EMDR Treatment for Trauma
- Allen RubinAllen RubinGraduate College of Social Work, University of Houston
Eye movement desensitization and reprocessing (EMDR) is one of the two most empirically supported treatments for adult populations with noncombat, single-episode posttraumatic stress disorder (PTSD), with the other being exposure therapy. This entry describes the unconventional origin, theoretical underpinnings, and treatment protocol of EMDR, including its distinctive use of bilateral stimulation (that is, dual-attention stimulation). Also discussed are possible contraindications, unresolved issues, and the need for more research regarding the effectiveness of EMDR with other populations with PTSD, such as children and individuals with combat PTSD and complex trauma.
Eye movement desensitization and reprocessing (EMDR) is a psychotherapeutic treatment approach for alleviating symptoms resulting from having experienced traumatic events. The most distinctive treatment component of the eight-stage EMDR process involves dual-attention stimulation (also called bilateral stimulation), in which the therapist moves her fingers back and forth (or uses an alternate device) to stimulate rapid back-and-forth eye movements as the client visualizes a distressful memory while keeping in mind a related feeling and cognition. Alternatively, the therapist might rapidly alternate right and left hand taps or sounds in the right and left ears during the visualization (Rubin, 2003).
Although hailed as a breakthrough therapy by its originator (Shapiro & Forrest, 2004), soon after the first publication on EMDR appeared—authored by its developer (Shapiro, 1989)—various critics expressed skepticism about its unconventional origins, unconventional treatment techniques, and the way it was being promoted by its proponents (Olatunji, Parker, & Lohr, 2005–2006). However, as more and more well-controlled outcome studies accumulated supporting its effectiveness in treating posttraumatic stress disorder (PTSD) symptoms, EMDR became recognized (along with exposure therapy) as one of the two most empirically supported treatments for that disorder among adults (Bisson et al., 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005; Davidson & Parker, 2001; Seidler & Wagner, 2006; van Etten & Taylor, 1998). Studies also are emerging with some promising results regarding EMDR’s effectiveness with traumatized children (Adler-Tapia & Settle, 2009; Field & Cottrell, 2011; Greyber, Dulmus, & Cristalli, 2012), although trauma-focused cognitive behavioral therapy (TFCBT) as of this writing in the early 21st century has accumulated more empirical support for its effectiveness with traumatized children—especially those who have been sexually abused (Cohen & Mannarino, 1996, 1997; Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen, Mannarino, & Knudsen, 2005; Deblinger, Lippmann, & Steer, 1996; Deblinger, Stauffer, & Steer, 2001; King et al., 2000).
EMDR originated as a “chance discovery” by its developer, Francine Shapiro, who earned her doctoral degree in clinical psychology at the Professional School of Psychological Studies. Shapiro was walking in the park one day and experiencing stressful thoughts related to having been recently diagnosed with cancer. She noticed that when her eyes were spontaneously moving back and forth the disturbing thoughts vanished and that when she brought the thoughts back into consciousness they were less disturbing than before, although she made no conscious effort to alleviate their impact. Over the course of the next 10 years, Shapiro asked acquaintances to think of disturbing thoughts and then move their eyes back and forth rapidly. She realized that she had to use her hand to guide their rapid eye movements. Based on this experience she developed the notion that the impact of the eye movements might be explained by feeling better about a disturbing thought after waking up from REM sleep. Over time, however, her thinking evolved regarding the psychological theories that might explain the impact of EMDR (Luber & Shapiro, 2009).
Having discovered EMDR by chance while walking in the park, Shapiro did not begin with a theoretical basis for developing it. In addition to the possible connection to the impact of REM sleep, the various reasons considered possible explanations for its effectiveness have included learning theory, emotional processing theory, physiological stimulation of a part of the brain where traumatic memories remain frozen and unprocessed, and helping the rational hemisphere of the brain gain access to and process traumatic memories that are stuck in the opposite hemisphere.
The currently accepted theoretical model for understanding the way EMDR works is the adaptive information processing model. In this model, which draws on concepts from learning theory and neurobiology, traumatic experiences can get locked as “information” in memory networks in the brain (Shapiro, 2001). These memory networks “are the basis of thoughts, feelings and behavior” (Dodgsen, 2009, p. 261). For most people who experience traumatic events, the brain will process the information in a way that enables the individual to reach “adaptive resolution” and therefore no longer have his or her current behavior, thoughts, or emotions affected in a dysfunctional way by the traumatic memory. Thus, for example, most survivors of natural disasters like hurricanes or floods will have their trauma symptoms resolved within 30 days after the disaster (and thus not develop PTSD).
