The problem with EMDR may not be that it “doesn’t work” but that it doesn’t work any better than other evidence-based trauma-informed therapies. Furthermore, EMDR training is often high priced with these costs passing on to clients who may not know that traditional trauma therapy could help them without the extra fees.

Eye Movement Desensitization and Reprocessing (EMDR) is a well-tolerated therapy for children and adults with PTSD. In this paper, EMDR is evaluated in comparison to Trauma Focused Cognitive Behavioural Therapy (TF-CBT), as well as Brain Spotting (BSP), and Body Scan Meditation (BSM). The eight steps of EMDR, which are history taking, preparation, assessment, desensitization, installation, body scan, closure, and re-evaluation, are outlined and expanded upon within this paper. Meta-analyses on EMDR were reviewed and considered for the justification of EMDR as well as its limitations. While EMDR has been shown to be effective for use in PTSD compared to no treatment, and is even comparable with TF-CBT in many cases, the justification for using EMDR as the standardized treatment before TF-CBT is weak.

Theoretical perspective of EMDR

Theoretical principles of EMDR

Eye Movement Desensitization and Reprocessing, or EMDR for short, was coined by Francine Shapiro in 1989 to describe a process wherein “the trauma response could be mitigated through rhythmic bilateral eye movements during periods of strategic exposure to trauma cues” (Balkin, 2022, p.115). The purpose of EMDR is to help clients overcome their traumatic memories by processing these memories in a controlled environment whilst focusing on something alongside their trauma (APA, 2017), such as a waving finger, whilst being directed by a therapist. There are eight phases of the EMDR therapy: history taking, preparation, assessment, desensitization, installation, body scan, closure, and re-evaluation (APA, 2017).

Justification for use of EMDR

EMDR is a well-tolerated treatment for PTSD and trauma and has been approved by the World Health Organization (WHO, 2013, August 6) and the American Psychological Association (APA, 2017). EMDR has been shown to be as effective as other trauma-focused therapies, plus it has also been shown to work in both pediatric cases (de Roos 2017 p.1227)and adult cases (Farrell et al., 2023)It is also cost-effective as it has been shown to work via both in-person therapy and telehealth therapy (McGowan et al., 2021; Farrell et al., 2023), thus making it a flexible treatment choice.

Intervention strategy with EMDR

Intervention outline

In EMDR, the patient will first give a trauma history and relay with their therapist the negative emotions and sensations which they would like to remove through the process of EMDR therapy. Unlike narrative or psychodynamic therapies, the purpose of EMDR is not to figure out what the trauma involves, but rather is intended to deal with traumas that are already identified by the client and/or therapist. EMDR is not toted as an exposure-based therapy, but is instead an information processing therapy (Rogers, 2002, p.56). EMDR is usually given throughout several sessions with a set goal in mind, and in this way is similar to Cognitive Behavioural Therapy. However, unlike CBT, EMDR is more person-centred (Mikelson, 2021, January 7). It is interesting to note that Briere et al. have categorized EDMR as a Cognitive Behavioural Therapy, despite clinicians and researchers proposing otherwise (Briere & Scott, 2015, p.193).

Once the therapist has established the trauma that the client would like to resolve, they begin working in sessions whilst moving their finger back and forth while the client talks about their trauma. Alternatively, flashing lights, auditory signals, or tapping may be used (Briere, 2015, p.193). The goal of this intervention is for the client to have new associations with the memories as they relive them, with emotional processing of trauma to a point of no longer being upset by these events set as the end goal of therapy. The intervention is applied until the client is satisfied with their response to reliving the memories of the traumatic response. A detailed step-by-step guide to EMDR is as follows:

Phase one: History taking. During the first phase of EMDR, the therapist will learn from their client what memories and traumas this client would like to work on during EMDR (APA, 2017). Unlike other psychodynamic therapies, the goal is not one of exploration and discovery, but rather to come into the therapy learning from the client which memories and associations they would like to work on.

Phase two: Preparation. During the second phase of EMDR, the therapist will prepare the client for EMDR, including letting them know the purpose of EMDR and how the process will work. It is also imperative that the client is given resources for any painful memories that arise post-session (APA, 2017).

