EMDR—TWENTY YEARS LATER
May 2, 2009
(Accepted for Publication in the Spring 2009 Issue of the Indiana Psychiatric Society Newsletter)
This year marks twenty years since the publication of the first study of Eye Movement Desensitization and Reprocessing (EMDR) for the treatment of post traumatic stress disorder. This article attempts an overview description of the current status of EMDR: what it is, what the research says, and theories as to the mechanism of action. In addition I will share some observations and clinical vignettes from my own practice.
EMDR is a psychotherapeutic approach, rather than a technique or a protocol. EMDR’s underlying theory has two hypotheses: (1) much of psychopathology has its origins in experience implicitly or explicitly perceived as traumatic and (2) there is a block in the central nervous system’s innate ability to process, i.e., to adaptively access and integrate aspects of the trauma into a coherent and temporally updated context. Traumatic experience is understood to exist in a wide range, from a parent’s dismissive remark to an embarrassing childhood experience to the DSM Criterion “A” events that anyone would identify as major trauma. While EMDR appears to “jump start” this innate ability for processing which has become blocked, its mechanisms of action are undetermined and discussions remain lively around just exactly what is happening and what are the minimal essential components of EMDR. Although the preponderance of research looks at EMDR treatment of post traumatic stress disorder (PTSD), most EMDR clinicians perceive little difference in the effectiveness of EMDR in treatment of major trauma and in the reprocessing of the day to day traumas that may appear small but nevertheless shape self-perception, perception of the world, and ways of relating to others. When EMDR is used to treat the lifelong smaller events that shape personality, the duration of the treatment is longer than that of type I PTSD.
A typical EMDR session identifies an event experienced as traumatic by the patient and apparently related to the presenting problem. Even a recent event meeting criterion “A” definition may have an antecedent in childhood which affects the way in which the current event is processed. Components of the trauma—sensory phenomena, negative cognitions about self, emotions and somatic re-experiencing—are elicited. A protocol facilitates the activation of these components so that they are accessible for processing and integration. Desirable alternatives are identified, intensities are measured, and a ground-work is laid to follow progress. These traumatic components are activated and paired with some type of alternating bilateral or dual-attention stimulation, e.g., eye movements, auditory tones, tapping, or vibrating electrodes, which are applied in sets lasting about 20-30 seconds
For example, if eye movements are chosen as the type of stimulation, the assessment is completed as described above. The patient then holds in mind the image representing the worst of the trauma (“I see the truck crossing the median and coming straight at me”), the negative belief about self connected to that image (“I’m going to die”), and where the memory is felt in the body (“my chest, my throat, my shoulders. My whole body feels tense.”) The therapist moves two fingers rapidly from side to side approximately 20 to 30 times in front of the patient, who tracks the finger movement with his eyes. At the end of each set of eye movements, feedback is elicited as to change or lack of change in one or more components, essentially “What comes up now?” If processing is not progressing, that is if some change is not occurring, the therapist has a number of options to help get the processing going again, using the least interference possible. Processing continues until the memory is no longer upsetting, the negative self cognition (usually about safety, responsibility, or choice) is changed to a more positive one, and the body is cleared of disturbance. Ideally past, present and future anticipated triggers are processed to resolution. My experience is that successful processing is in general accompanied by lasting changes in the life of the client, such as decrease or elimination of symptoms, loss of diagnosis, or noticeable difference in life choices. Positive spiritual changes, such as a deep sense of peace, are not uncommon.
Approximately twenty randomized controlled trials exist which positively compare EMDR to antidepressant medication, exposure therapy, cognitive behavioral therapies, and other psychotherapies in the treatment of PTSD. Many treatment guidelines, including the American Psychiatric Association, the International Society for Traumatic Stress Studies, and the Department of Defense, have rated EMDR at the highest level of evidence-based effectiveness in the treatment of PTSD. Numerous meta-analyses show no difference in effectiveness between EMDR and CBT treatments for PTSD, although EMDR requires no homework. The findings in a few studies indicate that it may require fewer sessions than CBT. Although some positive research exists for EMDR’s effectiveness with veterans, children, disaster survivors, and adults abused in childhood, and many clinicians report success with these types of clients, more research is needed for these specific populations. In my own practice childhood abuse survivors have expressed deep gratitude for the transformation that EMDR has brought to their lives. Others have described feeling a “lightness” to life previously unknown.
