Seven randomized clinical trials have compared EMDR to exposure therapies (Ironson et al., 2002; McFarlane, 2000; Rothbaum, 2001; Thordarson et al., 2001; Vaughan et al., 1994) and to cognitive therapies plus exposure (Lee et al., 2002; Power et al., 2002). These studies have found EMDR and the cognitive/behavioral (CBT) control to be relatively equivalent, with a superiority in two studies for EMDR on measures of PTSD intrusive symptoms, and for CBT in the study by Taylor and colleagues Taylor, Thordarson, and Maxfield (2002) on PTSD symptoms of intrusion and avoidance. There were two controlled studies without randomization; one (Devilly & Spence, 1999) found the CBT condition superior to EMDR and the other (Sprang, 2001) found EMDR superior to the CBT control on multiple measures. Two studies found EMDR to be more efficient than the CBT control condition, with EMDR using fewer treatment sessions to achieve effects (Ironson et al., 2002; Power et al., 2002). Two studies that compared treatment response on a session-by-session basis (Thordarson et al., 2001) and at mid-point (Rothbaum, 2001), reported that EMDR did not result in more rapid treatment effects than exposure. However, in both these studies the exposure treatment sessions were supplemented with one hour of daily homework, while the EMDR condition was implemented without homework. The only study to control for the ancillary effects of homework (Ironson et al., 2002) supplemented both exposure and EMDR treatments with the same number of hours of exposure homework (see above). Most studies noted that because EMDR has minimal homework requirements the overall treatment time was much shorter for EMDR (e.g., Lee et al., 2002; Vaughan et al., 1994). Treatment effects have generally been well maintained (see below).
The efficacy of EMDR in the treatment of PTSD is now well recognized. In 1998, independent reviewers (Chambless et al., 1998) for the APA Division of Clinical Psychology placed EMDR, exposure therapy, and stress inoculation therapy on a list of empirically supported treatments, as “probably efficacious” ; no other therapies for any form of PTSD were judged to be empirically supported by controlled research. In 2000, after the examination of additional published controlled studies, the treatment guidelines of the International Society for Traumatic Stress Studies gave EMDR an A/B rating (Chemtob, Tolin, van der Kolk, & Pitman, 2000) and EMDR was found efficacious for PTSD. The United Kingdom Department of Health (2001) has also listed EMDR as an efficacious treatment for PTSD.
Foa, Riggs, Massie, and Yarczower (1995) suggested that exposure therapy may not be very effective with clients whose prominent affect is anger, guilt, or shame. Reports by clinicians treating combat veterans (e.g., Lipke,1999; Silver & Rogers, 2002) indicate that EMDR may be effective with such PTSD presentations. A preliminary study found that EMDR reduced symptoms of guilt in combat-related PTSD (Cerone, 2000). Taylor et al. (2002) reported equivalent and significant effects for exposure therapy and EMDR on reducing symptoms of anger and guilt.
In addition to studies assessing the effectiveness of EMDR in the treatment of PTSD, phobias, and panic disorders (see Is EMDR an effective treatment of phobias, panic disorder, and agoraphobia?), some preliminary investigations have indicated that EMDR might be helpful with other disorders. These include dissociative disorders (e.g, Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen, 1995); performance anxiety (Foster & Lendl, 1996; Maxfield & Melnyk, 2000); body dysmorphic disorder (Brown et al., 1997); pain disorder (Grant & Threlfo, 2002); and personality disorders (e.g., Korn & Leeds, 2002; Manfield, 1998). These findings are preliminary and further research is required before any conclusions can be drawn. In Shapiro, 2002, applications of EMDR are described for complaints such as depression (Shapiro, 2002), attachment disorder (Siegel, 2002), social phobia (Smyth, & Poole, 2002), anger dyscontrol (Young, Zangwill, & Behary , 2002), generalized anxiety disorder (Lazarus, & Lazarus , 2002), distress related to infertility (Bohart & Greenberg, 2002), body image disturbance (Brown, 2002), marital discord (Kaslow, Nurse, & Thompson, 2002), and existential angst (Krystal, Prendergast, Krystal, Fenner, Shapiro, Shapiro, 2002); all such applications should be considered in need of controlled research for comprehensive examination.
