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EMDR - An overview of procedure and research
 

Christopher K. Johannes PhD, HMD


EMD what? When I first heard of Eye Movement Desensitisation and Reprocessing (EMDR), I thought it was some kind of fancy technique for dealing with neurological or ocular problems complicated by psychological issues, whatever that meant. Everyone seemed to have heard of it, but no one really new what all the fuss was about or what it really involved. I increasingly heard how it was becoming a very popular treatment for trauma/PTSD, fears, phobias, anxiety and stress based conditions. But, perhaps since the name sounded a little too sexy, something like when Neurolinguistic Programming (NLP) first started coming of age, I still treated it with an indifferent and somewhat sceptical attitude and put learning more about it on the backburner. When it started getting into the standard clinical and counselling textbooks, when it was hailed at international professional conferences, associations and medical schools as a stunning and state of the art breakthrough in psychotherapy treatment technology, and after learning that EMDR has more controlled outcome
research to support it than any other treatment methods for PTSD (Post-Traumatic Stress Disorder), I began paying attention!


As helping professionals, it is incumbent upon us to remain abreast of the newest and latest, continue our education and professional development and be able to refer responsibly and confidently in cases where our clients would be best served by someone else or with another form of treatment. The purpose of this article, then, is briefly to define and delineate the basics of the EMDR treatment process, summarise some of the results of EMDR outcome research and provide details on further education, information and training.


What EMDR is…


Developed by Francine Shapiro, PhD, (1995), EMDR is a complex, integrated and highly specialised form of exposure therapy originally designed for accelerated and durably effective treatment of traumatic memories and PTSD (post-traumatic stress disorder). It is applicable to presenting complaints and self-esteem issues that relate not only to upsetting past events, but also to the suffering of intolerable current life conditions. Since its development, it has been used with a great deal of success in a wide range of presenting complaints that include depression, addictions, childhood
neglect, self-esteem issues, performance anxiety, grief, sexual abuse, fears, phobias and anxiety disorders.


EMDR's claim to fame, however, remains in the documented and unusually rapid success of this procedure in the treatment of post-traumatic stress disorders. It is thought that traumas and stresses too severe or enduring over time overwhelm natural evolutionary processing mechanisms, such that
the felt strength of the event remains in a fragmented "raw" form in the psychophysiology. The incompletely processed event becomes stored (somewhat like iconic memories) as a distressing feeling-toned cognition-image complex in the brain/nervous system and physiology in a way that re-evokes the same distressing feelings each time that events are experienced which are similar
to the original activating trauma or stresses.


The unique benefit of EMDR's accelerated healing is thought to result from the manner in which the procedure engages the psychological healing response in synchrony with the rate that the body uses to heal physical ailments. The number of EMDR sessions required depends a great deal on the complexity of the presenting trauma or issues, but is nevertheless remarkably brief for the healing success it accomplishes. Successful results have been published after only two to three sessions (see resources below).


In the cognitive-behavioural spirit, EMDR's approach is collaborative and interactional and draws upon a wide range of behavioural and cognitive interventions that are procedurally standardised, but nevertheless incorporate well into or augment practises as diverse as Gestalt, Adlerian, Psychodynamic and Multimodal. The "core" of this approach involves a systematic reprocessing/restructuring of the idiosyncratic complex of cognitions, images and attendant feelings and sensations associated with a target event with the use of rythmic eye movements and other bilateral stimulation. This is done in a way that assists the client to neurologically and psychologically reprocess the information in order to "clear out" any adverse and unbidden physiological sequelae and psychological influence and ultimately catalyse a recovery into a healing transformation and integration.


Though formally classified within the behavioural camp, EMDR actually integrates elements from different schools of psychotherapy in a way that synergistically enhances the power of the approach, its applicability to a variety of clinical populations and it's methodological accessibility to therapists from diverging orientations.