But when the experiences do get locked in memory networks, the model postulates that they get “stored in the non-declarative, or sensory system, which is not readily accessible through verbal mediation” (Dodgsen, 2009, p. 262). Consequently, failing to get processed and put in the past as unfortunate memories that no longer irrationally impact current functioning, stimuli experienced in the future that are associated with traumatic events can trigger negative emotions, sensations, and cognitions along with a sense of reexperiencing the traumas as if they were currently happening (Dodgsen, p. 262). In addition to reexperiencing symptoms (such as intrusive thoughts, nightmares, and—in rare cases—flashbacks), other trauma symptoms can include numbing, hyperarousal, and efforts to avoid people, places, and things that might contain cues associated with the unprocessed traumatic material and thus might trigger the sense of reliving the trauma.
Because the locked information is stored in memory networks that cannot be accessed through conscious channels, they are harder to resolve through verbal therapies. EMDR attempts to access and facilitate the processing of that information thought an eight-stage process in which the emphasis is not on talk therapy but instead on using a largely physical dual-attention stimulation (that is, bilateral stimulation) technique. This technique focuses on targets for reprocessing. The targets are “nodes in the memory networks: significant points that link channels of association and may represent unprocessed experiences” (Dodgsen, 2009, p. 265).
The Eight-Stage EMDR Protocol
Although the most unique aspect of EMDR is its use of bilateral stimulation to access the targets for reprocessing, the EMDR protocol involves eight stages, some of which do not include administering bilateral stimulation. In fact, the first stage of EMDR, taking a client history, resembles somewhat the first stage of other treatment approaches to treating PTSD or other disorders. The eight stages are described below based on the way they are portrayed by Shapiro (2001) and Dodgsen (2009).
The EMDR International Association (EMDRIA) website provides extensive information about training and certification in EMDR. Social workers who visit that site will see that to be certified in EMDR they must be licensed and have had a minimum of two years of clinical experience. They must also have completed EMDR training by an EMDRIA-approved training program, have conducted at least 50 clinical sessions in which they used EMDR, and have received 20 hours of EMDR consultation by a consultant who has been approved by the EMDRIA. Also, every two years they must also complete 12 hours of continuing education in EMDR. Much more detailed information about certification criteria can be found at the EMDRIA website (http://www.emdria.org/displaycommon.cfm?an=1&subarticlenbr=21).
A clinician who is EMDRIA certified in EMDR has been licensed or certified in his or her profession for independent practice and has had a minimum of two years’ experience in the field.
Stage 1: Client History
In the first stage the clinician lets clients tell their story. A prime aim is to identify a history of traumatic experiences, including what are known as small-t traumas (such as being humiliated, painful relationship breakdowns, and so on) and large-T traumas (such as physical or sexual abuse, natural disasters, traumatic experiences during military combat, and torture, which are the type of events the DSM requires as prerequisites for a PTSD diagnosis). The clinician also asks the client to identify the “thoughts, images, emotions, and sensations that are associated with these experiences . . . present triggers that revoke feelings from the past . . . and future goals and the hopes and apprehension that may go with them” (Dodgsen, 2009, p. 267). Although taking a client history is the first phase, it might be revisited in later stages as new traumatic experiences are revealed.
Stage 2: Preparation
In the second stage the clinician provides psychoeducation about later stages of EMDR that incorporate bilateral stimulation. Also during this phase the clinician introduces clients to affect-management techniques, such as deep breathing, positive imagery, relaxation exercises, and establishing a mental image of a safe place where clients can go in their minds when the level of disturbance becomes too severe. These techniques, along with telling the client that he or she can stop the bilateral stimulation at any time simply by raising a hand, help give clients a sense of control. Giving clients a sense of control and empowerment is important in developing a therapeutic alliance with traumatized clients regardless of the therapeutic approach employed, and all empirically supported treatment approaches—including those that have manuals—require establishing a strong therapeutic alliance as a prerequisite for their effectiveness (Rubin, 2009).
