Eye movement desensitization and reprocessing

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that was developed to resolve symptoms resulting from disturbing and unresolved life experiences. It uses a structured approach to address past, present, and future aspects of disturbing memories. The approach was developed by Francine Shapiro to resolve the development of trauma-related disorders as resulting from exposure to a traumatic or distressing event, such as rape or military combat. Clinical trials have been conducted to assess EMDR's efficacy in the treatment of post-traumatic stress disorder (PTSD).

In some studies it has been shown to be equivalent to cognitive behavioral therapy and exposure therapies. Although some clinicians may use EMDR for various problems, its research support is primarily for disorders stemming from distressing life experiences.

Description of therapy
Although EMDR is established as an evidence-based treatment for PTSD        there are two main perspectives on EMDR therapy. First, Shapiro proposed that although a number of different processes underlie EMDR, the eye movements add to the therapy's effectiveness by evoking neurological and physiological changes that may aid in the processing of the trauma memories being treated. The other perspective is that the eye movements are an epiphenomenon, unnecessary, and that EMDR is simply a form of desensitization.

Theoretical basis
EMDR integrates elements of effective psychodynamic, imaginal exposure, cognitive therapy, interpersonal, experiential, physiological and somatic therapies. It also uses the unique element of bilateral stimulation (e.g. eye movements, tones, or tapping). According to Francine Shapiro's theory, when a traumatic or distressing experience occurs, it may overwhelm usual ways of coping and the memory of the event is inadequately processed; the memory is dysfunctionally stored in an isolated memory network.

When this memory network is activated, the individual may re-experience aspects of the original event, often resulting in inappropriate overreactions. This explains why people who have experienced or witnessed a traumatic incident may have recurring sensory flashbacks, thoughts, beliefs, or dreams. An unprocessed memory of a traumatic event can retain high levels of sensory and emotional intensity, even though many years may have passed.

EMDR uses a structured eight-phase approach and addresses the past, present, and future aspects of the dysfunctionally stored memory. During the processing phases of EMDR, the client attends to the disturbing memory in multiple brief sets of about 15–30 seconds, while simultaneously focusing on the dual attention stimulus (e.g., therapist-directed lateral eye movement, alternate hand-tapping, or bilateral auditory tones). Following each set of such dual attention, the client is asked what associative information was elicited during the procedure. This new material usually becomes the focus of the next set. This process of alternating dual attention and personal association is repeated many times during the session.

The theory is that EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other semantic memory networks. It is thought that the distressing memory is transformed when new connections are forged with more positive and realistic information. This results in a transformation of the emotional, sensory, and cognitive components of the memory so that, when it is accessed, the individual is no longer distressed. Instead he/she recalls the incident with a new perspective, new insight, resolution of the cognitive distortions, elimination of emotional distress, and relief of related physiological arousal.

When the distressing or traumatic event is an isolated, single incident, approximately three sessions are necessary for comprehensive treatment. When multiple traumatic events contribute to a health problem&mdash;such as physical, sexual, or emotional abuse, parental neglect, severe illness, accident, injury, or health-related trauma that result in chronic impairment to health and well-being, or combat trauma, the time to heal may be longer, and complex, multiple trauma may require many more sessions for the treatment to be complete and robust.

Therapy process
The therapy process and procedures are according to Shapiro (2001)