The Davidson and Parker (2001) meta-analysis evaluated outcomes in 34 different EMDR studies. This was a thorough and comprehensive meta-analysis, although some studies were overlooked. They concluded that EMDR was superior to no-treatment and non-specific treatment controls, and equivalent in outcome to exposure and cognitive behavioural therapies. As reported previously in this Appendix, such findings are consistent with those in the EMDR literature. Unfortunately in their investigation of the eye movement component, Davidson and Parker did not distinguish between clinical dismantling studies and component action studies (see below). In addition, they did not distinguish between analogue studies which used partial EMDR done for 15 minutes with normal students and dismantling studies with multiple sessions for persons with chronic PTSD. This lack of distinction created large variability in the meta-analysis, and made it difficult to find effects. However, they noted that their data indicated that the comparison effect size between EMDR-with-EMS and EMDR-without-EMs, was “marginally significant if one examines only clinical populations satisfying [DSM] diagnostic criteria” (p. 311). Even this evaluation, however, failed to evaluate whether the length of treatment offered to the various PTSD populations was clinically adequate to reveal differential main effects.
There is much variability in the outcomes of EMDR studies, with a range of outcomes reported, and with the efficacy of EMDR varying across studies. In a meta-analysis, Maxfield and Hyer (2002), sought to determine if differences in outcome were related to methodological differences. All published PTSD treatment outcome studies were reviewed to identify methodological strengths and weaknesses and rated using the Gold Standard (GS) Scale (adapted from Foa & Meadows, 1997). Then the relationship between methodological rigor and effect sizes in these studies was examined. Results indicated a significant relationship between scores on the GS Scale and effect size, with more rigorous studies reporting larger effect sizes. It appeared that methodological rigor removes noise and thereby decreases error measurement, allowing for the more accurate detection of true treatment effects. It should be noted that the association between methodology and outcome is purely correlational, and may actually be the effect of some unknown third variable. However, it can be argued that, when considering the aggregate evidence for the efficacy of EMDR, greater weight may be given to those studies with better methodology as these appear more likely to reveal accurate outcomes.
Marks, Lovell, Noshirvani, Livanou, & Thrasher (1998) propose that emotion can be conceptualised as a “skein of responses,” viewed as “loosely linked reactions of many physiological, behavioural, and cognitive kinds” (p. 324). They suggest that different types of treatment will weaken different strands within the skein of responses and that “some treatments may act on several strands simultaneously” (p. 324). EMDR is a multi-component approach that works with strands of imagery, cognition, affect, somatic sensation, and related memories. This complexity makes it difficult to isolate and measure the contribution of any single component, especially as different clients with the same diagnosis may respond differently to different elements.
Shapiro’s (2001) AIP model conceptualizes EMDR as working directly with cognitive, affective, and somatic components of memory to forge new associative links with more adaptive material. A number of treatment elements are formulated to enhance the processing and assimilation needed for adaptive resolution. These include: (1) Linking of memory components The client’s simultaneous focus on the image of the event, the associated negative belief, and the attendant physical sensations, may serve to forge initial connections among various elements of the traumatic memory, thus initiating information processing. (2) Mindfulness. Mindfulness is encouraged by instructing clients to “just notice” and to “let whatever happens, happen.” This cultivation of a stabilized observer stance in EMDR appears similar to processes advocated by Teasdale (1999) as facilitating emotional processing. (3) Free association. During processing, clients are asked to report on any new insights, associations, emotions, sensations, images, that emerge into consciousness. This non-directive free association method may create associative links between the original targeted trauma and other related experiences and information, thus contributing to processing of the traumatic material (see Rogers & Silver, 2002). (4) Repeated access and dismissal of traumatic imagery. The brief exposures of EMDR provide clients with repeated practice in controlling and dismissing disturbing internal stimuli. This may provide clients with a sense of mastery, contributing to treatment effects by increasing their ability to reduce or manage negative interpretations and ruminations. (5) Eye movements and other dual attention stimuli. There are many theories about how and why eye movements may contribute to information processing, and these are discussed in detail below.