Although EMDR’s efficacy has been established in the treatment of PTSD, research is still in the preliminary stages for its treatment of other disorders. For example, while EMDR has successfully eliminated secondary depressive symptoms in many PTSD studies, no published study has yet investigated EMDR treatment of primary depression. Similarly, research on EMDR treatment of panic disorder (with agoraphobia) has had uncertain results. It has been suggested that anxious patients may need lengthier preparation before targeting distressful experiences. For example, a recent case study with a woman who had suffered for 12 years from panic disorder with agoraphobia, provided 6 preparatory sessions and 15 EMDR sessions, with complete remission of symptoms and maintenance of positive behavioral changes at one-year follow-up. A clinical series of 4 patients with generalized anxiety disorder were provided with 15 EMDR sessions to each participant to treat etiological memories. At follow-up, two patients were still symptomatic, but all had lost the diagnosis.
There is also some indication that EMDR may be helpful for somatic symptoms with traumatic etiology. Several case studies provided preliminary evidence for EMDR treatment of phantom limb pain. In one case series, 5 patients with chronic (1-16 yrs) phantom limb pain, previously treated in both inpatient and outpatient settings, received 3 to 15 sessions of EMDR. Post-EMDR, there was a significant decrease or elimination of phantom limb pain, reduction in depression and PTSD symptoms to sub-clinical levels, and significant reduction or elimination of medications related to the phantom pain. There are also promising studies of EMDR as adjunct treatment for chemical dependency, conduct disorder, and sexual offense.
Current theories as to how EMDR works include the following: (1) synchronization of the two hemispheres, (2) de-conditioning caused by a relaxation response, (3) “jump-start” of a process similar to that of REM sleep, (4) the initiation of an orienting response, (5) the promotion of thalamocortical temporal binding in 40 Hz neural oscillation range which helps to integrate somatosensory, sensory, cognitive and affective material, and (6) the activation of the cerebellum, setting off a sequence of information processing which activates the thalamus and eventually the frontal lobes, increasing dorsolateral and orbitofrontal processing. Neuro-imaging studies pre- and post-EMDR show changes compatible with any successful treatment of PTSD but do not really clarify the mechanism of EMDR. Dismantling studies which have attempted to demonstrate whether or not eye movements are an essential component of the treatment, have significant methodological flaws and so far add little information. Numerous studies have shown that eye movements reduce the emotionality and vividness of distressing memories, produce physiological relaxation, and enhance episodic memory recall. While research has yet to investigate the effects of the other forms of bilateral or dual-attention stimuli (auditory tones, tapping, etc.) most clinicians report the various stimulation modalities to be equally effective, although they may prefer one over another.
In my own clinical experience with EMDR over the past 12 years, I find it to be a highly effective treatment approach. As with any treatment, EMDR is not appropriate for everyone. However, I have used it with good results in a wide range of patients, including veterans, rape victims with and without significant childhood trauma, accident victims, those witnessing the traumatic death of a loved one, patients with medical traumas such as awaking during surgery, men with anger-management problems stemming from their own childhood abuse, women with childhood physical, sexual and emotional abuse, selected patients with borderline personality disorder and still others with dissociative disorder.
Most (approximately 75 to 90%) of single-episode adult traumas in an otherwise relatively healthy person can be adequately resolved in one to three 90-minute sessions. The greater the number of traumas and the younger the person at the time the traumas occurred, the greater the care required in the stabilization and preparation phases of treatment, and the greater the care required not to “flood” the person with their traumas, resulting in destabilization and re-traumatization. “Fractionation” of the trauma, i.e., processing one aspect of the trauma at a time, may be required. Treatment in those with complex trauma histories, heavy reliance on dissociative defenses, and involvement of the structure of personality formation remains a lengthy process. However, for a number of such patients, therapy can be shortened significantly with the judicious use of EMDR in the hands of a skilled therapist. For many with fewer traumas even if they are severe, and with basically good ego strength, EMDR can produce results which are rapid and dramatic, unlike anything I have seen with other modalities. Results tend to be long-lasting, and positive effect may actually increase with time.
Amy Konkle, M.D.
May 2, 2009