 * Phase I: In the first sessions, the patient's history and an overall treatment plan are discussed. During this process the therapist identifies and clarifies potential targets for EMDR. Target refers to a disturbing issue, event, feeling, or memory for use as an initial focus for EMDR. Maladaptive beliefs are also identified.
 * Phase II: Before beginning EMDR for the first time, it is recommended that the client identify a safe place, an image or memory that elicits comfortable feelings and a positive sense of self. This safe place can be used later to bring closure to an incomplete session or to help a client tolerate a particularly upsetting session.
 * Phase III: In developing a target for EMDR, prior to beginning the eye movement, a snapshot image is identified that represents the target and the disturbance associated with it. Using that image is a way to help the client focus on the target, a negative cognition (NC) is identified – a negative statement about the self that feels especially true when the client focuses on the target image. A positive cognition (PC) is also identified – a positive self-statement that is preferable to the negative cognition.
 * Phase IV: The therapist asks the patient to focus simultaneously on the image, the negative cognition, and the disturbing emotion or body sensation. Then the therapist usually asks the client to follow a moving object with his or her eyes; the object moves alternately from side to side so that the client's eyes also move back and forth. After a set of eye movements, the client is asked to report briefly on what has come up; this may be a thought, a feeling, a physical sensation, an image, a memory, or a change in any one of the above. In the initial instructions to the client, the therapist asks him or her to focus on this thought, and begins a new set of eye movements. Under certain conditions, however, the therapist directs the client to focus on the original target memory or on some other image, thought, feeling, fantasy, physical sensation, or memory. From time to time the therapist may query the client about her or his current level of distress. The desensitization phase ends when the SUDS (Subjective Units of Disturbance Scale) has reached 0 or 1.
 * Phase V: The "Installation Phase": the therapist asks the client about the positive cognition, if it's still valid. After Phase IV, the view of the client on the event/ the initial snapshot image may have changed dramatically. Another PC may be needed. Then the client is asked to "hold together" the snapshot and the (new) PC. Also the therapist asks, "How valid does the PC feel, on a scale from 1 to 7?" New sets of eye movement are issued.
 * Phase VI: The body scan: the therapist asks if anywhere in the client's body any pain, stress or discomfort is felt. If so, the client is asked to concentrate on the sore knee or whatever may arise and new sets are issued.
 * Phase VII: Debriefing: the therapist gives appropriate info and support.
 * Phase VIII: Re-evaluation: At the beginning of the next session, the client reviews the week, discussing any new sensations or experiences. The level of disturbance arising from the experiences targeted in the previous session is assessed. An objective of this phase is to ensure the processing of all relevant historical events.

EMDR also uses a three-pronged approach, to address past, present and future aspects of the targeted memory.

Vocabulary
The following terms are described in Shapiro's 2001 text:


 * Information processing: During information processing, a physiologically-based system sorts new (perceptual) information, makes connections between new information and other information already stored in associated memory networks, encodes the material, and stores it in memory.
 * Adaptive resolution: When information processing is complete, learning takes place, and information is stored in memory with appropriate emotion.  The new information is therefore available to guide future action.
 * Dysfunctionally Stored Information: When information processing is incomplete, the information is not connected to more adaptive information, and it is stored in a memory network with a high negative emotional charge. It can cause reactivity and can be the cause of various symptoms.
 * Reprocessing: During reprocessing in EMDR, new associative links are forged between dysfunctionally stored information and adaptive information, resulting in complete information processing and adaptive resolution.
 * Memory networks: Neurobiological associations of related memories, sensations, images, thoughts, and emotions.
 * Target memory: The memory of a distressing or traumatic event, which still causes current distress, and which has been selected to be targeted during EMDR treatment.
 * Memory components: All components of the target memory are accessed during phase three to ensure that the memory network is fully activated. These components include the image, cognitions, emotions, and body sensations.
 * Validity of cognition (VOC) scale: VOC ratings are used in EMDR to measure baseline validity of the positive cognition during phase three, and to assess progress being made, where 1 = not true, and 7 = completely true.
 * Subjective units of disturbance (SUD) scale: SUD ratings are used in EMDR, exposure therapies, and other treatments to measure baseline emotional or physical pain and also to assess progress being made. This is a personal measurement of distress, where 0 = no distress, and 10 = worst distress possible.
 * Interweave: A specific strategy used by the clinician to assist processing if the client appears to be having difficulty accessing more adaptive information. Ideally, the interweave contains needed information that would have been available except for blockage of inner pathways by trauma responses.

Mechanism
The theory underlying EMDR treatment is that it works by helping the sufferer process distressing memories more fully which reduces the distress. EMDR is based on a theoretical information processing model which posits that symptoms arise when events are inadequately processed, and can be eradicated when the memory is fully processed. It is an integrative therapy, synthesizing elements of many traditional psychological orientations, such as psychodynamic, cognitive behavioral, experiential, physiological, and interpersonal therapies.

Overview
EMDR's most unique aspect is an unusual component of bilateral stimulation of the brain, such as eye movement, bilateral sound, or bilateral tactile stimulation coupled with cognitions, visualized images and body sensation. EMDR also utilizes dual attention awareness to allow the individual to vacillate between the traumatic material and the safety of the present moment. This prevents retraumatization from exposure to the disturbing memory. As EMDR is an integrative therapy which combines elements of cognitive behavioral and psychodynamic therapies to desensitize traumatic memories, some individuals have criticized EMDR and consider the use of eye movement to be an unnecessary component of treatment.