There have been 20 published studies that investigated the role of EMs in EMDR. Studies have typically compared EMDR-with-EMs to a control condition in which the EM component was modified (e.g., EMDR-with-eyes-focused-and-unmoving). There have been four different types of studies: (1) case studies, (2) dismantling studies using clinical participants (3) dismantling studies using nonclinical analogue participants, and (4) component action studies in which eye movements are examined in isolation.
Case studies. Four case studies evaluated the effects of adding EMs to the treatment process, and three demonstrated an effect for EMs. Montgomery and Ayllon (1994) found eye movements to be necessary for EMDR treatment effects in five of six civilian PTSD patients. They wrote that the addition of the eye movement component “resulted in the significant decreases in self-reports of distress previously addressed. These findings are reflected by decreases in psycho-physiological arousal” (Montgomery & Ayllon, 1994, p. 228). Lohr, Tolin, and Kleinknecht (1995) reported that “the addition of the eye movement component appeared to have a distinct effect in reducing the level of [SUD] ratings” (p. 149). When Lohr, Tolin and Kleinknecht (1996) treated two claustrophobic subjects, substantial changes in disturbance ratings were achieved only after EMs were added to an imagery exposure procedure that used the brief frequent exposures of EMDR. The fourth study (Acierno, Tremont, Last, & Montgomery, 1994) did not use standard EMDR protocol for phobias, nor the standard procedures for accessing the image, formulating the negative belief, or eliciting new associations. In addition, the client was instructed to relax between sets of EMs until the SUD rating was reduced to baseline, a procedure not used in EMDR. The procedures used in this study did not eliminate the phobia and no effect was found for the EM condition.
Clinical dismantling studies with diagnosed participants. There have been four controlled dismantling studies with PTSD participants, and two studies where participants were diagnosed with other anxiety disorders. These studies have tended to show that EMDR-with-EMs was slightly better than EMDR-with-modification; however such comparisons have not usually been statistically significant, and results are equivocal. For example, Devilly et al. (1998) reported rates of reliable change of 67% for the EM condition, compared to 42% of the non-EM condition; Renfrey and Spates (1994) reported a decrease in PTSD diagnosis of 85% for EM conditions and 57% for the non-EM group. These studies unfortunately are limited by severe methodological problems, including inadequate statistical power. For example, there were seven or eight persons per condition in the Renfrey and Spates (1994) PTSD study. The participants in the other three PTSD (Boudeywns & Hyer, 1996; Devilly et al., 1998; Pitman et al., 1996) studies were combat veterans, who received only two sessions or treatment of only one traumatic memories. Such an inadequate course of treatment produced only moderate effect sizes; therefore a large sample would be required to provide adequate statistical power for the detection of any possible differences between groups. There has yet to be a single rigorous dismantling study with a sample adequate to assess treatment effects.
Clinical dismantling studies with analogue participants. The controlled studies that used analogue participants with nonclinical anxiety found no effect for EMs. There are many problems with these analogue studies, which typically used normal college student participants. The EMDR protocol was often truncated (e.g., Carrigan & Levis, 1999; Sanderson & Carpenter, 1992), resulting in poor construct validity and making interpretation of results problematic. It is also unlikely that the responses of analogue participants can be generalized to persons with chronic PTSD, a disorder that appears resistant to placebo effects (Solomon, Gerrity, & Muff, 1992; Van Etten & Taylor, 1998). Analogue participants responded well to EMDR-without-EMs, a procedure which contains a number of active components. The minimal distress of the analogue participants was relieved with minimal treatment, and the assessment of differences between the EM and nonEM conditions was limited by a floor effect. Consequently it may not have been possible to detect differences between conditions.
Component action studies. Component action studies test EMs in isolation. These studies typically provide brief sets of EMs (not EMDR) to examine their effects on memory, affect, cognition, or physiology. The purpose is to investigate the effects of moving the eyes (not EMDR), and EMs are compared to control conditions such as imaging and tapping. For example, a participant might be asked to visualize a memory image, then to move their eyes for a brief period ,and then to rate the vividness of the image. This permits a pure test of the specific effects of EMs and non-EMs without the added effects of the active ingredients of the other EMDR procedures. The studies have generally used nonclinical participants and a within-subject design, that compares the differences in each individual’s responses to the various conditions. This reduces the variance of subjective responding, and eliminates possible floor effects.
