Eye Movement Desensitisation and Reprocessing (EMDR): Background, Structure and Applications
In this article, we explore what Eye Movement Desensitisation and Reprocessing (EMDR) is, how it works, which conditions are being treated with it, and what’s involved in each of its eight phases. A companion piece offers a snapshot of research conducted so far, outlines the main effects the therapy induces, and notes the requirements for EMDR certification, should you decide that it would be a useful tool in your therapist’s arsenal of techniques.
What is EMDR?
The creator and developer of EMDR, Francine Shapiro, defines it as “an empirically validated treatment for trauma, including such negative life experiences as commonly present in medical practice” (Shapiro, 2014). It is a fairly new, non-traditional type of psychotherapy which is growing in popularity and, as Shapiro noted, already has some randomised, controlled trials under its belt to bolster its claims to therapeutic effectiveness. If you’ve heard anything about it, though – or even registered its name of ‘eye movement reprocessing’ – you are probably wondering how, or why, it works, especially given that it doesn’t rely on talk therapy or medications. It doesn’t focus on changing the thoughts, emotions, or behaviours resulting from a traumatic event or distressing issue. Rather, EMDR uses a patient’s own rapid, rhythmic eye movements to allow the brain to resume its natural healing process (EMDRIA, 2021).
Like some other therapies, EMDR came into existence as a result of serendipity. One day in 1987, Shapiro, a California psychologist in private practice, took a walk in the woods, absorbed in distressing thoughts. Yet, as her walk concluded, she realised that her mood had lifted after moving her eyes back and forth while observing her environment. Curious, Shapiro tried different ways of bringing about the same experience for her clients and found that they, too, felt better afterwards. EMDR was born. After an initial study was published in 1989, numerous investigations and conference presentations focused on it as a surprisingly effective means of helping clients overcome the anxiety associated with PTSD and other anxiety disorders. It quickly became a go-to therapy for military veterans struggling with combat-related trauma (Arkowitz & Lilienfeld, 2012; Tejcek, 2016).
How does it work?
We don’t actually know the answer to this! Shapiro’s Adaptive Information Processing model proposes that EMDR therapy facilitates the accessing and processing of traumatic memories and other adverse life experiences, bringing them to an adaptive resolution. Our brains have an inbuilt mechanism for recovering from traumatic memories and events. It involves communication between the amygdala (our alarm signal for stressful events), the hippocampus (which helps us with learning – especially memories about safety and danger), and the prefrontal cortex (which analyses behaviour and emotion, working to control it). While it’s often true that traumatic experiences can be managed and resolved spontaneously, sometimes the system is overwhelmed and people need help.
Stress responses are part of our natural instincts of fight, flight, or freeze, but when distress remains with us after a traumatic – or at least disturbing – event, the upsetting images, thoughts, and emotions can create feelings of overwhelm. In these cases, it is like being back in that moment, or of being “frozen in time”. EMDR therapy helps the brain to process the memories, allowing normal healing to resume. The person still remembers the experience, but the fight/flight/freeze response from the original event is resolved (EMDRIA, 2021; EMDR Institute, 2020).
Upon the completion of successful treatment, emotional distress is decreased, negative beliefs are reformulated, and physiological arousal is reduced. During the therapy, the client concentrates on emotionally disturbing material in short sequential “doses” while simultaneously focusing on an external stimulus. Typically, the external stimulus is lateral eye movements directed by the therapist, but other stimuli, such as hand tapping and audio stimulation, are also used. Shapiro hypothesises that EMDR therapy helps clients access the traumatic memory network, so that information processing is enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. The new memories are thought to result in complete information processing, new learning, elimination of emotional distress, and development of cognitive insights.
EMDR’s three-headed protocol focuses on, in turn:
- The past events that have laid the groundwork for dysfunction, processing them and forging new associative links with adaptive information;
- The current circumstances that evoke distress, with both internal and external triggers desensitised;
- Imaginal templates of future events, incorporated to assist the client in acquiring the skills needed for adaptive functioning (EMDR Institute, 2020).
What EMDR is used for
As we noted, the therapy started out as a way to relieve the anxiety, intense emotion, and physiological arousal of trauma. Seeing how it helped traumatised clients, therapists began to extend its use, coming to employ EMDR for all of the following (although EMDR has not been empirically validated as effective with all of these):
- Depression and bipolar depression
- Attention Deficit Hyperactivity Disorder (ADHD)
- Chronic pain
- Panic attacks
- Eating disorders
- Grief and loss
- Performance anxiety
- Personality disorders
- Psychotic symptoms
- Self-esteem issues
- Sexual assault, violence, and abuse
- Sleep disturbance
- Stress-induced flare-ups of skin problems
- Dissociative disorders
- Addictions (Leonard, 2019; WebMD, n.d.; EMDRIA, 2021)
The Phases of EMDR
EMDR sessions may be around an hour to 90 minutes in length, and the full treatment may be delivered one to two times per week for a total of 6 – 12 sessions, although some people benefit from fewer sessions. There are generally eight phases of EMDR.