However, recent studies have examined the effects of eye movement and have found that eye movement in EMDR decreases the vividness and/or negative emotions associated with autobiographical memories,   enhance the retrieval of episodic memories, increase cognitive flexibility, and correlate with decreases in heart rate, skin conductance, and an increased finger temperature. These physiological changes associated with EMDR are consistent with earlier research on physiological changes associated with EMDR. Also recent studies that have removed the eye movement component from the method have found the procedure to be less effective.

Hypotheses
There is no definitive explanation as to how EMDR works. There is some empirical support for three explanations regarding how an external stimulus such as eye movement can facilitate the processing of traumatic memories.

Failure to process episodic memory
The first hypothesis views PTSD as a failure by the individual to process episodic memory; the bilateral eye movement involved in EMDR facilitate interaction between the brain's hemispheres, which then improves the processing of trauma-related memories. This hypothesis is supported by a study that tested the effects of eye movement on the ability to retrieve episodic memory. The study found better recall following a horizontal eye movement task compared to that following no eye movement or a vertical eye movement task.

Similarity to REM sleep
A second hypothesis suggests that eye movement facilitates processing of trauma memories by activating a neurobiological state similar to REM sleep wherein associative links to episodic memories are formed and these memories are then integrated into general semantic networks. Stickgold proposed that PTSD occurs when an event is sufficiently arousing to prevent its transfer from encoding from an episodic memory to a semantic memory. As a result of high arousal levels, associations between the traumatic event and other related events fail to develop. He argues that the attentional redirecting in EMDR induces a neurobiological state similar to REM sleep. He then reviews the research that suggests that REM sleep enhances processing of episodic memory through the preferential activation of weak associative and semantic links. Thus in EMDR trauma-related information that is closely associated with a target event is weakened and ancillary information loosely related to the event is strengthened, allowing the integration of trauma-related material with other loosely associated events in the person’s life. Support for this argument comes from a study that found that, compared to eye fixation, eye movement promoted attentional flexibility and increased preparedness to process metaphorical material.

Orienting response
A third hypothesis links the eye movement in EMDR with the orienting response. MacCulloch and Feldman argued that eye movement triggers the investigation component of the orienting response, which can either produce avoidance behaviour or inhibit avoidance responses. Inhibiting avoidance behaviour includes reducing both negative somatic responses and cognitive changes that would allow fresh investigatory behaviour to commence. MacCulloch and Feldman proposed that initially when danger is identified there is a negative affect response. However a second part of the orienting response is to scan for further danger, and this investigatory reflex seems to accompany a positive physical response. In the authors’ opinion, eye movement induces this investigatory reflex and produces a relaxation response. A relaxation response was, in fact, found in a study that investigated the autonomic responses of participants when they were engaged in an eye movement task as part of EMDR treatment and when participants focused on negative memories while engaging in eye movement. However there is not a differential effect of eye movement on a relaxation response when participants focused on positive memories.

This supports the hypothesis that eye movement is an orienting response mechanism rather than a simple relaxation mechanism. In addition, recent research that has examined the physiological correlates of eye movement in EMDR has found that a clear orienting response pattern of psycho-physiological de-arousal occurs when eye movement begins, and this de-arousal is characteristic of the physiological changes that occur when an orienting response is elicited.

Further data consistent with the orienting response hypothesis was the finding that EMDR treatment was associated with increased left pre-frontal hemisphere activation. Investigatory and approach behavior has been shown to be associated with the anterior left hemisphere regions.

Empirical evidence and comparison
Recent reviews have concluded that the data claimed to support EMDR derive mostly from uncontrolled case reports and poorly designed controlled experiments and that the theory of EMDR clashes with scientific knowledge of the role of eye movements

Based on the evidence of randomised controlled research trials the most recent scientific review by Cochrane rated EMDR in the highest category of effectiveness for the treatment of PTSD, and the International Society of Stress Studies practice guidelines  has recently ranked EMDR as an evidence-based level A treatment for PTSD in adults. This status is reflected in a number of international guidelines where EMDR is a recommended treatment for trauma.