Stage 3: Assessment
In the third stage the clinician asks the client to bring to mind a key traumatic event discussed in the first stage and an image of the event. Keeping the image in mind, the client next identifies an undesirable self-cognition, in the form of a self-statement, that is associated with the event and that continues to hinder his or her present sense of self. Then the client identifies an emotion that is connected to both the event and the cognition. For example, rape victims might bring to mind an image of the rape coupled with the emotion of fear or self-loathing and the irrational negative cognition that he or she was somehow partially to blame for the incident. Next, clients rate the extent to which they feel disturbed when currently imagining the incident. This rating is done using Wolpe’s (1969) 11-point Subjective Units of Distress scale (SUD) from 0 (no disturbance) to 10 (worst disturbance imaginable). After that, clients identify a positive self-statement that they would like to replace the negative one, such as “I am a good person” or “I am resilient and strong” or “It was not my fault.” Clients next rate how valid that positive cognition seems to them as they keep in mind the traumatic event. That “validity of cognition” (VoC) rating is on a 7-point scale from 1 (completely false) to 7 (completely true).
The image, negative and positive self-statements, and the current emotion identified as above during the assessment phase will serve as the initial focus of the desensitization phase, which comes next. If the SUD is low, say 4 or below, the clinician is likely to explore whether there is some more disturbing memory or image that should be the focus of the desensitization phase. Likewise, if the VoC is high, say 5 or above, the clinician is likely to probe for a positive self-statement that the client feels is less valid.
Stage 4: Desensitization
The fourth stage is the first of the three reprocessing stages. In this desensitization stage, bilateral stimulation (that is, dual-attention stimulation) is implemented while the client keeps in mind the image, negative and positive self-statements, and current emotion identified during the assessment stage. If eye movements are used as the stimulation, the therapist’s fingers move rapidly from side to side while the client’s eyes track them. If the client has difficulty tracking with his or her eyes using any of these motions or if the client does not seem to be making any progress in processing information or reducing the SUD score, the therapist can opt for rapidly alternating tapping the client’s right and left hands or rapidly alternating auditory tones in the client’s right and left ears. (Mechanical devices, such as headphones or bars with moving flashing lights, can be purchased to remove the need for the therapist to implement the bilateral stimulation manually.)
The therapy session (which is recommended to last 90 minutes) will consist primarily of many sets of bilateral stimulations. The number of back-and-forth eye movements (or taps or sounds) per set will vary, depending on the therapist’s perception of the client’s facial expressions during each set. (If the client seems to be experiencing emotional distress during a particular set, the therapist might extend the set while voicing brief reassurances that the client is just noticing things that are not really happening.) Most sets tend to last roughly between 15 and 30 seconds (Maxfield, 2007). After each set the therapist asks the client to take a deep breath and then report on what he or she is thinking, feeling, or noticing at that time. At that point, rather than engage in “talk therapy,” the clinician will simply ask the client to “go with that” and then begin the next set of bilateral stimulations, which is followed by the same procedure as after the previous set. This process continues throughout the various sets of the desensitization phase.
Although the emphasis is on minimizing therapist “intrusive” talking, if the client seems to become stuck the clinician might intervene with brief Socratic questioning or by asking the client “to notice the thoughts, feelings, or bodily sensations that they are experiencing. The client might also be asked to return to the target memory and the negative cognition, and again notice what she is feeling in her body” (Dodgsen, 2009, p. 268). The desensitization phase is considered completed when the client’s SUD score has dropped to near 0, the VoC is near 7, and no significant new material or sensations are being reported.
Stage 5: Installation
The fifth stage of EMDR attempts to help clients couple their positive self-statement with the memory of their trauma. In this “installation” phase, the positive self-cognitions that emerged during the desensitization phase are “installed” using additional sets of bilateral stimulation as described above. During this process, residual unprocessed material might emerge, necessitating a return to a desensitization focus of the bilateral stimulation.
Stage 6: Body Scan
The sixth stage of EMDR commences when the reprocessing that occurs during the previous two stages appears to be complete in regard to the target that was addressed in those phases. This stage involves a body scan, in which clients close their eyes, think about the positive cognition that has been installed, and scan different parts of their body, starting with their head and then scanning downward, looking for any unusual sensations, including negative ones such as tension or tightness as well as positive ones such as a sense of calm. Any noted sensations are then processed with bilateral stimulation. Even if no such sensations are noted, bilateral stimulation is used to further cement the progress that has been made and to prepare the client for the closure phase.
Stage 7: Closure
In the penultimate stage, closure, clients are told that processing might occur between sessions and they are encouraged to record any disturbing thoughts, dreams, or other experiences that can be addressed in a subsequent session. The use of self-care techniques by the client, such as relaxation and other exercises discussed in the preparation phase, is also encouraged between sessions. Labeling this phase “closure” is not meant to imply that the targeted material has been completely reprocessed within a single session. It merely means that the session has reached the closure phase. The therapist uses the affect-management techniques discussed above to help the client leave the session feeling safe and calm.