Procedural Outline:

 

EMDR (as applied to PTSD in this example) is a clinically oriented procedure used specifically to help clients reprocess information and restructure cognitions and subjective experience. It is divided into eight procedural phases, which are outlined briefly as follows:

  1. The first phase involves taking a full history and completing a full evaluation of the client, formulating any useful diagnostic impressions (DSM-IV) impressions as and where appropriate. This leads into formulation of a detailed treatment plan based on a clear problem definition and the identification and collaborative evaluation of specific outcome goals. In the tradition of behavioural therapy, the therapist conceptualises the presenting problem toward the selection of specific "targets" that could include the traumatic memory(s), triggering cues and the particular adaptive components identified that would comprise the psychological and behavioural elements to be in place for optimal functioning in the future.

  2. In the second, or preparation phase, the focus more now on establishing a collaborative rapport and therapeutic alliance. This phase involves explaining what EMDR is all about, discussion of expectations and any concerns, and creating a safe space within which to engage in relaxation
    procedures that allow the client to engage in emotive imagery. Relaxation procedures are initiated.

  3. Before processing begins, the assessment phase necessarily identifies and establishes the baseline response for the target components already identified. Establishing the baseline involves elicitation of the traumatic memory (imaginal) and identifying associated negative or maladaptive beliefs/cognitions, measures of associated emotions and physical sensations and evaluation along what's known as the subjective unit of disturbance (SUD) scale of images. A key final element of this stage is the identification of an adaptive belief/positive cognition that would eliminate or significantly ameliorate the anxious dysphoria associated with the with the event.

  4. Desensitisation begins in this phase with the client's imaginal exposure (visualising) to the traumatic image, attending to accompanying physical and subjective sensations, and verbalising the negative cognition/belief. It is during this exposure that the client receives the bilateral stimulation, which often consists of having the client visually track the therapist's index finger across their line of vision from between 12 to 24 times. The client is then instructed to breath deeply while momentarily blocking out the experience and to report on any thoughts, images, feelings and other associations that may arise. Time of exposure is kept minimal, with most clients not being exposed to the most distressing image for longer than a minute during any session.

  5. The next phase consists of installing the positive cognition/belief in place of the negative ones identified in order to associate the traumatic event with an adaptive belief. The positive belief installed should optimise the client's self-evaluation associated with the event, such that the memory not only looses its negative and anxiety inducing grip on functioning, but ideally facilitates healing through new meaning and esteem enhancing integration of the self. This function of the installation process is crucial for gains to maintained and needs to be carefully monitored. Work at this stage deals a great deal with increasing the strength and association
    of the positive cognition.

  6. Having installed the positive cognition, the client is re-exposed to the traumatic event (imaginal) while holding the positive cognition and mentally scans the body for any tension or subjective distress. The successful completion of this phase is when, during exposure (visualisation of the
    target event) the client no longer experiences tension, anxiety and distress and with evidence of having integrated the positive cognition.

  7. Maintenance, generalisation and "homework" counselling is provided to support the treatment outside the therapy sessions. This includes reviewing expectations, going over what may come up between sessions (e.g. disturbing imagery, thoughts and feelings), maintaining performance of relaxation and/or visualisation techniques and keeping a journal, and collaboration on a
    regimen of any additional self-management interventions (e.g. breathing exercises, self-monitoring, environmental engineering, meditation). This phase is considered crucial to maintain treatment gains and client stability between sessions.

  8. The re-evaluation phase consists of going over and checking in with the progress of the self-management (homework) and a progress review against the baseline measurements recorded in the assessment phase. Reprocessed targets are re-accessed with the EMDR procedure (phases 4-6) and responses are evaluated against baseline and treatment goals. Elements of this phase are integrated into the process of each therapy session as, in the behavioural tradition, evaluation and treatment are interwoven throughout the process. The therapist and client evaluate progress and collaborate on what/how to continue and/or alter in their therapeutic work together, and to bring closure to the process as appropriate. As with assessment, careful attention to appropriate closure is important to the process throughout each session.

The procedural synopsis of each phase above provides a structural overview of EMDR's specialised treatment approach that portray it's clinical orientation. In practise, of course, within this basic technical structure, the rigid phase division melds into a flowing and spontaneous process entailing all
the usual rapport characteristics common to most forms of psychotherapy and limited only by the collaborative and creative ingenuity of the therapist and client.


