Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing ('EMDR) is a form of psychotherapy that was developed by Francine Shapiro to resolve the development of trauma-related disorders caused by exposure to distressing events such as rape or military combat. According to Shapiro's theory, when a traumatic or distressing experience occurs, it may overwhelm usual cognitive and neurological coping mechanisms. The memory and associated stimuli of the event are inadequately processed, and are dysfunctionally stored in an isolated memory network. The goal of EMDR therapy is to process these distressing memories, reducing their lingering influence and allowing clients to develop more adaptive coping mechanisms.
Although some clinicians may use EMDR for other problems, its research support is primarily for disorders stemming from distressing life experiences, such as post-traumatic stress disorder (PTSD). However, EMDR remains somewhat controversial due to questions about its methods and theoretical foundations.
- 1 Approach
- 2 Mechanism
- 3 Empirical evidence and comparison
- 4 Other applications
- 5 Controversy over mechanisms and effectiveness
- 6 See also
- 7 References
- 8 External links
EMDR integrates elements of effective psychodynamic, imaginal exposure, cognitive therapy, interpersonal, experiential, physiological and somatic therapies. Distinguishing EMDR from other therapies, however, is the unique element of bilateral stimulation (e.g. eye movements, tones, or tapping) during each session.
EMDR uses a structured eight-phase approach (outlined in greater detail below) to address the past, present, and future aspects of a traumatic or distressing memory that has been dysfunctionally stored. During the processing phases of EMDR, the client focuses on disturbing memory in multiple brief sets of about 15–30 seconds. Simultaneously, the client focuses on the dual attention stimulus (e.g., therapist-directed lateral eye movement, alternate hand-tapping, or bilateral auditory tones). Following each set of such dual attention, the client is asked what associative information was elicited during the procedure. This new material usually becomes the focus of the next set. This process of alternating dual attention and personal association is repeated many times during the session.
When traumatic memory networks are activated, the client may re-experience aspects of the original event, often resulting in inappropriate overreactions. This explains why people who have experienced or witnessed a traumatic incident may have recurring sensory flashbacks, thoughts, beliefs, or dreams. An unprocessed memory of a traumatic event can retain high levels of sensory and emotional intensity, even though many years may have passed. The theory is that EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other semantic memory networks. It is thought that the distressing memory is transformed when new connections are forged with more positive and realistic information. This results in a transformation of the emotional, sensory, and cognitive components of the memory; when the memory is accessed, the individual is no longer distressed. Instead he/she recalls the incident with a new perspective, new insight, resolution of the cognitive distortions, elimination of emotional distress, and relief of related physiological arousal.
When the distressing or traumatic event is an isolated, single incident (e.g., a traffic accident), approximately three sessions are necessary for comprehensive treatment. When multiple traumatic events contribute to a health problem—such as physical, sexual, or emotional abuse, parental neglect, severe illness, accident, injury, or health-related trauma that result in chronic impairment to health and well-being, or combat trauma, the time to heal may be longer, and complex, multiple trauma may require many more sessions for the treatment to be complete and robust.
Although EMDR is established as an evidence-based treatment for PTSD there are two main perspectives on EMDR therapy. First, Shapiro proposed that although a number of different processes underlie EMDR, the eye movements add to the therapy's effectiveness by evoking neurological and physiological changes that may aid in the processing of the trauma memories being treated. The other perspective is that the eye movements are an unnecessary epiphenomenon, and that EMDR is simply a form of desensitization.
The therapy process and procedures are according to Shapiro (2001)
- Phase I
- In the first sessions, the patient's history and an overall treatment plan are discussed. During this process the therapist identifies and clarifies potential targets for EMDR. Target refers to a disturbing issue, event, feeling, or memory for use as an initial focus for EMDR. Maladaptive beliefs are also identified (e.g., "I can't trust people" or "I can't protect myself.")
- Phase II
- Before beginning EMDR for the first time, it is recommended that the client identify a "safe place" -- an image or memory that elicits comfortable feelings and a positive sense of self. This safe place can be used later to bring closure to an incomplete session or to help a client tolerate a particularly upsetting session.
- Phase III
- In developing a target for EMDR, prior to beginning the eye movement, a snapshot image is identified that represents the target and the disturbance associated with it. Using that image is a way to help the client focus on the target, a negative cognition (NC) is identified – a negative statement about the self that feels especially true when the client focuses on the target image. A positive cognition (PC) is also identified – a positive self-statement that is preferable to the negative cognition.
- Phase IV
- The therapist asks the patient to focus simultaneously on the image, the negative cognition, and the disturbing emotion or body sensation. Then the therapist usually asks the client to follow a moving object with his or her eyes; the object moves alternately from side to side so that the client's eyes also move back and forth. After a set of eye movements, the client is asked to report briefly on what has come up; this may be a thought, a feeling, a physical sensation, an image, a memory, or a change in any one of the above. In the initial instructions to the client, the therapist asks him or her to focus on this thought, and begins a new set of eye movements. Under certain conditions, however, the therapist directs the client to focus on the original target memory or on some other image, thought, feeling, fantasy, physical sensation, or memory. From time to time the therapist may query the client about her or his current level of distress. The desensitization phase ends when the SUDS (Subjective Units of Disturbance Scale) has reached 0 or 1.
