E. Eye Movement Desensitization and Reprocessing (EMDR)

BACKGROUND

EMDR is a psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories (Shapiro, 1989a; 1989b) . The developer of EMDR, psychologist Dr. Francine Shapiro, proposes the idea that EMDR facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution (Shapiro, 2001). T he possibility of obtaining significant clinical improvements in PTSD in a few sessions presents this treatment method as an attractive modality worthy of consideration.

During EMDR, the patient is asked to identify: (1) a disturbing image that encapsulates the worst part of the traumatic event; (2) associated body sensations; (3) a negative self-referring cognition (in concise words) that expresses what the patient "learned" from the trauma; (4) a positive self-referring cognition that the patient wishes could replace the negative cognition. The patient is then asked to hold the disturbing image, sensations, and the negative cognition in mind while tracking the clinician's moving finger back and forth in front of his or her visual field for about 20 seconds. In successive tracking episodes, the patient concentrates on whatever changes or new associations have occurred. Tracking episodes are repeated according to the protocol until the patient has no further changes. More tracking episodes then reinforce the positive cognition.

Between sessions, the patient is directed to keep a journal of any situations that provoke PTSD symptoms and of any insights or dreams about the trauma. The sessions required may be as few as two for uncomplicated PTSD. More sessions are required for multiple or more complicated trauma.

Standard CBT rating scales are used throughout the sessions to document changes in the intensity of the symptoms and the negative cognition, and the patient's belief in the positive cognition. The patient only needs to tell the therapist the concise negative and positive cognitions and whether (and what) cognition, image, emotion, or body sensation has changed. The therapist is physicially close to the patient and maintains direct eye contact as part of the protocol. This fosters a non-directive interaction that usually detects adverse reactions, which the therapist helps the patient manage with cognitive techniques. EMDR processing is internal to the patient, who does not have to reveal the traumatic event.

The protocol allows for substitution of left-right alternating tone or touch as alternatives in place of the eye movements. Studies attempting to ascertain the relative contribution of the eye-movement component have suggested comparable treatment results with or without eye movements, indicating that this aspect of the treatment protocol may not be critical to effectiveness.

DISCUSSION

EMDR was deemed to be an efficacious treatment for PTSD following a critical review of the literature in the treatment guidelines generated by a task force for the International Society for Traumatic Stress Studies (Chemtob et al., 2000). While the results of seven controlled published studies found large effect sizes for EMDR, EMDR as a treatment modality has been somewhat controversial due to a variety of reasons including the unique proprietary nature of the technique (training is solely marketed through a company vs. available through universities and medical schools as is the case with most other treatment modalities) and the purported relative speed and efficiency of EMDR compared to other techniques. EMDR may be more easily tolerated for patients who have difficulties engaging in prolonged exposure therapy.

Results of four independent reviews that involved 16 controlled trails were assessed by the guideline development panel (Davidson, 2001; Maxfield & Hyer, 2002; Shephard et al., 2000; Foa et al., 1997), . Overall, the findings indicated that EMDR represented an effective treatment compared to no treatment or delayed treatment conditions. When compared to other treatment modalities, most studies reviewed indicated that EMDR was as effective as other more traditional therapy approaches including relaxation training based treatments, exposure therapies, cognitive behavioral therapy, hypnotherapy, and psychodynamic therapy.

The review by Davidson (2001) compared EMDR against 7 other conditions including no treatment, cognitive behavioral therapy, exposure approaches not involving in vivo re-exposure, a number of dismantling studies looking at variants of EMDR, and other "nonspecific" treatments. Patient groups assessed within the included studies involved both PTSD and other conditions. Overall, EMDR was found to be more effective than no treatment and generally was comparable in effect to the other active treatment conditions. Dismantling studies indicated comparable effectiveness across variant presentations of EMDR.

Maxfield and Hyer (2002) conducted a meta-analysis involving comparisons of EMDR against wait list controls, CBT involving exposure, and treatment modalities described as other than CBT. Results indicated superiority of EMDR to the wait list control condition. Also, the authors found an overall superiority of EMDR compared to the other active treatment conditions, though they noted sufficient variability that they judged the summed results to indicate comparable vs. superior effectiveness of EMDR over other treatments.