Phase three: Assessment. During the assessment phase of EMDR, the therapy “activates the memory that is being targeted in the session, by identifying and assessing each of the memory components: image, cognition, affect and body sensation” (APA, 2017). Two measures are used during this phase. These are the Validity of Cognition (VOC) scale and the Subjective Units of Disturbance (SUD) scale. The VOC is a scale of 1-7 which asks the following question, “When you think of the incident, how true do those words (repeat the positive cognition) feel to you now on a scale of 1-7, where 1 feels completely false and 7 feels totally true?” (APA, 2017), whereas the SUD scale asks, “On a scale of 0-10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does it feel now?” (APA, 2017). These are repeated throughout the process to ensure that EMDR is working as intended.

Phase four: Desensitization. In phase four the client’s sensory experiences and associations are evaluated by the clinician. Next, “the client is asked to attend both the target image and eye movement simultaneously and is instructed to have openness to whatever happens” (Menon & Jayon, 2010).

Phase five: Installation. During phase five, bilateral stimulations are used in order to help along the positive cognition that is the desired outcome of the therapy (APA, 2017). In this phase, “the therapist attempts to increase the strength of positive cognition which is supposed to replace the negative one. Until the VOC reaches 7 or up to ecological validity, the most enhancing positive cognition is paired with the previously dysfunctional material during the bilateral stimulation” (Menon & Jayon, 2010).

Phase six: Body scan. The use of the body scan phase determines if there is a somatic response of tension left in the body after the stimuli.If so, further sessions will be necessary (APA, 2017; Menon & Jayon, 2010).

Phase seven: Closure. Whether or not the session ended in the positive cognition replacing the negative cognition, closure is a necessary part of the EMDR experience. As this part is done at the end of the session, it is useful for the therapist to provide resources for any negative feelings and emotions that will arise between sessions, as well as coping skills necessary for processing information between sessions (APA, 2017; Menon & Jayon, 2010).

Phase eight: Re-evaluation. The re-evaluation portion of EMDR usually happens in the next therapy session in order to see if there has been lasting change or negative emotions arising from treatment (APA, 2017). In this phase, the client and therapist could agree on a new focus of EMDR, such as focusing on another memory, continuing with the prior theme, or concluding that the therapy has been sufficient (APA, 2017).

Special considerations

While accepted by the World Health Organization (WHO) as a valid treatment approach, research on EMDR has not been conducted within Indigenous populations or in sufficient cross-culturally relevant studies. While there are some, such as (Bilal et al., 2015), that show cross-cultural validity, more attention should be paid towards Western versus Eastern values when it comes to EMDR, especially since the WHO and the American Psychological Association tend to be Western value-based enterprises.

Critique of EMDR

Benefits and limitations of use

It is notable that Hoogsteder (2022) found that EMDR was not an appropriate treatment for adolescents experiencing behavioural problems due to trauma and concluded that “trauma interventions TF-CBT and EMDR were only more effective than no treatment in reducing trauma symptoms and externalizing behavior problems in adolescents” (Hoogsteder, 2022, p.747). It is important to note that the adolescents within this study were criminal offenders and thus not representative of the general population of youth.

Whether or not there is a benefit to the use of eye movements within EMDR is up for debate (Briere, 2015, p.193). However, this does not mean that the therapy cannot work as an emotional processing activity for trauma. I personally think that the focus on the finger or other stimuli could be helpful as a placebo effect in the beginning to help the client feel safe with the exercise and less focused on their trauma. I do think more research needs to be conducted on the use of eye movement, but I think that even as a placebo, it may be a useful soothing tool for clients who have had traumatic experiences.

According to a meta-analysis on EMDR, “[r]esearch involving client outcomes associated with EMDR practices continues to be mixed. These results could come from the actual aspect of talking about traumatic events rather than the unfounded neurophysiological assertions of EMDR (Balkin, 2022, p.121). Another limitation of EMDR is that oftentimes these therapies do not take into account neurobiology and emerging brain research, thus “the application of EMDR beyond non-dissociative PTSD should take into account the predominant emotion-regulation strategies in specific posttraumatic disorders” (González, 2017). At its best, EMDR has been proposed as a well-tolerated form of trauma therapy that is just as effective as CBT for treating trauma. However, at its worst, EMDR has been accused of being a pseudoscience with little to no evidence (Cordón 2005; Thyer, 2015).