- Phase V
- The "Installation Phase": the therapist asks the client about the positive cognition, if it's still valid. After Phase IV, the view of the client on the event/ the initial snapshot image may have changed dramatically. Another PC may be needed. Then the client is asked to "hold together" the snapshot and the (new) PC. Also the therapist asks, "How valid does the PC feel, on a scale from 1 to 7?" New sets of eye movement are issued.
- Phase VI
- The body scan: the therapist asks if anywhere in the client's body any pain, stress or discomfort is felt. If so, the client is asked to concentrate on the sore knee or whatever may arise and new sets are issued.
- Phase VII
- Debriefing: the therapist gives appropriate info and support.
- Phase VIII
- Re-evaluation: At the beginning of the next session, the client reviews the week, discussing any new sensations or experiences. The level of disturbance arising from the experiences targeted in the previous session is assessed. An objective of this phase is to ensure the processing of all relevant historical events.
EMDR also uses a three-pronged approach, to address past, present and future aspects of the targeted memory.
The theory underlying EMDR treatment is that it works by helping the sufferer process distressing memories more fully which reduces the distress. EMDR is based on a theoretical information processing model which posits that symptoms arise when events are inadequately processed, and can be eradicated when the memory is fully processed. It is an integrative therapy, synthesizing elements of many traditional psychological orientations, such as psychodynamic, cognitive behavioral, experiential, physiological, and interpersonal therapies.
EMDR's unique aspect is an unusual component of bilateral stimulation of the brain, such as eye movement, bilateral sound, or bilateral tactile stimulation coupled with cognitions, visualized images and body sensation. EMDR also utilizes dual attention awareness to allow the individual to vacillate between the traumatic material and the safety of the present moment. This can help prevent retraumatization from exposure to the disturbing memory.
There is no definitive explanation as to how EMDR may work. There is some empirical support for each of three different explanations regarding how an external stimulus such as eye movement could facilitate the processing of traumatic memories.
Empirical evidence and comparison
A recent review rated EMDR as an effective method for the treatment of PTSD, and the International Society of Stress Studies practice guidelines categorized EMDR as an evidence-based level A treatment for PTSD in adults. A number of international guidelines include EMDR as a recommended treatment for trauma.
Research on the application of EMDR therapy continues, and several meta-analyses have been performed to further evaluate its efficacy in the treatment of PTSD. In one meta-analysis of PTSD, EMDR was reported to be as effective as exposure therapy and SSRIs. Two separate meta-analyses suggested that traditional exposure therapy and EMDR have equivalent effects both immediately after treatment and at follow-up. A 2007 meta-analysis of 38 randomized controlled trials for PTSD treatment suggested that the first-line psychological treatment for PTSD should be Trauma-Focused CBT (Cognitive Behavioral Therapy) or EMDR. A review of rape treatment outcomes concluded that EMDR had some efficacy. Another meta-analysis concluded that all "bona fide" treatments were equally effective, but there was some debate regarding the study's selection of which treatments were "bona fide". A comparative review concluded EMDR to be of similar efficacy to other exposure therapies and more effective than SSRIs, problem-centred therapy, or treatment as usual.
Although controlled research has concentrated on the application of EMDR to PTSD, a number of studies have investigated EMDR’s efficacy with other anxiety disorders as well as numerous reports of diverse clinical applications.
EMDR can work on a multitude of problems that are less complex than PTSD. One of these is uncomplicated depression. The EMDR Casebook by Philip Manfield documents case studies in which EMDR was used. In the case about uncomplicated depression, Manfield was able to help his client, George, resolve several childhood issues that have plagued his adult life. Moreover, EMDR can work for postpartum depression. By having the client target a distinctive memory and work through it with a series of eye movements, the client is then able to achieve a positive cognition.
EMDR is often cited as a component in the treatment of complex post-traumatic stress disorder, emotional dysregulation, and in the treatment of children exposed to chronic early maltreatment that is related to attachment disorder.
For personal improvement
Controversy over mechanisms and effectiveness
The working mechanisms that underlie the effectiveness of EMDR, and whether the eye movement component in EMDR contributes to its clinical effectiveness are still points of uncertainty and contentious debate.
EMDR has generated a great deal of controversy since its inception in 1989. Critics of EMDR argue that the eye movements do not play a central role, that the mechanisms of eye movements are speculative, and that the theory leading to the practice is not falsifiable and therefore not amenable to scientific inquiry.
Although one meta-analysis concluded that EMDR is not as effective, or as long lasting, as traditional exposure therapy, several other researchers using meta-analysis have found EMDR to be at least equivalent in effect size to specific exposure therapies.
The exposure that occurs in EMDR should, according to the assumptions of emotional processing theory, sensitise rather than desensitise and decrease the fear and distress associated with traumatic memories. However, EMDR is effective, therefore processes other than imaginal exposure must play a role in the effectiveness of EMDR in the treatment of PTSD.
An early critical review and meta-analysis that looked at the contribution of eye movement to treatment effectiveness in EMDR concluded that eye movement is not necessary to the treatment effect. Salkovskis (2002) reported that the eye movement is irrelevant and that the effectiveness of the procedure is solely due to its having properties similar to cognitive behavioral therapies, such as desensitization and exposure.
Effect of eye movement on memory, cognitive processes, and physiology
Although a wide range of researchers have proposed various models and theories to explain the effect of eye movement, and the possible role that eye movement may play in the process of EMDR, to date, no single model or theory exists that can explain all of the above mentioned findings. Further research is therefore required in this area.
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