Stage 8: Reevaluation
The eighth phase, reevaluation, actually happens not at the end of a session, but at the beginning of the next session. As such, it is not the end of the EMDR treatment process, but rather a link for returning to earlier phases to address lingering unprocessed material. It begins with asking the client to bring to mind the targeted material of the previous session and to provide a SUD and VoC rating. If these ratings suggest the need for further reprocessing of that material, the session then proceeds to the bilateral stimulation reprocessing phases regarding that material (that is, desensitization, installation, and body scan). If the ratings indicate no need for further reprocessing of that material, then the clinician and client discuss whether there is any remaining unprocessed material from earlier sessions or from what happened between sessions. Such material can be the focus of the next target for the reprocessing phases, as can other possible targets that the client introduces during the reevaluation phase.
Present and Future
The above stages are not limited to the reprocessing of past events. Once the reprocessing of the past has been concluded, the phases of EMDR protocol can be applied to present triggers of distress or of ones that are anticipated to be encountered in the future. As this occurs, additional unprocessed material from the past might emerge and need to be reprocessed.
EMDR may be contraindicated for some clients. Possible contraindications suggested by the clinical literature on EMDR include the possibility that conditions may be exacerbated by intense levels of emotion that can result from reprocessing. These include medical conditions such as pregnancy, seizures, or other neurological disorders. Other possible contraindications that must be considered include the use of psychotropic medications or substance abuse. Clinicians also should look for indicators of dissociation and dissociative disorders and should not use EMDR with dissociative clients unless they have had extensive experience as an EMDR clinician and have received formal training in treating people with dissociative disorders.
Complex Trauma and Other Disorders
The empirical support for EMDR is strongest for single-trauma, noncombat, and acute forms of PTSD among adults (Bisson et al., 2007; Bradley et al., 2005; Davidson & Parker, 2001; Rubin, 2003; Seidler & Wagner, 2006; van Etten & Taylor, 1998). Nevertheless, many clinicians use it with children; adult clients who have other, more complex forms of PTSD; and clients with other types of disorders. Indeed, as indicated above regarding the client history phase, the EMDR literature advises clinicians to look for a history of small-t traumas that do not meet DSM requirements for a PTSD diagnosis. Among the large-T traumas mentioned are some that are associated with more severe and chronic forms of PTSD that typically involve multiple traumas and for which there is scant well-controlled research support (in the form of randomized clinical trials), such as traumatic experiences during military combat and torture (Dodgsen, 2009).
Maxfield (2007), a staunch proponent of EMDR and prolific writer about it, cautioned that EMDR is often used by clinicians to treat problems for which EMDR’s efficacy has not yet been strongly established. Among these are phobias that do not follow a traumatic experience, panic disorders, complicated grief after a loved one’s death, and depression following marital breakup. Maxfield adds, “Many therapists also use EMDR to help individuals deal with life stressors, family problems, and attachment issues. While there are many anecdotal reports, and conference presentations, recommending various strategies for EMDR work with these issues, very few of them have research support” (2007, p. 8).
EMDR with Children
The clinical literature on how to implement EMDR with children recommends that clinicians be creative in fine-tuning the EMDR protocol to make it fit the child’s developmental level (Adler-Tapia & Settle, 2008). Although many clinicians use EMDR in treating children, the empirical support for its efficacy with children is insufficient. In their review, Greyber et al. (2012), for example, found only five randomized clinical trials (RCTs) of the efficacy of EMDR with children. The studies had uneven results, and Greyber et al. concluded that EMDR is only a promising practice with children and that it “tends to produce less positive results when compared to other trauma-focused interventions, although some research indicates the opposite” (p. 409). Adler-Tapia and Settle (2009) also reviewed the literature evaluating the efficacy of EMDR with children. Although their results with regard to RCTs essentially mirrored the results of Greyber et al., they interpreted their findings more optimistically, reasoning that “the efficacy or EMDR with young children cannot be dismissed simply because of the limited quantity of rigorous empirical studies with RCTs” (2012, p. 245). They also contended that the many less rigorous studies and anecdotal reports comprise “a substantial amount of research [that] also demonstrates that EMDR with children is a promising practice rapidly moving toward substantiation as evidence-based practice” (Greyber et al., p. 245).