One important limitation of EMDR is that some studies have shown that the eye-movement portion of EMDR does not actually change outcomes (Davidson & Parker, 2001), which explains the decision by Briere and Scott (2015) to categorize EMDR as a Cognitive Behavioural Therapy.

EMDR has been shown to work in pediatric cases, and “EMDR and CBWT [Cognitive Behavior Writing Therapy], involving no training in coping skills… prior to trauma memory work and with minimal parental involvement, were acceptable, well-tolerated treatments that yielded clinically significant reductions in single-incident PTSD and comorbid difficulties… with gains being maintained up to one year posttreatment” (de Roos 2017 p.1227). There were also no significant differences in the efficacy of EMDR versus CBWT (de Roos, 2017, p.1225). In a study conducted on front-line workers during the COVID-19 pandemic, EMDR was shown to be an effective therapy for both PTSD and complex PTSD, and this treatment was also delivered via telehealth (Farrell, 2023, p.5). This was not the only study which showed EMDR to work in a virtual delivery setting, as McGowan reported similar results (2021).

Interestingly, EMDR might be an appropriate treatment for those experiencing religious problems, as one study found a positive impact on religion and spirituality from the use of EMDR treatment (Loewenthal, 2022, p.382). EMDR has also been used successfully by researchers in Pakistan, suggesting cross-cultural relevance (Bilal, p.519). Since EMDR is promoted by the World Health Organization and the American Psychological Association, and is in use on every continent, EMDR has been shown to be effective within numerous cultures (Nickerson, 2016, p.3). However, more research on specific cultures and interventions using EMDR are necessary.

Comparison with other treatments

According to Lewey et al. (2018), when compared to Trauma-Focused Cognitive Behavioural Therapy (TF-CBT), EMDR was similarly effective in treating adult populations, but with faster results. However, the same author concludes that TF-CBT is a better choice for younger children. While some studies have shown that EDMR is significantly more effective than other therapies for PTSD (Cuijpers et al., 2020, p. 175), Cuijpers warns that many of these studies were not without “significant risk of bias” (Cuijpers et al., 2020, p. 175) and goes on to mention that “[w]hether or not EMDR actually works through the cognitive behavioral elements that are included, most notably exposure to the traumatic memory, cannot be established in randomized controlled trials” (Cuijpers et al., 2020, p. 176). However, the meta-analysis by Cuijpers et al. (2020) does conclude that with the limited results available, EDMR is comparable to other trauma treatments for PTSD.

Much of the research regarding comparisons of trauma treatment approaches compare EMDR to TF-CBT (Lewey et al., 2018; Khan et al., 2018). Some research has proposed that EMDR is better than CBT for the treatment of PTSD, as is reported by one meta-analysis which concludes: “the results of this meta-analysis suggested that EMDR is better than CBT in reducing post-traumatic symptoms and anxiety” (Khan, et al., 2018). However, one comparative study looked at EMDR, Brain Spotting (BSP), and Body Scan Meditation (BSM) for efficacy in treating distressing memories (D’Antoni et al., 2022). In this study, “EMDR and BSP were found to be more effective than not only BR [book reading, active control], but also BSM” (D’Antonio et al., 2022, p.13).

Recommendations

Since the research on EMDR has been referred to as “mixed” (Balkin, 2022, p.121) or otherwise in-conclusive, it is imperative that therapists consider this research before choosing EMDR as a treatment plan for their clients. While I had come into this paper with an open mind about EMDR, the research for its use was not compelling in the end. I see no reason why EMDR should be selected versus other evidence-based treatments such as Trauma Focused Cognitive Behavioral Therapy, unless there is a shift in the research with more studies coming out proving the efficacy of the treatment.

While EMDR might be good for adult populations due to its speed, there is not enough evidence justifying its use over TF-CBT to warrant its consideration as a first-line approach. However, if the client would prefer to try EMDR, its efficacy is enough for it to potentially be well-tolerated and yield similar results, but it should be stressed that the need for bilateral stimulation as part of its process is still undetermined and requires more stringent studies without bias.

References

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