If you were to have a traumatised client, which type of therapy would you choose to treat them? In a previous article, we explored the use of CBT and CBT-related therapies to treat trauma. In this article we’ll focus on eye movement desensitisation and reprocessing, or EMDR.

Background

EMDR is a trauma-focused psychological intervention created from an accelerated information-processing model. Because it also incorporates dissociation and nonverbal representation of traumas (such as visual memories), EMDR is sometimes classified as a cognitive therapy. It is based on the assumption that, during a traumatic event, overwhelming emotions or dissociative processes may interfere with information processing. This leads to the experience being stored in an ‘unprocessed’ way, disconnected from existing memory networks. In an EMDR session, the client is asked to focus on trauma-related imagery, negative thoughts, emotions, and body sensations while their eyes simultaneously follow the movement of the therapist’s fingers across their field of vision for 20-30 seconds or more; the process may be repeated many times. EMDR’s proponents argue that this dual attention facilitates the processing of the traumatic memory into existing knowledge networks.

Francine Shapiro developed EMDR in 1987 as a treatment for traumatic memories (Shapiro, 1995), The client’s eye movements are part of the structured, multistage treatment, which involves a combination of exposure therapy elements and eye movements, hand taps, or sounds to distract clients’ attention. After each sequence, clients indicate their Subjective Units of Distress (measurements used to describe an individual’s level of suffering or grief associated with painful memories). If the Subjective Units of Distress rating is high, the client practices relaxation techniques. When the client is ready, EMDR resumes. Shapiro (1995) claims that EMDR, with its brief exposures to trauma material, an external/internal focus, and structured therapeutic protocol, represents a different new paradigm in therapy (Dass-Brailsford, 2007).

Controversy and Applications

However, EMDR is not without its attendant controversies. One point of contention is that EMDR lacks a theoretical foundation, empirical data, and sound methodology (Resick, 2004). Secondly, claims that EMDR is a rapid and effective treatment have been subjected to much scientific scrutiny and not always supported. A study of Vietnam veterans (Devilly, Spence, and Rapee, 1998) compared EMDR to control conditions using two different forms of EMDR and psychotherapy. While the EMDR groups showed improvement, those gains were not maintained at the six-month follow-up. In a separate study, Devilly and Spence (1999) compared EMDR with a combination of exposure, SIT, and cognitive therapy techniques in a mixed sample of traumatised clients with PTSD. EMDR was found to be effective, but inferior to cognitive therapy, the treatment gains from which were maintained at the three-month follow-up.

Over time, EMDR has increasingly included treatment components that are comparable with CBT-based interventions such as exposure therapy/prolonged exposure, systematic de-sensitisation, cognitive processing therapy, cognitive therapy, narrative exposure therapy (NET) and stress inoculation therapy (SIT). These include “cognitive interweaving”, which is analogous to cognitive therapy, imaginal templating (rehearsal of coping responses to anticipated stressors), and standard in vivo exposure. We can note that, in combination with the imaginal focus on traumatic images which was originally part of EMDR, the therapy now includes all of the core elements of standard trauma-focussed CBT. Moreover, the original protocol of a single session is now expanded to eight phases of treatment with the above elements included, which makes it a similar length to standard trauma-focused CBT. The unique feature of EMDR is the use of eye movements as a core and fundamental component throughout treatment (Australian Centre for Posttraumatic Mental Health, 2013a).

But the question arises as to whether those same core eye movements are actually necessary. There are differing opinions about how EMDR works and what the underlying mechanisms are. Some researchers have claimed that EMDR might be understood as an exposure or imaginal flooding technique (Seidler & Wagner, 2006). Others (Lee, Taylor, & Drummond, 2006) have suggested that EMDR and exposure are different processes, and that EMDR processes trauma in a more disidentified way. A study by Davidson and Parker (2001) concluded that eye movements might even be unnecessary for a positive outcome. It may be that EMDR’s efficacy derives from a client engaging with and processing the traumatic memory, rather than from eye movements. EMDR may thus be more effective if extensive behavioural and imaginal exposure is included (Dass-Brailsford, 2007).

EMDR’s creator, Shapiro, claims that even a single session of EMDR produces positive results (1989). The research continues to illuminate aspects of this therapy, but there is some evidence meanwhile that attentional alternation, which is unique to EMDR, may facilitate the accessing and processing of traumatic material in adults (Chemtob, Tolin, van der Kolk, & Pitman, 2000, in Dass-Brailsford, 2007).

Ultimately, sampling and methodological flaws and lack of control groups in some of the studies already produced limit the generalisability of findings that are already out; we can only hope that replication studies will be undertaken in order to confirm their reliability (Dass-Brailsford, 2007).

This article was adapted from the “Working with Trauma” Mental Health Academy CPD course. Learn more at www.mentalhealthacademy.com.au.

References:

  • Australian Centre for Posttraumatic Mental Health. (2013a). Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. ACPMH, Melbourne, Victoria.
  • Dass-Brailsford. (20007). Models of trauma treatment. Retrieved on 4 August, 2015, from: hyperlink.
  • Devilly, G.J., & Spence, S.H. (1999). The relative efficacy and treatment distress of EMDR and cognitive behavioral trauma treatment protocol in the amelioration of post-traumatic stress disorder. Journal of Anxiety Disorders, Vol 13, No 1-2, 131-157.
  • Devilly, G.J., Spence, S.H., & Rapee, R.M. (1998). Statistical and reliable change with eye movement desensitization and reprocessing: Treating trauma with a veteran population. Behavior Therapy, Vol 29, 435-455.
  • Lee, C.W., Taylor, G., & Drummond, P.D. (2006). The active ingredient in EMDR: Is it traditional exposure or dual focus of attention? Clinical Psychology and Psychotherapy, Vol 13, 97-107.
  • Resick, P.A. (2004). Stress and trauma. Philadelphia: Taylor Francis.
  • Seidler, G.H., & Wagner, F.E. (2006). Counselling for post-traumatic stress disorder (3rd Ed.). London: Sage.
  • Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press.