Eye Movement Desensitization and Reprocessing

Abstract

Eye Movement Desensitization and Reprocessing is a relatively new method that has been developed in the treatment of Post Traumatic Stress Disorders (PTSDs). Its historical development is traced to discoveries made by Francine Shapiro while she was pursuing her doctoral studies. This method for treating patients with certain traumatic disorders has been widely adopted by numerous psychologists and psychotherapists in the short time since its development in 1989.

Researchers are divided on the usefulness of this method in treating Post Traumatic Stress Disorder or other related stress disorders. Some researchers have pointed to considerable benefits of using this approach in comparison to other methods. Other researchers are suggesting that there are several methodological and theoretical weaknesses and limitations of the method. Overall the method is being used extensively, even though certain methodological issues have yet to be resolved because there is limited research into corresponding or alternative methods for treating stress-related disorders.

Introduction

The use of the Eye Movement Desensitization and Reprocessing in psychotherapy with patients who are suffering from a variety of traumatic disorders has been given considerable attention by researchers. Since it was developed several researchers have adopted its strategies and principles in empirical studies to examine its usefulness in the treatment of traumatic disorders. There have been a considerable number of researchers who are advocating the usefulness of this method based on empirical findings with trauma patients. Other researchers have presented a contrary view of the matter.

Opponents of the method have themselves conducted empirical research into the usefulness of the EMDR approach to treating traumatic disorders. Their reports, they argue, do not demonstrate much promise for EMDR. With the camp divided on the overall effectiveness of EMDR it is difficult to predict the future prospects of the method. Given the comparatively bad reports by researchers in and the continued propagation of this method despite those criticisms, it is fair to assume that this method will continue to be the one of choice for psychotherapists. Of course further research may be necessary and that research may only serve to strengthen the position of the advocates of EMDR.

Definition

Eye Movement Desensitization and Reprocessing, shortened EMDR, is a type of exposure or desensitization psychotherapy which involves clients re-experiencing a traumatic event and mentally dealing with the trauma associated with the event. The patient is required to move their eyes at the same time as they are mentally recalling the event (Hyer & Brandsma 1997). This method makes use of certain techniques that have been used in the field of psychotherapy such as free association, desensitization and cognitive and emotional processing (Hyer & Brandsma 1997, p. 515).

EMDR is considered an active psychological treatment for Post-traumatic Stress Disorder (Perkins & Rouanzoin 2002, p. 77) and has been hailed as a very unique form of treatment (Shapiro 2002, p. 2). It is often considered as a strain of cognitive behavioral therapy. The method is multifaceted and applied principles from various disciplines. The method, which is carried out in eight phases, functions primarily from an information processing model. This model assumes that traumatic disorders arise when perceptual information has not been appropriately or correctly adapted to by the patient.

Treatment of such conditions would therefore focus on altering these perceptions whether they are cognitive, affective, or somatic in nature. Psychotherapists using this method would therefore attempt to accelerate the rate ate which previously experienced traumatic events are accessed and processed in an attempt to facilitate the patients managing these events. Additionally EMDR aims at strengthening the patient’s internal resources in order to accomplish positive behavioral and interpersonal change (Shapiro 2002).

As it suggests, one of the critical elements in the EMDR method is the role of eye movements as an essential element of treatment. The very name of the method, however, begs for confusion and misinterpretation. Spector and Read (1999) point out that, contrary to what the name implies, EMDR involves an assortment of therapeutic elements for the treatment of traumatic disorders. Eye movements are only one element of this method.

Shapiro (2002) also highlights this fact. She points out that eye movement is only one form of dual simulation that can be used with this treatment method and that there are other recognizable elements that are widely used in dealing with traumatic disorders. Other forms of dual simulation that could be used have been enumerated and these include handtaps and tones.

Furthermore dual simulations are in themselves a component of a more multifaceted approach. Lateral simulations such as finger taps are also possible and Spector and Read (1999) suggest that these might be even as effective as eye movements. Left-right sensory simulations have also been proposed as alternatives. These may take visual, auditory or tactile or tactile forms. All these procedures are suggested to facilitate information processing, an essential component of the method (Spector & Read 1999, p. 166).

