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Eye movement desensitization and reprocessing

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File:EMDR cover image.jpg
Cover of the book EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma by Francine Shapiro, published 1997

Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapeutic approach developed by Francine Shapiro[1] to resolve symptoms resulting from exposure to a traumatic or distressing event, such as rape. Clinical trials have demonstrated EMDR's efficacy in the treatment of post-traumatic stress disorder (PTSD). It has shown to be more effective than some alternative treatments and equivalent to cognitive behavioral and exposure therapies (see effectiveness sections below). Although some clinicians may use EMDR for various problems, its research support is primarily for disorders stemming from distressing life experiences.[2][3]

The theoretical model underlying EMDR treatment hypothesizes that EMDR works by processing distressing memories.[1] 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 behavioural, experiential, physiological, and interpersonal therapies.[4]

EMDR's most controversial aspect is an unusual component of dual attention stimulation, such as eye movements, bilateral sound, or bilateral tactile stimulation. The contention is the effective elements of cognitive behavioral therapy, desensitization and reprocessing, have been rebranded with eye movements as a novel therapy. As such some individuals have criticized EMDR and consider the use of eye movements to be completely unnecessary.[5][6][7]

Description of therapy

According to Shapiro's theory, when a traumatic or distressing experience occurs, it may overwhelm usual ways of coping and be inadequately processed; it is then dysfunctionally stored in an isolated memory network. When this memory network is activated, the individual 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 incident can retain high levels of intensity, even though many years may have passed.

EMDR uses a structured eight-phase approach and addresses the past, present, and future aspects of the dysfunctionally stored memory. During the processing phases of EMDR, the client attends to the disturbing memory in multiple brief sets of about 15-30 seconds, while simultaneously focusing on the dual attention stimulus (e.g., therapist-directed lateral eye movements, 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.

EMDR works directly with memory networks and enhances information processing by forging associations between the distressing memory and more adaptive information contained in other 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 so that, when it 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.[8]

When the distressing or traumatic event is an isolated incident, the symptoms can often be cleared with one to three EMDR sessions. But 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 - the time to heal may be longer.[9]

Therapy process

  • 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.
  • 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 movements, 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 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 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 his current level of distress. The desensitization phase ends when the SUDS (Subjective Units of Disturbance Scale) has reached 0 or 1.[10]

EMDR also uses a three-pronged approach, to address past, present and future aspects of the targeted memory.

Vocabulary of terms

The following basic terms are described in Shapiro's 2001 text[1]

Information Processing: During information processing, a physiologically-based system sorts new (perceptual) information, makes connections between new information and other information already stored in associated memory networks, encodes the material, and stores it in memory.

Adaptive Resolution: When information processing is complete, learning takes place, and information is stored in memory with appropriate emotion. The new information is therefore available to guide future action.

Dysfunctionally Stored Information: When information processing is incomplete, the information is not connected to more adaptive information, and it is stored in a memory network with a high negative emotional charge. It can cause reactivity and can be the cause of various symptoms.

Reprocessing: During reprocessing in EMDR, new associative links are forged between dysfunctionally stored information and adaptive information, resulting in complete information processing and adaptive resolution.

Memory Networks: Memory networks are neurobiological associations of related memories, sensations, images, thoughts, and emotions.

Target Memory: The target memory is the memory of a distressing or traumatic event, which still causes current distress, and which has been selected to be targeted during EMDR treatment.

Memory Components: All components of the target memory are accessed during Phase Three to ensure that the memory network is fully activated. These components include the image, cognitions, emotions, and body sensations.

VOC (Validity of cognition) scale: VOC ratings are used in EMDR to measure baseline validity of the positive cognition during Phase Three, and to assess progress being made, where 1 = not true, and 7 = completely true.

SUD (Subjective units of disturbance) scale: SUD ratings are used in EMDR, exposure therapies, and other treatments to measure baseline emotional or physical pain and also to assess progress being made. This is a personal measurement of distress, where 0 = no distress, and 10 = worst distress possible.