EMDR and Comorbidity with Substance Abuse
Epidemiological research has shown that PTSD is often comorbid with substance-use disorders (Gulliver & Steffen, 2010). Given that many individuals seeking treatment for PTSD will have such comorbidity, it stands to reason that social workers considering using EMDR for their clients with PTSD should be aware of the caveats regarding its use with such clients. There is disagreement in the literature as to whether EMDR or any other exposure-based treatment should be initiated for PTSD before the client’s abstinence has been achieved. Some say it should not and that prematurely providing such treatment will exacerbate the substance-use disorder. Others contend that PTSD clients are “too volatile to be treated in substance abuse settings” (Gulliver & Steffen, 2010, p. 2). Practitioners should be cognizant of this uncertainty and realize that despite the extensive empirical support for EMDR with noncomorbid PTSD, there is insufficient research regarding its impact (and possible deleterious effects) on clients whose PTSD is comorbid with substance abuse.
EMDR and Complex PTSD
Although there is strong empirical support for the effectiveness of EMDR as well as exposure therapy in treating simpler forms of PTSD, such as noncomorbid PTSD resulting from a single-episode trauma, that empirical support should not be generalized to complex forms of PTSD, for which there is much less evidence. Complex PTSD is distinguished from simpler forms of PTSD by its comorbidity with other disorders, its association with multiple traumas (often beginning at an early age), and the severe nature of the traumatic events (such as multiple episodes of physical or sexual abuses, torture, military combat, and so on). Although the clinical literature on EMDR provides a brief protocol for its application with complex PTSD (Korn, 2009), much more research is needed on how best to provide it with individuals who have complex PTSD and its effectiveness with them (Korn, 2009; Maxfield, 2007).
EMDR and Combat-Related PTSD
EMDR is being recommended by various groups, including the Department of Veterans Affairs and Department of Defense (2004), as a treatment for PTSD among military combat veterans (Albright & Thyer, 2010). Combat-related PTSD is likely to be chronic and to involve comorbidity with traumatic brain injury and other disorders (Cukor, Olden, Lee, & Difede, 2010; Rubin, 2013). Recognizing the likely unique nature of combat-related PTSD and that the effectiveness of EMDR with other forms of PTSD therefore might not generalize to it, Albright and Thyer reviewed outcome studies on the “effects of EMDR on PTSD among military combat veterans” (p. 1). They concluded that there is limited evidence supporting EMDR’s effectiveness with that population. However, they also noted the varying methodological quality of some of the studies they reviewed. In that regard, the limited evidence does not imply that EMDR is ineffective with this population—just that more strong studies are needed. Nevertheless, Albright and Thyer concluded that the “lack of evidence raises concerns about the apparent premature adoption of EMDR as an officially endorsed treatment for members of the military and veterans diagnosed with PTSD by the Department of Defense and the Department of Veterans Affairs” (2010, p. 14). They also noted that the samples in the studies they reviewed consisted predominantly of veterans from the Vietnam War and, in light of the unique nature of combat in the current Global War on Terror, more research is needed to assess whether EMDR might be more effective with more recent combat veterans.
Is the Dual-Attention Stimulation Component Really Necessary?
As discussed by Maxfield (2007), some skeptics have contended that EMDR is merely a variant of exposure therapy because both treatments involve having the client focus on a distressing memory. Others, however, have argued that EMDR differs from exposure therapy in important ways, including a less stressful sense of reliving the trauma and less need for between-session homework. Pertinent to this debate is the unresolved issue regarding whether the bilateral stimulation component of EMDR is really required for its effectiveness. Some studies found no significant differences in outcome between EMDR with the bilateral stimulation component and EMDR without it (Davidson & Parker, 2001). Although Maxfield has expressed strong support for the efficacy of EMDR in her prolific writings on the topic, she acknowledged that the “possible contribution of [eye movements] remains a contentious issue, with critics . . . arguing that there is no compelling evidence that eye movements contribute to outcome in EMDR” (2007, p. 10). Maxfield added that others have attributed the lack of evidence to methodological shortcomings in the research and called for more rigorous research on this issue.
Despite the unresolved issues regarding EMDR, social workers can be assured that it has ample empirical support for its effectiveness with single-episode, simpler forms of PTSD with noncomorbid, adult, civilian populations. In addition, they should recognize that exposure therapy also has ample empirical support for those populations and that each of these treatment approaches is recognized as having the most empirical support for those populations. Although emerging evidence portrays EMDR as a promising treatment approach for children with PTSD, for now the evidence base supporting TFCBT for children is more substantial. When treating combat veterans or other populations with more complex forms of PTSD, social workers should view EMDR as a promising treatment approach, but one for which much more evidence is needed.
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