Since eye movements are not the sole methods of simulation that may be employed in this method, researchers are realizing that eye movements may not necessarily be essential. Though researchers acknowledge that eye movements are an integral aspect of the basic method, these researchers propose that this technique is not always necessary (Davidson & Parker 2001, p. 305).

Researchers have suggested alternatively that any form of exposure technique that contains a thought-stopping component, is effective in accomplishing the objectives of EMDR. In fact, researchers have discovered that, even though eye movements may have some effect on patients during sessions, the empirical data has not demonstrated that this aspect is absolutely essential and has very little impact on the outcome of therapeutic sessions (Davidson & Parker 2001, p. 305).

Perkins and Rouanzoin (2002) argue that the eye movement component should not be discounted. They suggest that, even though prior empirical research has not revealed the absolute necessity of using eye movements, further research must still be carried out.

Research designed to examine the effects of EMDR treatment at the group level have been conducted but the results do not say much and are therefore inconclusive. Other research among groups of combat veterans has yielded the same questionable results. What these researches lacked fundamentally were properly constructed methodological frameworks. Perkins and Rouanzoin highlight that the two basic methodological flaws are the use of inadequate sample sizes and the short duration of the treatment sessions based on the population used.

Therefore, though previous studies were not focused on researching this specific question and therefore, before conclusions can be drawn and this element discounted, specific research into the eye movement component must be undertaken. They contend that “eye movement component in the EMDR process awaits empirical validation” (p. 83) and that the conclusions that have been drawn by researchers denying its usefulness are premature and groundless.

Shapiro (2002) clarifies a further misconception about EMDR. The aspect of desensitization suggests simply attempts at reducing the anxiety levels of patients. What is not evident is that the method is also responsible for drawing out positive behavioral and interpersonal adjustments, alterations in beliefs and perceptions and new perspectives.

These effects, though not the primary focus of the method, are positive side effects that contribution to improvements in the perceptual readjustment of the patients. These elements focus on the processing aspects of the method and demonstrate the multidimensionality of EMDR.

Therefore, even though the name Eye Movement Desensitization and Reprocessing has been used to describe the method, it is limited in that it does not give a good representation of the methods that are involved and the outcomes that are anticipated. Shapiro (2002) suggests an alternative term for this method – “Reprocessing Therapy” (p. 2).

Aims of EMDR

There are three primary goals of EMDR. These goals are accomplished via the standardized procedures and protocols that have been developed. These procedures, as highlighted above, are comprehensive in nature, incorporating the principles of varying theoretical orientations such as cognitive-behaviorism, psychology, physiology, experiential an interactional therapy among others. The principal aims of this procedure are:

1. To help patients come to terms with and resolve traumatic memories by eliciting insight, cognitive reorganization, adaptive effects and physiological responses (Shapiro 2002, p. 2).
2. Using second-order conditioning to facilitate desensitization of the stimuli which activates trauma (Shapiro 2002, p. 2).
3. To incorporate modified perceptions, skills and behaviors in enhancing the patient’s ability to effectively maintain interpersonal relationships with other members in the society.

Treatment Areas

EMDR is a therapeutic method and was initially advocated as a treatment option for patients who have had difficult coping with traumatic events. In its original conceptualization EMDR was aimed at treating patients with traumatic or memory disorders. This method attempted to help patients deal with these experiences and their consequences. When the method was first developed it was quite popular among psychotherapists and was hailed by many as a very novel approach to the treatment of trauma patients. The method was therefore widely used specifically in patients experiencing post-traumatic stress disorder. Here psychotherapists attempted to alter the traumatic memories experienced by patients following a distressing event.

EMDR in the field of psychology and psychotherapy has evolved in the types of disorders it is now being used to treat particularly in more recent years. Among the new treatment areas in which the EMDR method has been proliferated Davidson and Parker (2001) note anxiety disorders, panic disorders, claustrophobia, blood injection phobias and spider phobia (p. 305).