Findings from these studies suggest that EMs may have an effect on physiology, decreasing arousal (e.g., Barrowcliff et al., in press; D. Wilson et al., 1996) on attentional flexaility (Kuiken, Bears, Miall & Smitth (2001-2001) and on memory processes, enhancing semantic recall (Christman et al., in press). Four studies (Andrade, Kavanagh, & Baddeley, 1997; Kavanaugh, Freese, Andrade, & May, 2001; Sharpley et al., 1996; van den Hout, Muris, Salemink, & Kindt, 2001) have demonstrated that EMs decrease the vividness of memory images and the associated emotion. No (or minimal) effect has been found for tapping conditions. These studies suggest that EMs may make a contribution to treatment by decreasing the salience of the memory and its associated affect. (See discussion below on mechanisms of action).
Various reviews of the related EM research have provided a range of conclusions. Some reviewers (e.g., Lohr, Lilienfeld, Tolin, & Herbert, 1999; Lohr, Tolin, & Lilienfeld, 1998) stated that there is no compelling evidence that eye movements contribute to outcome in EMDR treatment and the lack of unequivocal findings has led some reviewers to dismiss EMs altogether (e.g., McNally, 1999). Other reviewers (e.g., Chemtob et al., 2000; Feske, 1998; Perkins & Rouanzoin, 2002) identified methodological failings (e.g., lack of statistical power, floor effects) and called for more rigorous study.
Numerous controlled studies have also indicated that eye movements cause a decrease in imagery vividness and distress, as well as increased memory access. Andrade, J., Kavanagh, D., & Baddeley, A. (1997). Eye-movement and visual imagery: a working memory approach to the treatment of post-traumatic stress disorder. British Journal of Clinical Psychology, 36, 209-223. Barrowcliff, A.L., Gray, N.S., MacCulloch, S. Freeman, T.C.A., & MacCulloch, M.J. (in press). Horizontal rhythmical eye-movements consistently diminish the arousal provoked by auditory stimuli. British Journal of Clinical Psychology. Christman, S.D., Garvey, K.J., Propper, R.E. & Phaneuf, K.A. (in press). Bilateral eye movements enhance the retrieval of episodic memories. British Journal of Clinical Psychology, 40, 267-280. Kavanaugh, D.J., Freese, S., Andrade, J., & May, J. (2001). Effects of visuospatial tasks on desensitization to emotive memories. British Journal of Clinical Psychology, 40, 267-280. Kuiken, D., Bears, M., Miall, D., & Smith, L. (2002-2002). Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition and Personality, 21, (1), 3-30. Sharpley, C.F., Montgomery, I.M., & Scalzo, L.A. (1996). Comparative efficacy of EMDR and alternative procedures in reducing the vividness of mental images. Scandinavian Journal of Behaviour Therapy, 25, 37-42. van den Hout, M., Muris, P., Salemink, E., & Kindt, M. (2001). Autobiographical memories become less vivid and emotional after eye movements. British Journal of Clinical Psychology, 40, 121-130.
There are several research studies (e.g., Andrade et al., 1997; Kavanaugh et al., 2001; van den Hout et al., 2001) indicating that EMs and other stimuli have an effect on perceptions of the targeted memory, decreasing image vividness and associated affect. Two possible mechanisms have been proposed to explain how this effect may contribute to EMDR treatment. Kavanaugh et al. (2001) hypothesize that this effect occurs when EMs disrupt working memory, decreasing vividness, and that this results in decreased emotionality. They further suggest that this effect may contribute to treatment as a “response aid for imaginal exposure” (p. 278), by titrating exposure for those clients who are distressed by memory images and/or affect. Van den Hout et al. (2001) hypothesize that EMs change the somatic perceptions accompanying retrieval, leading to decreased affect, and therefore decreasing vividness. They propose that that this effect “may be to temporarily assist patients in recollecting memories that may otherwise appear to be unbearable” (p. 129). This explanation has many similarities to reciprocal inhibition.
