an individual is choosing a therapist who uses EMDR compared to one who uses more standard cognitive-behavioral techniques because EMDR interventions are often more expensive than standard cognitive-behavioral treatments. However, some individuals may become more involved in therapies that use different or unique approaches, and may experience more satisfaction as a result of the overall approach used by EMDR therapists and its concentration on the relationship between the client and therapist.