Additional areas are in personality disorders, to treat chronic gambling habits and to cope with work performance and pain (Spector & Read 1999, p. 165). Perkins and Rouanzoin (2002) add dissociative disorders, eating disorders, learning problems, depression, drug abuse, and tobacco addiction, enhancing peak performance to the list of possible treatment areas.

Spector and Read (1999) go on to suggest that there is hardly an area of psychopathology in which EMDR is not being used. This method has even been applied in the area of special needs education focusing on children with learning disabilities.

It would appear from all this that EMDR is being presented as a panacea for all stress-related disorders. Therefore, though EMDR was initially relevant to anxieties related to traumatic memories, it is now being used increasing to treat a variety of experientially based disorders (Shapiro 2002, p. 2).

Historical Development

As she was strolling in a park in 1987, doctoral candidate Francine Shapiro made a significant discovery in the field of psychotherapy and psychology. She discovered that upsetting thoughts went away once she moved her eyes quickly from side to side. This observation resulted in the phenomenal discovery of EMDR, a procedure that could be used in the treatment of PTSD.

In this procedure the therapist asks the patient to recall an unsettling image and describe it while following the therapist moving his fingers from side to side. This eye movement aspect is conducted once every 30 seconds for between five and fifteen seconds. The patient then has to report on any changes in the image, its description and related feelings. The patient also has to record his level of anxiety based on a rating scale of zero to ten. Each distressing memory that is encountered is treated with the same procedure until the anxiety level associated with the event is reduced to two or less.

These findings were later submitted in her doctoral dissertation. She found that the EMDR procedure was more effective than a compared treatment where patients report on traumatic experiences without the eye-movement aspect being present. Subsequent to her discoveries she proceeded to promote her strategy as a possible method. She also began to train other professionals to use the procedure.

She advocated that her method was unique in that it could see results in as little as one session. To date she has trained thousands of professionals. In the initial stages training was conducted exclusively by Shapiro at significantly high costs to those who demonstrated interest. These professionals that were trained were further limited as Shapiro forbade them training others in the use of her procedure. An advantage of personally conducting this training is to ensure that quality is maintained.

A wide range of individuals caught on to her procedure including several behavior therapists. The media also gave her research considerable coverage and initial corresponding studies by independent researchers supported her findings (Spector & Read 1999).

In the initial stages of training and its subsequent usage by practitioners in the field, the method was labeled as experimental. This is so probably because at the time very little had been known about treatment options for PTSD and other trauma-related disorders. This experimental status required practitioners to obtain consent from their patients prior. They were required to continue doing so until research in the form of independent, controlled studies had been conducted concretizing the results of the procedure.

Monitoring was extensive so as to avoid the procedure being used wrongfully. It was only when the result of eight controlled studies were published that the procedure was no longer considered experimental. Following this event a textbook outlining the method involved in EMDR was published. Perkins and Rouanzoin (2002) comment on Shapiro’s book as being well written, giving a clear description of the EMDR theory as well as clear methodological procedures. They add that the book provides a clear historical background of research into treatments for PTSD, highlighting the limited research that had then been available in this field.

Because Shapiro detailed in her observations that a noticeable desensitization effect was present even after a sing therapeutic session, many researchers began criticizing this one-session cure idea, suggesting that it was too good to be true. This conclusion is not in conformity with what Shapiro outlines. Rather, as Perkins and Rouanzoin observe “the method is not portrayed as a cure-all” (p. 90). Furthermore Shapiro clarifies that the method does not propose to eliminate symptoms and complications associated with PTSD or even to supply strategies to cope with such trauma but rather to desensitize the reactions that the patients have towards stimulus (Shapiro 2002, p. 3)

Even though some critics have proposed that the wide proliferation in the use of EMDR is unwarranted and that the method is incorrectly being promoted as superior to previous methods that were tested and proven (Shapiro 2002, p. 3), research would demonstrate the fallacy in this argumentation. It must here be noted that EMDR was one of the first treatments of its kind for PTSD that was evaluated using empirical evidence.