Rauch, van der Kolk, and colleagues (1996) conducted positron emission studies of patients with PTSD in which they were exposed to vivid, detailed narratives which they had written about their own traumatic experiences. Patients showed heightened activity only in the right hemisphere, in the areas most involved in emotional arousal, and heightened activity on the right visual cortex, reflecting the flashbacks reported by these patients. Perhaps most significantly, Broca’s area – the part of the left hemisphere responsible for translating personal experiences into communicable language -“turned off”. These findings indicate that PTSD symptoms are reflected in actual changes in brain activity.
Case study research by van der Kolk and colleagues (Levin, Lazrove, & van der Kolk, 1999; van der Kolk, Burbridge, & Suzuki, 1997; Zoler, 1998) has provided some preliminary evidence that changes in brain activation patterns may follow effective treatment. SPECT scans were administered pre and post-EMDR for 6 PTSD subjects who each received 3 EMDR sessions. The Zoler article has photos of pre and post SPECT scans. Findings indicated metabolic changes after EMDR in two specific brain regions. First, there was an increase in bilateral activity of the anterior cyngulate. This area moderates the experience of real versus perceived threat, indicating that after EMDR, PTSD sufferers may no longer be hypervigilant. Second, there appeared to be an increase in pre-frontal lobe metabolism. An increase in frontal lobe functioning may indicate improvement in the ability to make sense of incoming sensory stimulation. Levin et al. concluded that EMDR appeared to facilitate information processing. Because there was no control group, there is no evidence that these effects were unique to EMDR; effective treatment of any kind may produce similar results.
Daniel Amen (2001) has been taking pre and post SPECT scans of his patients. He has used EMDR with PTSD patients, and reported a decrease in anterior cingulate, basal ganglia and deep limbic activity. The 12th chapter of Shapiro’s (2001) text details some related recent neurological research and explains the possible relevance of these findings to EMDR. Also of interest is an article by Stickgold (2002), a sleep researcher, who has developed a theory to explain the effects of EMDR’s alternating, bilateral stimulation which forces the client to constantly shift his or her attention across the midline. He proposed that REM-like neurobiological mechanisms are facilitated by this shifting attention, resulting in the activation of episodic memories, and their integration into cortical semantic memory. Independent research by Christman and Garvey (2000) provides some support for this theory. They determined that alternating leftward and rightward eye movements produced a beneficial effect for episodic, but not semantic, retrieval memory tasks.
1. distressing and unresolved memories may emerge
2. some clients may experience reactions during a treatment session that neither they nor the administering clinician may have anticipated, including a high level of emotion or physical sensations
3. subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories feelings, etc., may emerge.
1. Have they received both levels of training;
2. Was the training approved by EMDRIA;
3. Have they kept informed of the latest protocols and developments;
4. How many cases have they treated with your particular problem/disorder;
5. What is their success rate.
We note there are some distinctive differences between hypnosis and EMDR, which we would like to briefly highlight. First, one of the major uses of hypnosis among clinical practitioners is to deliberately begin by inducing in the patient an altered state of mental relaxation. In contrast, when beginning EMDR mental relaxation is not typically attempted. In fact, deliberate attempts are often actually made to connect with an anxious (i.e. an emotionally disturbing as opposed to relaxed) mental state.
Second, therapists often use hypnosis to help a patient develop a single, highly focused state of aroused receptivity (Spiegel & Spiegel, 1978). In contrast, with EMDR attempts are made to maintain a duality of focus on both positive and negative currently held self-referencing beliefs, as well as the emotional arousal brought about by imaging the worst part of a disturbing memory. However, in this sense, EMDR does have a similarity to Spiegel’s (Spiegel & Spiegel, 1978) split-screen cognitive restructuring technique.
Third, one of the proposed effects of hypnotizing a person is that they will have a decrease in their generalized reality orientation (GRO: Shor, 1979). This induced decrease in a person’s GRO is often utilized in order to promote an increase in fantasy and imagination, perhaps by capitalizing on an increase in trance logic (Orne, 1977). In contrast, in EMDR attempts are made towards repeatedly grounding the patient by referencing current feelings and body sensations to prevent the patient from drifting away from reality. Specific encouragement/inducement is made towards rejecting previously irrational/self-blaming beliefs in favor of a newly, reframed positive belief with an increase in subjective conviction about that belief. Shapiro and Forrest (1997) and Nicosia (1995) have also noted additional differences between hypnosis and EMDR.
