Eye movement desensitization and reprocessing (EMDR) is a psychotherapy approach used to process distressing memories that are the basis of a wide range of clinical complaints. Comprehensive treatment includes attention to past, present, and future not only to address overt symptoms but also to increase attributes associated with a positive quality of life.
Eye movement desensitization and reprocessing is an integrative approach originally developed to resolve symptoms resulting from exposure to a traumatic event. Its clinical applications are directed by a theoretical model that emphasizes the brain’s information processing system and that views symptoms as arising when memories are inadequately processed. In addition to the efficacious treatment of posttraumatic stress disorder (PTSD), EMDR is also now used to process all kinds of negative life experiences, such as rejection, failure, loss, stress, and conflict, and to bring these to an adaptive resolution.
EMDR uses an eight-phase approach to directly address the experiences physically stored in the brain’s memory networks. Treatment involves processing the past experiences that set the groundwork for the problem, the current situations that trigger the disturbance, and new memory “templates” for adaptive future functioning. During the processing phases of EMDR, the client initially attends to the disturbing memory while simultaneously focusing on an external stimulus (e.g., therapist-directed lateral eye movements, alternate hand tapping, or bilateral auditory tones). Standardized procedures are used that allow the emergence of new insights, memories, and emotions, until the targeted event arrives at an adaptive resolution. The client then recalls the incident with a new perspective, elicitation of insight, resolution of the cognitive distortions, elimination of emotional distress, and relief of related physiological arousal.
History of Eye Movement Desensitization and Reprocessing
EMDR was introduced in 1989 by Francine Shapiro with the publication of a randomized controlled treatment study with traumatized individuals. At that time, the therapy was called eye movement desensitization, or EMD, because it was thought that the eye movements resulted in desensitization of the memory. However, it became apparent to Shapiro that desensitization was only one of the many changes occurring with treatment. In 1991, she changed the name to eye movement desensitization and reprocessing, or EMDR, to emphasize the role of the information processing system in producing the treatment effects.
Because EMDR is an unusual treatment, it originally attracted a number of critics who erroneously argued that its effects were due entirely to a placebo effect. Since then, EMDR has been rigorously researched, and its efficacy in the treatment of PTSD is now recognized. EMDR has been effectively used in numerous cultures around the world, and more than 100,000 therapists have received EMDR training.
Approximately 20 controlled research studies have established EMDR’s efficacy in the treatment of PTSD. These studies have compared EMDR to pharmaceuticals and various forms of psychotherapy, with results demonstrating that it is as effective and long lasting as the most researched cognitive-behavioral therapy (CBT) methods. EMDR is recommended as an “A” level treatment for PTSD in numerous international treatment guidelines. The American Psychiatric Association and the U.S. Departments of Defense and Veterans Affairs also rate it in the highest category of effectiveness and research support.
As with any form of psychotherapy, the neurobiological underpinnings of EMDR’s treatment effects are currently unknown. Several studies have attempted to determine the direct effect of eye movements on EMDR outcome. Unfortunately, most of these studies had methodological flaws, and no definitive conclusion can be made. For example, one study reported a decrease in PTSD diagnosis of 85% for eye movement conditions and 50% for the non-eye movement group, but the results were not significant because of the small sample size. A meta-analysis of these studies reported marginally significant effects for the eye movement condition with clinical populations.
Laboratory research investigating the effects of eye movements on memory has consistently demonstrated strong effects. Numerous studies have shown that eye movements decrease the vividness and emotionality of memory images. Other studies have demonstrated that eye movements produce a relaxation effect, decreasing heart rate and galvanic skin response. Research has also found that eye movements increase cognitive flexibility and access to episodic memories. While it is thought these effects are integral to the EMDR treatment process, the extent to which eye movements contribute to treatment outcome is not currently known. Noted sleep researcher Robert Stickgold has suggested that the eye movements in EMDR may activate many of the same neurochemicals released during rapid eye movement (REM) sleep, thus facilitating free associations and memory processing.
Adaptive Information Processing Model
Shapiro developed the adaptive information processing (AIP) model to describe EMDR treatment and to predict its effects. This model posits that humans have an inherent physiological processing system geared to process all internal and external experiences and to bring these to an adaptive and healthy resolution. When a current experience is similar to those stored in memory, related networks are activated and relevant information becomes readily accessible. This adaptive system allows us to function smoothly throughout our daily lives as we engage in every type of task, from grocery shopping to work-related projects, from socializing to parenting. New experiences are consolidated in memory when associative links are created between them and other related material, forging connections to numerous other memory networks. Learning takes place, and the individual is able to access the new information as needed.
Although this system typically operates in an adaptive way, Shapiro hypothesized that highly disturbing perceptions may not always be adequately processed. When this occurs, the upsetting experience is not integrated with other memory networks that contain more adaptive information. Instead, the distressing memory is stored in an isolated network, in what Shapiro referred to as an “unprocessed state,” with the original sensory components. When this distressing memory is activated, the individual experiences the emotions, sensations, and cognitions endured at the time of the original event. Furthermore, these negative sensations influence the individual’s perception of the current event, often resulting in misunderstandings or over-reactions. Then a memory of the current event is stored within the dysfunctional memory network, strengthening and reinforcing it. The unprocessed memory network remains isolated and unable to link up with more adaptive and positive information.