The Shephard et al. (2000) meta-analysis involved studies that included patients meeting varying diagnostic criteria of PTSD (i.e., DSM-III, DSM-III-R, and DSM-IV) along with patients who failed to fully meet the diagnostic criteria. EMDR was compared to a broad variety of other treatment conditions including behavioral treatment, CBT, antidepressants, relaxation based training, anxiety reduction techniques, exposure based treatments, and variants of EMDR itself. The results indicated that EMDR was an effective treatment. Comparisons between active treatment conditions were less clear, but EMDR was found to be as effective as other treatments in some studies and less effective than other treatments in a few studies. However, taken on the whole the results were interpreted to indicate generally comparable effectiveness.

Foa and colleagues (1997) conducted a meta-analytic review of studies that involved subjects with PTSD and victims of highly stressful events. EMDR was compared to multiple therapies across the set of studies including hypnotherapy, psychodynamic psychotherapy, CBT, and a variety of no treatment and waiting list control conditions. The authors found several studies that indicated no difference between EMDR and various control conditions. The authors cite a contrary finding in one study suggesting that EMDR was superior to the control condition. The overall conclusions of the authors suggested a more guarded outlook on EMDR as an effective treatment with the bulk of their findings suggesting that EMDR was not effective. Methodological problems in the reviewed studies resulted in a call for further study at the time the review was written.

In two recent “Point” “Counterpoint” reviews of EMDR, (Cahill, 2000; Servan-Schreiber, 2000) two psychiatrists with experience in the area of PTSD treatment debate the merits of EMDR. Servan-Schrieber (2000) reviewed the existing literature on EMDR and concluded “only the combination of imaginal exposure and in vivo exposure has approached [the] degree of effectiveness shown by EMDR.” He further argues that the mechanism of eye movement contributes an additional level of therapeutic effect beyond that of simple exposure. Servan-Schrieber cites a meta-analysis published in 1998 by Van Etten and Taylor that “identified more controlled studies of EMDR in PTSD than any other psychotherapeutic treatment modality. Van Etten and Taylor also found EMDR to be the most rapidly effective and best tolerated of all the treatments reviewed, including pharmacotherapy and behavior therapy.” In his “Counterpoint” review, Cahill (2000) reviews the same general set of studies but concludes that because of methodological deficiencies in the studies, EMDR cannot be regarded as superior to CBT or other forms of exposure therapy. He does not believe that EMDR operates in a unique or different way from other forms of exposure or cognitive therapy.

Support for the unique property of therapeutic eye movement is provided by a set of seven studies recommended by a member of the Expert Group (Andrade et al., 1997; Barrowcliff et al., in press; Christman and Garvey, 2000; Kavanaugh et al., 2001; Kuiken et al., 2001-2002; Sharpley et al., 1996; and van den Hout et al., 2001). These studies attempt to resolve the issue of the unique role of eye movements, and they demonstrate the effectiveness of eye movements on the desensitization and retrieval of memories.

There may be some basis for or against recommending this treatment depending upon the trauma basis of the PTSD. Specifically, studies of EMDR efficacy with combat veterans have demonstrated considerable variability, with a number of authors suggesting that the treatment may be less than optimal for this condition (Boudewyns et al., 1993; Jensen, 1994). However, other studies that are more recent have suggested the opposite (Carlson et al., 1998; Devilly et al., 1998). It should be noted that only two of the cited studies had a full course of treatment – all the others were short duration studies, unlike the ET combat studies that offered ten or more sessions on all memories. Thus it is impossible to base a conclusion about the use of EMDR for combat trauma on these studies.

This variability in findings and associated evaluations of efficacy appears to be less evident in studies involving groups with different sources of trauma (e.g., sexual assault). Foa et al. (1995) note that exposure therapy may not be appropriate for use with clients whose primary symptoms include guilt, anger, or shame. Given the clinical reality of multiply-traumatized combat veterans' PTSD, this would be a major limitation on the applicability of ET and exposure-based CBT. Finally, the originators of the method have cautioned against the use of this technique with individuals having a past history of some type of dissociative disorder.

Overall, argument can reasonably be made that there are sufficient controlled studies that have sufficient methodological integrity to judge EMDR as effective treatment for PTSD.