Shapiro (2002) points out that, prior to 1988, there were no established treatments for PTSD that had been tested and substantiated empirically. In fact, in 1991 a group of researchers Solomon, Gerrity and Muff examined the very absence of substantial research into treatment methods for PTSD (cited in Shapiro). According to their research there had been only six such studies and all of them had noted methodological weaknesses that invalidated their findings.

At the time of Shapiro’s discovery only one reliable study examining PTSDs had been published (Shapiro 2002, p. 2). In that study relaxation and biofeedback desensitization were the methods used to desensitize patients to traumatic memories. In this Peniston study conducted over 45 sessions the results were compared to a treatment group that had no treatment intervention. Findings revealed that there were significant self-reported differences in levels of muscle tension, nightmare occurrences and anxiety.

In Shapiro’s initial studies it had been discovered that there were positive improvements after only one session of eye movement therapy. Variations to the initial method have incorporated other elements such as the handtap, (as highlighted above) in order to attain the most favorable results.

With the inclusion of these additional procedures two separate terms for the method are evident. EMD refers to the original formulations using just one simulation methods while EMDR is used in reference to the more comprehensive methods. In training sessions conducted in 1991, these additional principles and methods were formalized in training sessions and eventually codified and published in 1995.

Even though Shapiro’s initial reports demonstrated promising findings, very little attention was paid to her work. It was not until Joseph Wolpe reported on his own successes in a published case utilizing the EMD, that serious attention was drawn to Shapiro’s method.

Following his report a further 100 case studies were published, all advocating the merits of the method. In all these reports there was an evident impact on stress-related disorders. These researchers concluded that the EMDR was indeed a breakthrough as it radically altered thinking on the possibilities for treating PTSDs. (Shapiro 2002, p. 3).

Later the EMDR method was hailed as an effective treatment. The Treatment Guidelines Committee of the International Society for Traumatic Stress Studies, with responsibility for overseeing and evaluating treatments for PTSD, gave the method an A/B rating (Perkins & Rouanzoin 2002, p. 78)

Additionally an independent professional association was formed that would establish the standards for the training of professionals within EMDR as well as guidelines governing the practice (Shapiro 2002, p. 4).

Phases of EMDR

The EMDR method has the following eight phases:

Phase 1            (History taking phase) – the therapist gets an understand of the history behind the patient’s situation

Phase 2            (Preparation phase) – the  principles governing the relationship between the patient and the therapist are established as well as anticipated outcome, patient training and educating.

Phase 3            (Assessment phase) – The therapists elicits an image of the trauma from the patient. A negative perception of the situation is given by the patient as well as a preferred positive belief. Therapist ascertains the types of emotional reactions that are brought up by the trauma and describe their level of anxiety and to identify physical connections to that anxiety. Therapist has to ensure that client feels safe before proceeding.

Phase 4            (Desensitization and reprocessing phase) – Therapist alternates between lateral attention focusing via eye movements and focusing on the traumatic event. Stress is placed on getting the patient to notice what is being experienced. This process continues until anxiety levels fall zero or one.

Phase 5           (Installation phase) – The positive belief expressed in phase three is strengthened.

Phase 6           (Body scan) – Client mentally scans for any lingering disturbances.

Phase 7           Closure phase

Phase 8            Reevaluation phase – the progress of the client is reviewed (Spector & Read 1999, p. 166).

Supporting Research

There has been a considerable amount of research conducted on the effectiveness and usefulness of EMDR in the treatment of PTSD and other related traumatic disorders. In fact there has been more research on this method alone than for all other methods used in total to treat PTSD (Spector & Read 1999, p. 165). Spector and Read (1999) highlight 15 such studies up to 1999.

Perkins and Rouanzoin (2002) also highlight several researches in support of the EMDR method. They point to five major studies conducted among various individuals or groups that tested the efficacy of the method. Civilians and ex-military personnel experiencing PTSD were examined. EMDR was also compared with other methods such as exposure therapy and it was found that, while both methods were equally effective, EMDR achieved its results at a much faster rate.

Follow-up of previous researches were also examined and it was discovered that the effects of treatment using EMDR were lasting and had a very low relapse rate after a 15 month period. In even further reports patient reactions with and without the eye movement aspect were examined. It was discovered that there were no significant reductions in anxiety levels without eye movement but reductions in stress levels were noticeably higher when the eye-movement component was included (Perkins & Rouanzoin 2002, p. 78 & 84).