Interweave: The interweave is a specific strategy used by the clinician to assist processing if the client appears to be having difficulty accessing more adaptive information. Ideally, the interweave contains needed information that would have been available except for blockage of inner pathways by trauma responses.


How does EMDR work?

This is a very controversial topic as there is no definitive explanation as to how EMDR works. There is some empirical support for three explanations regarding how an external stimulus such as eye movement can facilitate the processing of traumatic memories. The first hypothesis views PTSD as a failure by the individual to process episodic memory;[11][12] the bilateral eye movements involved in EMDR facilitate interaction between the brain's hemispheres, which then improves the processing of trauma-related memories. This hypothesis is supported by a study that tested the effects of eye movement on the ability to retrieve episodic memory. The study found better recall following a horizontal eye movement task compared to that following no eye movement or a vertical eye movement task.[13] A second hypothesis suggests that eye movements facilitate processing of trauma memories by activating a neurobiological state similar to REM sleep wherein associative links to episodic memories are formed and these memories are then integrated into general semantic networks. Stickgold proposed that PTSD occurs when an event is sufficiently arousing to prevent its transfer from encoding from an episodic memory to a semantic memory.[12] As a result of high arousal levels, associations between the traumatic event and other related events fail to develop. He argues that the attentional redirecting in EMDR induces a neurobiological state similar to REM sleep. He then reviews the research that suggests that REM sleep enhances processing of episodic memory through the preferential activation of weak associative and semantic links. Thus in EMDR trauma-related information that is closely associated with a target event is weakened and ancillary information loosely related to the event is strengthened, allowing the integration of trauma-related material with other loosely associated events in the person’s life. Support for this argument comes from a study that found that, compared to eye fixation, eye movement promoted attentional flexibility and increased preparedness to process metaphorical material.[14]

A third hypothesis links the eye movements in EMDR with the orienting response.[15] MacCulloch and Feldman argued that eye movements trigger the investigation component of the orienting response, which can either produce avoidance behaviour or inhibit avoidance responses. Inhibiting avoidance behaviour includes reducing both negative somatic responses and cognitive changes that would allow fresh investigatory behaviour to commence. MacCulloch and Feldman proposed that initially when danger is identified there is a negative affect response. However a second part of the orienting response is to scan for further danger, and this investigatory reflex seems to accompany a positive physical response. In the authors’ opinion, eye movement induces this investigatory reflex and produces a relaxation response. A relaxation response was, in fact, found in a study that investigated the autonomic responses of participants when they were engaged in an eye movement task as part of EMDR treatment[16] and when participants focused on negative memories while engaging in eye movement [23]. However there is not a differential effect of eye movement on a relaxation response when participants focused on positive memories.[17] This supports the hypothesis that eye movements are an orienting response mechanism rather than a simple relaxation mechanism.

Further data consistent with the orienting response hypothesis was the finding that EMDR treatment was associated with increased left pre-frontal hemisphere activation.[18][19] Investigatory and approach behavior has been shown to be associated with the anterior left hemisphere regions.[20]

Controversy

EMDR has created a good deal of controversy since its inception. The mechanisms of action are still speculative; many doubt that the eye movements have a central role, and some have argued that the theory leading to the practice is considered non-falsifiable and not amenable to scientific inquiry,[5][6][21] Devilly (2002), in a review and meta-analysis, concludes that although EMDR is effective, it is because it operates as an exposure therapy for which the eye movements are unnecessary, and is neither as effective nor as long-lasting as specific exposure therapy.[21]

Eye movements

Eye movements are not the therapeutic ingredient in EMDR. Studies looking at the contribution of eye movements to treatment effectiveness in EMDR conclude that eye movements are not necessary to the treatment effect.[22][23][24][21] A researcher from London's Institute of Psychiatry confirmed the Davidson and Parker meta-analysis findings and stated that if eye movement was not relevant to EMDR, then all that remained was cognitive behavioral therapy.[25]