1. distressing and unresolved memories may emerge
2. some clients may experience reactions during a treatment session that neither they nor the administrating clinician may have anticipated, including a high level of emotion or physical sensation
3. subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories, feelings, etc., may emerge.
1) EMDR is only superior to no treatment and/or has not been throughly tested.
This is inaccurate. EMDR has been found superior in controlled studies to Veterans Administration (V.A.) standard care, biofeedback assisted relaxation, simple relaxation, active listening, and various forms of individual psychotherapy used at an HMO (e.g. exposure, cognitive, psychodynamic). It has also been compared to and found generally equal to forms of exposure therapy with and without forms of cognitive therapy. While exposure therapy used 1-2 hours of daily homework, EMDR has achieved equivalent results with none [view Efficacy].
2) EMDR is only exposure therapy.
This is inaccurate. EMDR has been found to be equivalent to exposure therapy in 5 studies. However, exposure therapy uses 1-2 hours of daily homework and EMDR uses none. In addition, the EMDR practices have little in common with exposure therapy. A process analysis of the two found significant differences (Rogers et al., 1999) and some researchers subsequent to another study stated: “In strict exposure therapy the use of many of [‘a host of EMDR-essential treatment components’] is considered contrary to theory. Previous information also found that therapists and patients prefer this procedure over the more direct exposure procedure” (Boudewyns & Hyer, 1996, p.192) For additional references and details see Is EMDR an exposure therapy?
3) There is no theory for EMDR effects or reasons for the eye movements.
This is inaccurate. The information processing model was articulated in 1991 and has been thoroughly described in three texts. A number of neuropsychologists have also given detailed theories and descriptions of reasons for EMDR’s effects. Numerous researchers have also articulated theories and conducted hypothesis driven research supporting the use of eye movements and other dual attention stimulation. For references and details see: Theory: The Adaptive Information Processing Model Eye Movements and Alternate Dual Attention Stimuli What has research determined about EMDR’s eye movement component? What are some hypothesized mechanisms of action for eye movements in EMDR?
4)Perkins, B. R., & Rouanzoin, C. C. (2002). A critical examination of current views regarding eye movement desensitization and reprocessing (EMDR): Clarifying points of confusion. Journal of Clinical Psychology, 58, 77-97.
EMDR is an active psychological treatment for PTSD that has been surrounded by confusion in the research review literature. One article (Perkins & Rouanzoin, 2002) examined the original empirical research in light of the review literature in order to understand the contradictory conclusions that had been drawn by various authors and some significant conclusions were suggested.
The confusion appears to be due to (a) an inadequate awareness of the lack of placebo effects in treating PTSD; (b) a theoretical and methodological lack of distinction between EMDR and exposure procedures; (c) debates over the importance of the eye movement component of EMDR; (d) poorly designed outcome studies; and (e) historical misinformation which then becomes confounded with empirical research findings. In considering these issues it is important to understand that PTSD is highly refractory to nonspecific treatment factors and that the effects of EMDR are much larger than would be expected by such placebo effects. Secondly, while the general treatment effects of EMDR and exposure procedures appear to be approximately equivalent, EMDR is much more efficient in producing the therapeutic changes. Furthermore, the EMDR method (which involves brief interrupted periods of exposure) is inconsistent with exposure theory that prescribes extended, uninterrupted periods of exposure. Third, the role of eye movements has not received adequate empirical exploration primarily due to inadequate sample sizes, inappropriate populations, and poor treatment fidelity. Until that is accomplished, the eye movements are a part of the validated procedure and their removal is without empirical justification. Moreover, there are general methodological and fidelity problems in some empirical studies that confuse the outcome research, including poor fidelity to the EMDR method as well as inadequate treatment dosage, poor research designs, and truncated protocols (especially as it pertains to multiply traumatized populations). And finally a relatively small group of authors appear to have engaged in the inaccurate and selective reporting of past research findings as well as the misstatement of historical events in the development of EMDR. Readers of research reviews will find it helpful to have a knowledge of research design as well as the EMDR method to assess the generalizability of research findings and the adequacy of treatment fidelity respectively. Then when confusion arises, the reader can frequently reduce or eliminate the confusion by reading the original research.