Detailed explanation of Eye Movement Desensitization and Reprocessing, EMDR as an alternative anxiety disorder treatment.
Eye Movement Desensitization and Reprocessing (EMDR) is still considered by many mental health professionals to be an "alternative" treatment for PTSD. By alternative, we mean treatments other than the more standard forms of treatment, such as anxiety medication or Cognitive Behavioral Therapy (CBT). These alternative treatments are, for the most part, less well-studied than the standard treatments and have met with varying degrees of acceptance from mental health professionals.
EMDR was developed by Francine Shapiro, Ph.D. in 1987. One day, while walking in a park, Dr. Shapiro made a connection between her involuntary eye movements and the reduction of her negative thoughts. She decided to explore this link and began to study eye movements in relation to the symptoms of Posttraumatic Stress Disorder (PTSD). PTSD is an anxiety disorder that is characterized by the development of symptoms after exposure to a traumatic event. Symptoms can include re-experiencing the event - either in flashbacks or nightmares - avoidance of reminders of the event, feeling jumpy, having difficulty sleeping, having an exaggerated startle response, and experiencing feelings of detachment.
The theory behind EMDR is that traumatic memories that are not processed properly cause blockages and can lead to disorders such as PTSD. EMDR therapy is used to help individuals to process these memories properly and develop adaptive changes in thinking.
The EMDR Process
EMDR is an eight-step process, with steps three through eight being repeated as necessary. The number of sessions devoted to each phase varies on an individual basis.
Step 1: The therapist takes a complete history of the patient and a treatment plan is designed.
Step 2: Patients are taught relaxation and self-calming techniques.
Step 3: The patient is asked to describe the visual image of the trauma as well as the associated feelings and negative thoughts, such as "I'm a failure." The patient is then asked to identify a desired positive thought, such as "I really can succeed," this positive thought is rated against the negative thought on a scale of 1-7, with 1 being "Completely false" and 7 being "Completely true." This process helps create a goal for treatment. The patient then combines the visual image of the trauma with the negative belief, usually evoking strong feelings, which are then rated on the Subjective Unit of Disturbance (SUD) scale. While focusing on the combination of the traumatic image and negative thought, the patient watches the therapist move his hand in a particular pattern causing the patient's eyes to move involuntarily. Blinking lights are sometimes substituted for hand movements, likewise hand tapping and auditory tones may be used instead of eye movements. After each set of eye movements the patient is asked to clear his mind and relax. This may be repeated several times during a session.
Step 4: This phase involves desensitization to the negative thoughts and images. The patient is instructed to focus on the visual image of the trauma, the negative belief he has of himself, and the bodily sensations caused by the anxiety, while at the same time following the therapist's moving finger with his eyes. The patient is asked to relax again and determine what he is feeling, these new images, thoughts, or sensations are the focus for the next eye movement set. This is continued until the patient can think of the original trauma without significant distress.
Step 5: This step focuses on cognitive restructuring, or learning new ways to think. The patient is asked to think about the trauma and a positive thought about himself (e.g., "I can succeed"), while completing another eye movement set. The point of this step is to bring the patient to the point of believing the positive statement about himself.
Step 6: The patient focuses on the traumatic image and the positive thought, and is once again asked to report any unusual bodily sensations. The sensations are then targeted with another set of eye movements. The theory behind this is that improperly stored memories are experienced through bodily sensation. EMDR is not considered complete until the patient can think of the traumatic event without experiencing any negative bodily sensations.
Step 7: The therapist determines whether the memory has been adequately processed. If it hasn't been, the relaxation techniques learned in Step 2 are employed. Memory processing is thought to continue even after the session has concluded, so patients are asked to keep a journal and record dreams, intrusive thoughts, memories and emotions.
Step 8: This is a reevaluation step and is repeated at the beginning of each EMDR session after the initial session. The patient is asked to review the progress made in the previous session and the journal is reviewed for areas that may need further work.
The eight steps may be completed in a few sessions, or over a period of months, depending on the needs of the patient.
Does EMDR Work?
In 1998 an American Psychological Association task force declared that EMDR was one of three "probably efficacious treatments" for PTSD. Nonetheless, EMDR remains a controversial treatment, supported by some and criticized by others. Although originally developed to treat PTSD, some proponents of EMDR have recently begun advocating its use in the treatment of other anxiety disorders. The evidence of its efficacy in these cases is even more controversial than it is for PTSD. There are claims that EMDR is a pseudoscience that cannot be empirically proven to work. Other claims are made suggesting that the eye movements, hand tapping and auditory tones are useless and any success achieved with the treatment can be attributed to its use of traditional exposure therapy. Michael Otto, Ph.D., Director of the Cognitive Behavior Therapy Program at Massachusetts General Hospital, points out that EMDR is a contentious issue. He goes on to say, "There is good evidence that the eye movements offer no efficacy. So without this part of the procedure, what do you have? You have a procedure that offers some cognitive restructuring and exposure."
Many of the studies which have found EMDR to be successful have been criticized for their scientific method, while studies which have found EMDR to be unsuccessful have faced criticism by proponents of the method for not using the proper EMDR procedure. Norah Feeny, Ph.D., Assistant Professor of Clinical Psychology at Case Western Reserve University, explains that conflicting study results are not unique to EMDR and in part depend on varying research methods and how tightly controlled the studies are. Therefore, the results of any single study are less important than the pattern of results that emerge over several well-done studies. Overall, Dr. Feeny says, it looks like EMDR, "works in the short run, but is not better than exposure therapy or other well researched treatment options like cognitive therapy. Moreover, some studies have begun to raise questions about the long-term efficacy of EMDR."
Carole Stovall, Ph.D. is a psychologist in private practice and has been using EMDR as one of her therapeutic tools for more than ten years. She uses the technique to address various types of disorders and traumas and claims that she has had excellent results. She does recommend, however, that consumers make sure that their mental health professional is proficient in more than one type of therapy because, although she feels that EMDR is a "wonderful tool," she admits that it may not be the best treatment for everyone.
As Dr. Feeny has pointed out, "The more effective treatments we have, the better. We just have to be careful and be guided by data."
- Anxiety Disorders Association of America newsletter