Phase 1: History-taking and treatment planning
As the therapy begins, the therapist evaluates the client’s case, particularly assessing whether the person can tolerate exposure to distressing memories. Based on the person’s symptoms, therapist and client work together to identify targets for treatment. Targets include past memories, current triggers, and future goals.
Phase 2: Preparation
The therapist helps the client get ready for treatment by establishing a solid therapeutic alliance, explaining what the treatment will involve, and introducing the client to the procedures. At this phase, the client should practice the eye movement and/or other bilateral stimulation components that will be worked with in earnest at later phases. The therapist teaches the client self-control techniques and ensures that the person has adequate resources to manage the intense emotions that may surface later (this may include, for example, mindfulness or other relaxation practices).
Phase 3: Assessment
At this third phase, the therapist identifies the traumatic memories that need to be addressed. Any memory that is being targeted is activated in session by assessing each of the memory components: image, cognition, affect, and body sensation. The client chooses an image to represent each memory, noting the negative beliefs and physical sensations that accompany each memory. The person then identifies a positive thought to replace the negative beliefs. Two measures are used during the sessions to evaluate changes in emotion and cognition: The Subjective Units of Disturbance (SUD) Scale and the Validity of Cognition (VOC) Scale. Both measures will be used again later during the treatment process, in accordance with the standardised procedures.
Phase 4: Desensitisation
Here’s where the client’s disturbing reactions to the traumatic memory, including physical sensations such as rapid heart rate or sweating, are reduced. During this phase, the client focuses on the memory while engaging in eye movements or other bilateral stimulation. Then the client reports whatever new thoughts have emerged. The therapist determines the focus of each set of bilateral stimulation using standardised procedures, but usually the associated material becomes the focus of the next set of (brief) bilateral stimulation. The process continues until the client reports that the memory is no longer distressing.
Phase 5: Installation
The preferred positive thoughts identified at Phase 3 are now strengthened, or installed.
Phase 6: Body scan
The meditative technique of body scan occurs here, with clients observing their physical response while thinking of the incident and the positive cognition and noticing any residual physical sensations. These are then the target of further processing, via standardised techniques involving bilateral stimulation.
Phase 7: Closure
This is the phase for stabilising the client using the self-control and emotion regulation techniques discussed in Phase 2. The therapist explains what the client can expect between sessions, and if the targeted memory was not fully processed in the session, specific instructions and techniques are offered to provide containment and ensure safety until the next session. The client is asked to keep a record of any negative experiences that occur so that they can be targeted at the next meeting.
Phase 8: Re-evaluation
The next session starts with this final phase, during which the therapist evaluates the client’s current psychological state and whether treatment effects have maintained. Therapist and client will also identify any additional traumatic effects to target which may have emerged since the last session; those become the target for the current session (American Psychological Association, 2017; Leonard, 2019).
This article has introduced EMDR, explained how it is hypothesised to work, listed the conditions for which it has been a treatment, and detailed the contents of its eight phases. If you still wonder whether EMDR is too weird to be true, you are not alone. Yet behind the Adaptive Information Processing model that explains it, lies a substantial complement of research demonstrating its validity. We look at some of the research, the changes that EMDR therapy has been known to effect, and what is required for certification, in our next edition.
- American Psychological Association (APA). (2017). Eye Movement Desensitization and Reprocessing (EMDR) Therapy. APA. Retrieved on 18 January, 2021, from: Website.
- Arkowitz, H, & Lilienfeld, S. (2012). EMDR: Taking a closer look. Scientific American. Retrieved on 18 January, 2021, from: Website.
- EMDR Institute. (2020). What is EMDR? EMDR Institute, Inc. Retrieved on 18 January, 2021, from: Website.
- EMDRIA. (2021). About EMDR therapy. EMDR International Association. Retrieved on 18 January, 2021, from: Website.
- Leonard, J. (2019). EMDR therapy: Everything you need to know. Medical News Today. Retrieved on 18 January, 2021, from: Website.
- Shapiro, F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical symptoms stemming from adverse life experiences. Permanente Journal. 2014 Winter; 18(1): 71–77. doi: 10.7812/TPP/13-098 PMCID: PMC3951033 PMID: 24626074
- Tejcek, J. (2016). 35 life changes that can happen after EMDR eye movement therapy sessions. LinkedIn. Retrieved on 19 January, 2021, from: Website.
- WebMD. (n.d.). EMDR: Eye movement desensitization and reprocessing. WebMD. Retrieved on 18 January, 2021, from: Website.