EMDR was found in the first ever meta-analysis of PTSD to be equally effective as exposure therapy and SSRIs. Two recent meta-analyses concluded that traditional exposure therapy and EMDR have equivalent effects both immediately after treatment and at follow-up. A 2007 meta-analysis looked at 38 randomized controlled trials for PTSD treatment and concluded that the first-line psychological treatment for PTSD should be Trauma-Focused CBT or EMDR. The next year, a meta-analysis concluded that all "bona fide" treatments were equally effective, but this paper was soon dismissed for its arbitrary selection of which treatments were "bona fide". An APA comparative review in CNS Spectrums found EMDR to be of similar efficacy to other exposure therapies, and superior to SSRI, problem-centred therapy or treatment as usual.

Typical treatments
EMDR has been demonstrated to have significant advantages over usual treatment for PTSD in an HMO setting, and improvement was maintained at a six month follow-up. EMDR has been shown to be effective on measures of trauma, depression and anxiety in women and men who have been sexually abused as children.

Medication
To date EMDR has only been compared directly to medication in one study. Van der Kolk et al. found EMDR to be more effective than the SSRI fluoxetine in treating trauma, especially six months post-treatment. The study also suggests a role for SSRIs as a reliable first-line intervention.

Exposure treatment
EMDR proved significantly better than stress inoculation training with prolonged exposure in a study with 24 participants diagnosed with post traumatic stress disorder Although reduction in symptom severity was equivalent post treatment, at follow-up, EMDR lead to greater gains on both self report and observer rated measures of PTSD and self report measures of depression. In another study of 22 participants who had also been diagnosed with PTSD, both EMDR and prolonged exposure were found to be effective post treatment. Participants receiving EMDR appeared to improve more quickly; 70% reached a level of clinically significant improvement in PTSD symptoms after three EMDR sessions compared to 17% in the prolonged exposure condition.

EMDR was also found to work more quickly than exposure based treatments in a larger trial with 105 participants. At a fifteen-month follow-up, gains for both treatments were generally maintained. The only significant difference at follow-up was an improvement in depression according to an independent observer in favour of EMDR.

EMDR and Prolonged Exposure (PE) were found to be equivalently efficacious and both superior to a waitlist control in a controlled trial of 74 female rape survivors. Measures used by blind assessors included PTSD, depression, dissociation and state anxiety. Unlike other studies noted above, there was no difference between the active treatments in rate of improvement. However EMDR seemed to do adequately well despite utilising no homework tasks and less exposure. The study met the highest criteria for methodological rigour proposed by Foa and Meadows.

Cognitive behavioral therapy
Although most studies show EMDR and CBT to be equally effective in the treatment of PTSD, one study reported an opposite effect. Analysis of changes in symptoms for the 15 participants who completed treatment indicated greater reductions on symptom measures of avoidance and re-experiencing for imaginal exposure treatment over EMDR but equivalent reductions on hyperarousal. However, there were no differences between the two treatments in the intent to treat analysis and there was no differences between the two treatments on percentage of people with PTSD diagnosis at follow-up.

The effectiveness of EMDR compared to cognitive behavioral therapy (CBT) is not limited to English speaking cultures. In a study involving Iranian girls who had been sexually abused, EMDR was found to be significantly more efficient than CBT, with similar treatment effects achieved within fewer sessions of EMDR than CBT.

Other applications
Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR’s efficacy with other anxiety disorders as well as numerous reports of diverse clinical applications.

Personality disorders
Case reports have been published on the application of EMDR to the treatment of (a) personality disorders (Fensterheim, 1996a; Korn & Leeds, in press; Manfield, 1998), (b) dissociative disorders (Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen, 1995; Twombly, 2000), (c) a variety of anxiety disorders (De Jongh & Ten Broeke, 1998; Goldstein & Feske, 1994; Lovett, 199; Nadler, 1996; Shapiro & Forrest, 1997) and (d) somatoform disorders (Brown, Mcgoldrick, & Buchanan, 1997; Grant & Threlfo, 2002). However, controlled research is needed to evaluate the efficacy of these applications.

Body dysmorphic disorder
In designing the research the entire EMDR protocol should be evaluated within the context of the potential special needs of the particular population. For instance, Brown et al. (1997) evaluated the application of EMDR in seven consecutive cases of Body Dysmorphic Disorder (BDD), which has been reported to necessitate 8 to 20 sessions of cognitive behavior therapy with varying success rates (Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996; Beale et al., 1996; Wilhelm, Otto, Lohr, & Deckersbach, 1999). In contrast, Brown et al. reported the elimination of BDD in five of the seven consecutive cases in one to three sessions of EMDR through the processing of the etiological memory. While this result indicates the EMDR holds promise for the treatment of this disorder, future controlled research should include a greater number of sessions in order to evaluate the more comprehensive clinical picture.