Similarity to desensitization and exposure treatments

Several papers have highlighted key differences between EMDR and traditional exposure treatments.[26][27] A recent study has found key differences in the crucial processes of EMDR and traditional exposure.[28] Unlike traditional exposure where reliving responses in the treatment session was found to be associated with post session improvement[29] reliving responses were not associated with any improvement in EMDR.[30] Rather greater improvement in PTSD symptoms was found to be associated with distancing responses given in session.

See also

References

  1. EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma . NY: Basic Book, 1997. ISBN 0-465-04301-1
  2. EMDR as an Integrative Psychotherapy Approach: Experts of Diverise Orientations Explore the Paradigm Prism. American Psychological Associations Book, 2002. ISBN 1-55798-922-2
  3. EMDR: Eye Movement Desensitization of Reprocessing: Basic Principles, Protocols and Procedures. NY: Guilford Press, 2001. ISBN 1-57230-672-6

Notes and references

  1. ^ a b c Shapiro, Francine (1995). Eye movement desensitization and reprocessing: basic principles, protocols, and procedures. New York: Guilford Press. p. 398. ISBN 0-89862-960-8.
  2. ^ Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61-81.
  3. ^ Louise Maxfield; Shapiro, Francine; Kaslow, Florence Whiteman (2007). Handbook of EMDR and Family Therapy Processes. New York: Wiley. p. 504. ISBN 0471709476.{{cite book}}: CS1 maint: multiple names: authors list (link)
  4. ^ Shapiro, F. & Maxfield, L. (2002). Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of Clinical Psychology, 58, 933-948.
  5. ^ a b Herbert, Lilienfield et al. 'Science and Pseudoscience in the development of eye movement and reprocessing: Implications for Clinical Psychology'. Clinical Psychology Review, Vol.20, No.8, pp945-971, 2000[1]
  6. ^ a b Devilly, G.J., & Spence, S.H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of post traumatic stress disorder. Journal of Anxiety Disorders, 13, 131–157 Full text PDF Cite error: The named reference "Devilly 1999" was defined multiple times with different content (see the help page).
  7. ^ [2] Traumatology, Vol. 9, No. 3 (September 2003) 169. EMDR: Why the Controversy? Charlotte Sikes and Victoria Sikes
  8. ^ Maxfield, L. (2003). Clinical implications and recommendations arising from EMDR research findings. Journal of Trauma Practice, 2, 61-81.
  9. ^ Phillips, Maggie., (2000). Finding the Energy to Heal: How EMDR, hypnosis, TFT, imagery, and body focused therapy can help restore the mind body health. NY:Nortonn.com
  10. ^ Manfield, Philip. (2003). EMDR Casebook. NY: W.W. Norton & Company, Inc.
  11. ^ Shapiro, Francine (2001). Eye Movement Desensitization and Reprocessing (EMDR), Second Edition: Basic Principles, Protocols, and Procedures. New York: The Guilford Press. p. 472. ISBN 1572306726.
  12. ^ a b Stickgold R (2002). "EMDR: a putative neurobiological mechanism of action". Journal of clinical psychology. 58 (1): 61–75. PMID 11748597.
  13. ^ Christman SD, Garvey KJ, Propper RE, Phaneuf KA (2003). "Bilateral eye movements enhance the retrieval of episodic memories". Neuropsychology. 17 (2): 221–9. PMID 12803427.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Kuiken, D., et al., Eye movement desensitization reprocessing facilitates attentional orienting. Imagination, Cognition & Personality, 2001. 21(1): p. 3-20.
  15. ^ MacCulloch, M.J. and P. Feldman, Eye Movement Desensitisation Treatment Utilises the Positive Viscereal Element of the Investigatory Reflex to Inhibit the Memories of Post-Traumatic Stress Disorder: a Theoretical Analysis. British Journal of Psychiatry, 1996. 169(5): p. 571-579.
