Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy in which the person being treated is asked to recall distressing images; the therapist then directs the patient in one type of bilateral stimulation, such as side-to-side eye rapid movement or hand tapping. EMDR was developed by Francine Shapiro starting in 1988. According to the 2013 World Health Organization (WHO) practice guideline: "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." EMDR is included in several evidence-based guidelines for the treatment of post-traumatic stress disorder (PTSD), with varying levels of recommendation and evidence (very low to moderate per WHO stress guidelines). As of 2020, the American Psychological Association lists EMDR as an evidence-based treatment for PTSD but stresses that "the available evidence can be interpreted in several ways" and notes there is debate about the precise mechanism by which EMDR appears to relieve PTSD symptoms with some evidence EMDR may simply be a variety of exposure therapy. Even though EMDR is effective, critics call it a pseudoscience because only the desensitization component has scientific support.
Exposure therapy began in the 1950s, when South African psychologists and psychiatrists used it to reduce pathological fears. They then brought their methods to England in the Maudsley Hospital training program. Since the 1950s several sorts of exposure therapy have been developed, including systematic desensitization, flooding, implosive therapy, prolonged exposure therapy, in vivo exposure therapy, and imaginal exposure therapy.
EMDR therapy was first developed by American psychologist Francine Shapiro after noticing, in 1987, that eye movements appeared to decrease the negative emotion associated with her own distressing memories. She then conducted a scientific study with trauma victims in 1988 and the research was published in the Journal of Traumatic Stress in 1989. Her hypothesis was that when a traumatic or distressing experience occurs, it may overwhelm normal coping mechanisms, with the memory and associated stimuli being inadequately processed and stored in an isolated memory network.
Shapiro noted that, when she was experiencing a disturbing thought, her eyes were involuntarily moving rapidly. She further noted that her anxiety was reduced when she brought her eye movements under voluntary control while thinking a traumatic thought. Shapiro developed EMDR therapy for post-traumatic stress disorder (PTSD). She speculated that traumatic events "upset the excitatory/inhibitory balance in the brain, causing a pathological change in the neural elements".
EMDR consists of eight essential phases. The first phase includes history taking and treatment planning. The second phase includes preparation. The third phase is an assessment phase followed by the fourth phase of desensitisation. Phases 5 & 6 involve installing positive cognitions and body scan. The last phase is the reevaluation phase EMDR is typically undertaken in a series of sessions with a trained therapist.The number of sessions can vary depending on the progress made. A typical EMDR therapy session lasts from 60-90 minutes.
The person being treated is asked to recall an image, phrase and emotions which represents a level of distress related to a trigger while generating one of several types of bilateral sensory input, such as side-to-side eye movements or hand tapping. The 2013 World Health Organization practice guideline says that "Like cognitive behavioral therapy (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."
While multiple meta-analyses have found EMDR to be as effective as trauma focused cognitive behavioral therapy for the treatment of PTSD, these findings have been regarded as tentative given the low numbers in the studies, high risk rates of researcher bias, and high dropout rates.
Despite these limitations, the results of this meta-analysis aid us in concluding that EMDR may be effective in the treatment of PTSD in the short term and possibly have comparable effects as other treatments. However, the quality of studies is too low to draw definite conclusions. Further, it is evident that the long-term effects of EMDR are unclear and that there is certainly not enough evidence to advise its use in patients with mental health problems other than PTSD.
Some smaller studies have produced positive results.
The 2009 International Society for Traumatic Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults. Other guidelines recommending EMDR therapy – as well as CBT and exposure therapy – for treating trauma have included NICE starting in 2005, Australian Centre for Posttraumatic Mental Health in 2007, the Dutch National Steering Committee Guidelines Mental Health and Care in 2003, the American Psychiatric Association in 2004, the Departments of Veterans Affairs and Defense in 2010, SAMHSA in 2011, the International Society for Traumatic Stress Studies in 2009, and the World Health Organization in 2013 (only for PTSD, not for acute stress treatment). The American Psychological Association "conditionally recommends" EMDR for the treatment of PTSD.
EMDR is included in a 2009 practice guideline for helping children who have experienced trauma. EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder.
