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
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:
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.
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.
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.
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.
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.
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.
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
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.
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
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:
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."
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.
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
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.