In a study conducted among civilian victims involving 50 hours of treatment along with homework a remarkable 100% success rate in reported disappearance of PTSD was reported among single trauma patients. In another research with both single and multiple trauma patients similarly positive results were demonstrated.  A reported 75% of patients reported no longer suffering form PTSD (Shapiro 2002, p. 4). Four out of five further studies among civilian patients demonstrated similar results with success rates ranging between 77 and 100% after only 3-6 hours of treatment.

Several advantages of the method have been pointed out. Hyer and Brandsma (1997), while not arguing for the superiority of the EMDR over other methods, have suggested that it has produced the most positive changes in patients. Additionally research points to more efficient results in patients with only mild disorders (p. 516). Furthermore the method is less time consuming. Perkins and Rouanzoin (2002) support that this method requires much less treatment time than other methods used to treat PTSD (p. 83). In several researches among civilians, it is reported that after only between 3 to 10 hours of treatment there were between 77 and 90% of patients that reported no longer suffering from PTSD (Shapiro 2002, p. 6).

Traditional treatments usually required between 16 to 90 hours of treatment before results were demonstrated (Shapiro 2002, p. 6). The length of time in exposure to treatment does not seem to have an adverse effect on results and the effects are quite lasting (Perkins & Rouanzoin 2002, p. 78). In the same researches just mentioned in Shapiro, follow showed there were no relapses at intervals between 3 and 15 months. Researchers also claim that the EMDR is more user-friendly. Spector and Read (1999) accounts for the success of the method in its use of ‘acceptable principles of psychotherapy’ (p. 166).

In comparing EMDR to methods such as drug therapies, exposure therapies and behavior therapies, Spector and Read (1999) point out that EMDR is the most effective, based on the abundance of supporting evidence from empirical researches. Spector and Read further argue that “there is now abundant evidence from controlled studies that EMDR is a therapeutically effective treatment for PTSD (p. 171)

Even critics who are not in full support of the method have highlighted some merits in its use for treating PTSD. DeBell and Jones as well as Feske, though calling for additional research into its procedures and theoretical foundations, acknowledge that it is probably the most effective treatment of PTSD for at least some populations (cited in Davidson & Parker 2001, p. 306).

Limitations

There are reports that suggest contrary viewpoints to those aforementioned as well as a few limitations on the use of EMDR. Some researchers are arguing that, based on their findings, EMDR has been shown to be of no more merit than alternative treatments.

One of the major criticisms of EMDR research is that there have not been sufficient controlled studies to examine its usefulness and, where studies have been conducted these also suffer from significant methodological weaknesses. Spector and Read (1999) acknowledge that new therapeutic measures have to go through stages of innovation, scientific corroboration and then diffusion to practitioners and the general populace.

Critics are suggesting, however, that Shapiro’s method has overstepped the middle ground because it has yet to be truly validated by scientific means. They critics suggest that the sizes used for sampling in the researches conducted thus far are too small to be useful and in any case, this method has not being used independently of other methods but rather in collaboration with already established techniques.

Shapiro’s own initial report has been noted to contain significant flaws. Among these Spector and Read (1999) highlight that there was an absence of blind assessors, the sample as well as the diagnostic assessment tools was not clearly defined and proven standardized measurement methods were not extensively adopted (p. 168).

Furthermore critics are questioning whether the use of eye movement is a necessary technique to the achievement of results within the method.  Davidson and Parker (2001) do not believe that eye movement or any other form of alternating movement is necessary.

They report that there is an almost zero rate of correlation effect of this technique on the outcome of treatment. Similarly using alternating movements other than the eyes did not demonstrate any better results. They therefore conclude that there is absolutely no evidence to suggest that ‘eye movements or other alternating stimuli are necessary’ (Davidson & Parker 2001, p. 313).