That said, EMDR is a very intricate treatment technology and therapeutic method requiring specialised training and clinical supervision. Though it may appear a relatively simple and straightforward process to some, the ethical parameters of the approach cannot be overemphasised, as it has been shown that clients may be at serious risk from untrained clinicians attempting to use the procedure. For this reason, most EMDR training courses limit participants to only those mental health professionals who are appropriately qualified to provide treatment and supervised student trainees. This often means at least a graduate degree in an appropriate field along with registration, accreditation and/or some form licensure to provide treatment.

The best and soundest source of EMDR training, currently, are training conferences around the world which are authorised by the EMDR Institute based in Pacific Grove, California. A list of scheduled trainings in the U.K., Europe and world-wide can be provided by contacting the EMDR institute at
P.O. Box 51010, Pacific Grove, California, U.S.A., 93950, or through on of
the following websites:

www.emdr.com

www.emdr-practitioner.net

www.emdr-europe.net

 

EMDR Outcome Research

 

"The speed at which change occurs during EMDR contradicts the traditional notion of time as essential for psychological healing."


Bessel A. van der Kolk, MD-Director, HRI Trauma Centre Past President, International Society for Traumatic Stress Studies

 

EMDR "comes of age…recent independent studies have found it up to 90% successful." 

American Association for the Advancement of Science


"EMDR is a powerful tool for relieving human suffering. Its study opens new doors to our understanding of the mind." Steven Lazrove, MD, Yale University School of Medicine


"Dr Shapiro's work has proven invaluable to clinicians around the world in helping people following trauma."
Alte Dyregrov, PhD, UN Consultant to UNICEF and UNCHR


As stated previously, EMDR has more controlled outcome research to support it than any other method of treatment currently in use for PTSD. It is the most thoroughly researched method in the treatment of trauma. A 1998 meta-analysis study of all psychological and drug treatments for PTSD
reported EMDR to be "effective for PTSD…and that it is more efficient than other treatments" (Van Etten & Taylor, 1998).


The procedure has been acknowledged by the American Psychological Association to be a therapeutic method with solid empirical support. Various controlled outcome studies with single and multiple civilian trauma victims have shown response success rates ranging from 77% to 100% for no longer meeting criteria for PTSD in as little as two to five sessions. References for review and further study are given below. Further details on EMDR outcome studies and research can also be obtained by contacting the EMDR Institute or by visiting one of the EMDR websites listed below.


Recommended references:

Van Etten, M.L. & Taylor, S. (1998). Comparative efficacy of treatments for
post-traumatic stress disorder: A meta-analysis. Clinical Psychology and
Psychotherapy, 5, 129-144.


Shapiro, F. (1995). Eye movement desensitisation and resprocessing: Basic
principles, protocols, and procedures. New York: Guilford Press.

Shapiro, F. (1997). EMDR: The breakthrough therapy for overcoming anxiety,
stress and trauma. New York: Basic Books.


Shapiro, F. (1998). Eye movement desensitisation and reprocessing (EMDR):
Historical context, recent research, and future directions. In L.
Vandecreek, S. Knapp, & T.L. Jackson (Eds.), Innovations in Clinical Practise: A Sources Book (Vol. 16, pp. 143-162). Sarasota, FL: Professional Resource Press.


Marcus, S. V., Marquis, P., & Sakai, C. (1997). Controlled study of treatment of PTSD using EMDR in an HMO setting. Psychotherapy, 34(3), 307-315.


Wilson, S. A., Becker, L. A., & Tinker, R. H. (1997). Fifteen-month follow-up of eye movement desensitisation and resprocessing (EMDR) treatment for post-traumatic stress disorder and psychological trauma. Journal of Consulting and Clinical Psychology, 65(6), 1047-1056.


Christopher K. Johannes, PhD, HMD, MNCP, MGCP is a psychologist, homeopath/naturopath and polarity therapist in private practise, specialising in family counselling and psychotherapy services, behavioural and naturopathic medicine and homeopathic psychiatry. As a lecturer, he is on the faculty of several colleges and universities.

 

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