A 2017 meta-analysis of randomized controlled trials in children and adolescents with PTSD found that EMDR was at least as efficacious as cognitive behavior therapy (CBT), and superior to waitlist or placebo.
Studies have indicated EMDR effectiveness in depression. A 2019 review found that "Although the selected studies are few and with different methodological critical issues, the findings reported by the different authors suggest in a preliminary way that EMDR can be a useful treatment for depression."
EMDR may have application for psychosis when co-morbid with trauma, Other studies have investigated EMDR therapy’s efficacy with borderline personality disorder, and somatic disorders such as phantom limb pain. EMDR has also been found to improve stress management symptoms. EMDR has been found to reduce suicide ideation, and help low self-esteem. Other studies focus on effectiveness in substance craving and pain management. EMDR may help people with autism who suffer from exposure to distressing events.
Many proposals of EMDR efficacy share an assumption that, as Shapiro posited, when a traumatic or very negative event occurs, information processing of the experience in memory may be incomplete. The trauma causes a disruption of normal adaptive information processing, which results in unprocessed information being dysfunctionally held in memory networks. According to the 2013 World Health Organization practice guideline: "This therapy [EMDR] is based on the idea that negative thoughts, feelings and behaviours are the result of unprocessed memories."
EMDR is posited to help in the correct processing of the components of the contributing distressing memories. EMDR may allow the client to access and reprocess negative memories (leading to decreased psychological arousal associated with the memory). This is sometimes known as the Adaptive Information Processing (AIP) model.
The mechanism by which EMDR achieves efficacy is unknown, with no definitive finding. Several possible mechanisms have been posited;
A 2013 meta-analysis focused on two mechanisms: (1) taxing working memory and (2) orienting response/REM sleep.
It may be that several mechanisms are at work in EMDR.
Bilateral stimulation is a generalization of the left and right repetitive eye movement technique first used by Shapiro. Alternative stimuli include auditory stimuli that alternate between left and right speakers or headphones, and physical stimuli such as tapping of the therapist's hands. Research has attempted to correlate other types of rhythmic side-to-side stimuli, such as sound and touch, with mood, memory and cerebral hemispheric interaction.
Research results and opinions have been mixed on the effectiveness and importance of the technique;
Francine Shapiro noticed that eye movements appeared to decrease the negative emotion associated with her own distressing memories. Bilateral stimulation seems to cause dissipation of emotions.
Concerns have included questions about its effectiveness and the importance of the eye movement component of EMDR. In 2012, Hal Arkowitz, and Scott Lilienfeld summed up the state of the research at the time, saying that while EMDR is better than no treatment and probably better than merely talking to a supportive listener,
Yet not a shred of good evidence exists that EMDR is superior to exposure-based treatments that behavior and cognitive-behavior therapists have been administering routinely for decades. Paraphrasing British writer and critic Samuel Johnson, Harvard University psychologist Richard McNally nicely summed up the case for EMDR: "What is effective in EMDR is not new, and what is new is not effective."
Client perceptions of effectiveness are also mixed.
Skeptics of the therapy argued that EMDR is a pseudoscience, because the underlying theory is unfalsifiable. Also, the results of the therapy are non-specific, especially if the eye movement component is irrelevant to the results. What remains is a broadly therapeutic interaction and deceptive marketing. According to Yale neurologist and skeptic Steven Novella:
[T]he false specificity of these treatments is a massive clinical distraction. Time and effort are wasted clinically in studying, perfecting, and using these methods, rather than focusing on the components of the interaction that actually work.
Shapiro has been criticized 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. This included requiring the completion of an EMDR training program in order to be qualified to administer EMDR properly, after researchers using the initial written instructions found no difference between no-eye-movement control groups and EMDR-as-written experimental groups. Further changes in training requirements and/or the definition of EMDR included requiring level II training when researchers with level I training still found no difference between eye-movement experimental groups and no-eye-movement controls and deeming "alternate forms of bilateral stimulation" (such as finger-tapping) as variants of EMDR by the time a study found no difference between EMDR and a finger-tapping control group. Such changes in definition and training for EMDR have been described as "ad hoc moves [made] when confronted by embarrassing data".