In comparisons of treatment with and without alternating eye movement, researchers have also found no difference in the results. Similar comparisons with lateral simulation did not reveal any variations either. Davidson and Parker therefore recommend that the method be proposed as an imaginal exposure technique rather than a completely novel method (p. 305-6).

Additionally, in controlled evaluations researchers are arguing that the success of the procedure is only in this regard – its adoption of traditional imaginal exposure components (Spector & Read 1999, p. 165-166). These studies have found EMDR to be either completely ineffective or not more effective than other traditional methods in the treatment of PTSD.

Another serious problem with EMDR is the apparent lack of diagnostic procedures that are objective. Neither are there procedures utilized to cater for therapist bias in evaluation. When patients are presented for examination the therapists are already aware of the type of treatment they received and this foreknowledge could have effects on the diagnosis presented. Furthermore the patients are not involved in rating their own progress but this aspect is left up to the therapist to decide whether there has been a change or improvement in stress-related symptoms (Perkins & Rouanzoin 2002).

Finally critics argue that EMDR is being too broadly promoted as a treatment for certain trauma-related symptoms that already have effective and established treatment. With the evolution of this method to address an increasing array of disorders, established, validated treatments are being ignored and substituted. It appears that therapists are no longer presenting these viable alternatives to their patients but are giving them little or no choices. Perkins and Rouanzoin (2002) fear that the mental health profession is at risk of defamation if scientific evidence arises proving the uselessness of EMDR.

Recommendations

The following recommendations would be useful to consider for patients, clinicians and researchers contemplating further study into the use of EMDR as a treatment option.

• Therapists should offer their patients alternative options of what therapeutic methodology to employ, informing them of the limitations of each (Perkins & Rouanzoin 2002).
• Number of treatment sessions for patients should be determined based on the nature and severity of their trauma case. Shapiro (2002) proposes, for example, that multiple trauma victims such as war veterans have a larger number of sessions than single trauma victims.
• The sample sizes should be broadened and more carefully chosen ensuring effective sampling of a wide cross-section of the population.
• There should be some amount of blind assessment of patients treated with varying methods so that observations by the initial therapist and the independent observer may be compared to determine areas of convergence or divergence in findings. This Shapiro (2002) suggests should help maximize the external validity of the study.
• The EMDR method should be tested in isolation of other traditional techniques to determine exactly how levels of success are achieved and factors that contribute to such.
• Sufficient follow-up studies of patients need to be conducted at regular intervals after treatment has stopped to establish rates of attrition.

Conclusion

The Eye Movement Desensitization and Reprocessing Method seems to possess some merits for use in the treatment of Post-Traumatic Stress Disorders and a few other stress-related disorders. It is appears, however, to not be the only viable method to address these issues.

Because research into its effectiveness has been indecisive in some cases, the method cannot be put forward as definitive the best alternative for treating PTSD. There are considerable concerns and unresolved issues that must be addressed before the EMDR method can truly be proclaimed as a breakthrough method. Further research is essential before this is possible. Until then therapists and researchers have to proceed carefully with this method, ensuring that patients are aware of the limitations and other available alternatives for treatment.

REFERENCES

Davidson, P. R. & Parker K. C. H. 2001, ‘Eye Movement Desensitization and Reprocessing (EMDR): A meta-analysis’, Journal of Consulting and Clinical Psychology, vol. 69, no. 2, pp. 305-316.

Hyer, L. & Brandsma, J. M. 1997, ‘EMDR minus eye movements equals good psychotherapy’, Journal of Traumatic Stress, vol. 10, no. 3, pp. 515-522.

Perkins, B. R. & Rouanzoin. 2002, ‘A critical evaluation of current views regarding Eye Movement Desensitization and Reprocessing (EMDR): Clarifying points of confusion’, Journal of Clinical Psychology, vol. 58, no. 1, pp. 77-97.

Shapiro, F. 2002, ‘EMDR 12 years after its introduction: Past and future research’, Journal of Clinical Psychology, vol. 58, no. 1, pp. 1-22.

Spector, J. & Read, J. 1999, ‘The current status of Eye Movement Desensitization and Reprocessing (EMDR)’, Clinical Psychology and Psychotherapy, vol. 6, pp. 165-174.