Depression
EMDR can work on a multitude of problems that are less complex than PTSD. One of these is uncomplicated depression. The EMDR Casebook by Philip Manfield, has documented several case studies in which EMDR was used. In the case about uncomplicated depression, Manfield was able to help his client, George, resolve several childhood issues that have plagued his adult life. Moreover, EMDR can work for postpartum depression. By having the client target a distinctive memory and work through it with a series of eye movements, the client is then able to achieve a positive cognition.

In children
It has been used in the treatment of children who have experienced trauma and complex trauma.

It is often cited as a component in the treatment of complex post-traumatic stress disorder, emotional dysregulation, and in the treatment of children exposed to chronic early maltreatment that is related to attachment disorder. It is recognised by the UK National Institute for Health & Clinical Excellence (NICE) Guidelines as a treatment for PTSD.

For personal improvement
EMDR has also been used in performance and creativity enhancement with athletes and stage performers.

Controversy over mechanisms and effectiveness
The working mechanisms that underlie the effectiveness of EMDR, and whether the eye movement component in EMDR contributes to its clinical effectiveness are still points of uncertainty and contentious debate.

EMDR has generated a great deal of controversy since its inception in 1989. Critics of EMDR argue that the eye movements do not play a central role, that the mechanisms of eye movements are speculative, and that the theory leading to the practice is not falsifiable and therefore not amenable to scientific enquiry.

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

Exposure
Several papers have highlighted key differences between EMDR and traditional exposure treatments. However, despite the treatment procedures being quite different between EMDR and traditional exposure therapy, some authors continue to argue that the main effective component in EMDR is exposure. Other authors argue that EMDR is a complex therapy with many elements. Thus, it is too simple to assume that any one mechanism of action is responsible for positive treatment effects.

Although exposure to traumatic memories occurs in EMDR, the form of exposure is different as it is short and intermittent as opposed to uninterrupted and prolonged, it is non-directive and allows for free association, and reliving is not a requirement of effective therapy like it is in traditional exposure. Recent research by Lee and colleagues has found key differences in the crucial processes of EMDR and traditional exposure. They have demonstrated that reliving within EMDR is not associated with symptom improvement. Rather greater improvement in trauma symptoms occur when trauma material is processed in a more detached or distant way. The distraction created by the eye movements in EMDR also distinguishes EMDR processes from those in traditional exposure. Although it has been shown recently that some level of distraction in exposure assists in anxiety reduction, traditionally distraction tasks in exposure were thought to interfere with treatment effectiveness.

In sum, the exposure that occurs in EMDR should, according to the assumptions of emotional processing theory, sensitise rather than desensitise and decrease the fear and distress associated with traumatic memories. However, EMDR is effective, therefore processes other than imaginal exposure must play a role in the effectiveness of EMDR in the treatment of PTSD.

Eye movements
An early critical review and meta-analysis that looked at the contribution of eye movement to treatment effectiveness in EMDR concluded that eye movement is not necessary to the treatment effect. However, recent research has demonstrated that when the eye movement component of EMDR is removed from the method the procedure is less effective. This finding supports previous research that has demonstrated that EMDR with eye movement is more effective than treatment conditions that do not use eye movement in the method, or instead use a dual attention task such as tapping.

MacCulloch (2006) argued that the eye movement makes a unique contribution to EMDR, whereas Salkovskis (2002) reported that the eye movement is irrelevant and that the effectiveness of the procedure is solely due to its having properties similar to cognitive behavioral therapies, such as desensitization and exposure.

Effect of eye movement on memory, cognitive processes, and physiology
Although the necessity of eye movement in EMDR is still a point of controversy and contentious debate, a separate body of research has examined the effects of eye movement on physiology, memory, and cognition during the process of EMDR. To date the research in this area has demonstrated that eye movement decreases the vividness and/or emotional valence of autobiographical memories, enhances the retrieval of episodic memories, produces a physiological relaxation effect similar to that which is characteristically seen when an orienting response is elicited,  and increases cognitive flexibility. Although a wide range of researchers have proposed various models and theories to explain the effect of eye movement, and the possible role that eye movement may play in the process of EMDR, to date, no single model or theory exists that can explain all of the above mentioned findings. Further research is therefore required in this area.