  16. ^ Wilson DL, Silver SM, Covi WG, Foster S (1996). "Eye movement desensitization and reprocessing: effectiveness and autonomic correlates". Journal of behavior therapy and experimental psychiatry. 27 (3): 219–29. PMID 8959423.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Barrowcliff, A.L., et al., Eye-movements reduce the vividness, emotional valence and electrodermal arousal associated with negative autobiographical memories. Journal of Forensic Psychiatry & Psychology, 2004. 15(2): p. 325-345.
  18. ^ Lansing K, Amen DG, Hanks C, Rudy L (2005). "High-resolution brain SPECT imaging and eye movement desensitization and reprocessing in police officers with PTSD". The Journal of neuropsychiatry and clinical neurosciences. 17 (4): 526–32. doi:10.1176/appi.neuropsych.17.4.526. PMID 16387993.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Levin P, Lazrove S, van der Kolk B (1999). "What psychological testing and neuroimaging tell us about the treatment of Posttraumatic Stress Disorder by Eye Movement Desensitization and Reprocessing". Journal of anxiety disorders. 13 (1–2): 159–72. PMID 10225506.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Kinsbourne, M., Evolution of language in relation to lateral action., in Asymmetrical function of the brain., M. Kinsbourne, Editor. 1978, New York Cambridge University Press. p. 553-556.
  21. ^ a b c Devilly, G.J. (2002). Eye Movement Desensitization and Reprocessing: A chronology of its development and scientific standing. Scientific Review of Mental Health Practice, 1, 113-138 [3] Cite error: The named reference "Devilly" was defined multiple times with different content (see the help page).
  22. ^ Davidson PR, Parker KC (2001). "Eye movement desensitization and reprocessing (EMDR): a meta-analysis". Journal of consulting and clinical psychology. 69 (2): 305–16. PMID 11393607.
  23. ^ Lohr JM, Lilienfeld SO, Tolin DF, Herbert JD (1999). "Eye Movement Desensitization and Reprocessing: an analysis of specific versus nonspecific treatment factors". Journal of anxiety disorders. 13 (1–2): 185–207. PMID 10225508.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Cahill SP, Carrigan MH, Frueh BC (1999). "Does EMDR work? And if so, why?: a critical review of controlled outcome and dismantling research". Journal of anxiety disorders. 13 (1–2): 5–33. PMID 10225499.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  25. ^ Salkovskis P (2002). "Review: eye movement desensitization and reprocessing is not better than exposure therapies for anxiety or trauma". Evidence-based mental health. 5 (1): 13. PMID 11915816.
  26. ^ Rogers S, Silver SM (2002). "Is EMDR an exposure therapy? A review of trauma protocols". Journal of clinical psychology. 58 (1): 43–59. PMID 11748596.
  27. ^ Smyth, N.J. and A.D. Poole, EMDR and cognitive-behavior therapy: Exploring convergence and divergence, in EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism, F. Shapiro, Editor. 2002, American Psychological Association: Washington, DC. p. 151-180.
  28. ^ Lee, C.W., G. Taylor, and P. Drummond, The active ingredient in EMDR; is it traditional exposure or dual focus of attention? Clinical Psychology & Psychotherapy, 2006. 13: p. 97-107.
  29. ^ Jaycox LH, Foa EB, Morral AR (1998). "Influence of emotional engagement and habituation on exposure therapy for PTSD". Journal of consulting and clinical psychology. 66 (1): 185–92. PMID 9489273.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  30. ^ Lee, C.W., G. Taylor, and P. Drummond, The active ingredient in EMDR; is it traditional exposure or dual focus of attention? Clinical Psychology & Psychotherapy, 2006. 13: p. 97-107.

Supporting EMDR

Skeptical of EMDR

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