Shapiro recognizes that some psychiatric disorders or symptoms are organic in nature and that some functional impairments are caused by a lack of experience or information. However, she maintains that the majority of Axis I and II disorders result from unprocessed earlier life experiences and that this processing failure results in a pathological pattern of affect, cognitions, behavior, and sense of identity. Furthermore, she argues that most difficulties in coping with current life stressors are a result of unprocessed memories. The presenting cognitive and emotional symptoms are understood to be a manifestation of the earlier memory. Therefore, it is anticipated that the complete processing and resolution of these memories will result in remission of the diagnosis and elimination of the problematic symptoms.
Phase 1—Client History and Treatment Planning
The first phase of EMDR shares similarities with most psychotherapies, with the identification of the presenting problem, development of a therapeutic alliance, collection of a thorough history, assessment of current function, and determination of treatment goals. In addition to these elements, during the history-taking process, the EMDR clinician seeks to identify the dysfunctional memory networks and related targets for EMDR processing. The therapist inquires about earlier experiences that have laid the groundwork for the presenting symptoms, current situations that are triggering the memory network, and the client’s concerns about related future situations.
For example, John sought treatment to help him cope with workplace stress related to a bullying and critical supervisor. John found himself over-reacting with anger and anxiety, his function was impaired, and he was afraid he would lose his job. When the therapist inquired about earlier similar experiences, John explained that as a child he had been the victim of bullying. The therapist and John identified several specific memories of bullying and harassment that still carried an emotional charge for John. They also discussed current triggers for his feelings of shame and incompetence and John’s fears related to a future job evaluation.
From an AIP perspective, John’s childhood memories were not adequately processed, and were stored in an isolated memory network that contained experiences of humiliation and derogation. This network was not connected to memories of positive experiences such as John’s academic accomplishments. Currently, the harsh criticisms of his employer triggered the dysfunctional memory network, and John’s reactions were driven by his childhood experiences.
John was unable to shift out of that state or to access material in more positive, and realistic, networks.
Phase 2—Client Preparation
In the second phase, the clinician ensures that the client has adequate stabilization before proceeding to process the distressing memories, which can be expected to elicit strong negative affect and cognitions. In particular, the therapist evaluates the client’s ability to regulate emotion and handle distressing situations. Some affect management techniques may be taught, such as using safe place imagery to shift out of a negative affective state. If the client lacks skills in this area, or if his or her life situation is unstable or chaotic, Phase 2 may extend for a period of time. John’s therapist assisted John in developing a list of affect management techniques that he used regularly. These included a range of exercise activities, recreational pastimes, creative projects, social contacts, and meditation. It appeared that John had adequate stabilization and affect management skills.
Phase 3—Assessment of the Target Memory
The third phase is structured to fully access the memory network by identifying its major sensory, cognitive, affective, and somatic elements. First the client describes the most salient sensory image of the event. Next, the therapist assists the client in articulating a current negative cognition (NC) about him- or herself that is related to the target memory, (e.g., “I’m incompetent”). The NC is formulated in the present tense to activate the information as it is currently stored in the memory network. This also serves to assist the client in recognizing the impact of the past event on his or her current self-image. The client is then asked to specify a preferred positive cognition (PC; e.g., “I’m competent”) and to rate how true the statement feels when combined with the image of the event, using the Validity of Cognition (VOC) scale (where 1 = false, and 7 = completely true). This rating provides a baseline by which the client and clinician can assess progress. In addition to offering the client a “light at the end of the tunnel,” the PC forges a preliminary associative link between the isolated memory network and the adaptive information that is expressed in the positive cognition.
After this, the client is asked to identify the negative emotions that are elicited by the memory, and to rate his or her level of distress on the Subjective Unit of Disturbance (SUD) scale (where 0 = neutral, and 10 = worst possible distress). The baseline is used to assess progress. In addition, the specification of the emotions allows both client and therapist to recognize changes in the type of affect experienced during processing. Finally, the client identifies and locates the body sensations that accompany the disturbance.
The first target memory addressed by John was of himself at age 7, surrounded by a circle of children who were calling him names. His NC was “I’m a social outcast”; his PC was “I’m a socially competent adult” with a VOC of 3. His emotions were anger, fear, and shame with a SUD of 9 and a body location in the stomach.
This phase begins with instructions to the client to focus on the visual image, NC, and body sensations, and then to “let whatever happens, happen.” The client maintains this internal focus while simultaneously moving the eyes from side to side for 15 to 30 seconds, following the therapist’s fingers as they move across the visual field. Other bilateral stimuli (e.g., bilateral hand tapping or auditory stimulation) can be used instead of eye movements. After the set of eye movements, the client is told to “let it go” and is then asked, “What do you get now?” The client reports any changes in the memory or associative material (image, thought, sensation, or emotion). Following standardized procedures, typically the clinician then directs the client’s attention to the new material for the next set of eye movements, or back to the original target. This cycle of alternating focused attention and client feedback is repeated many times, as associations are forged to other memory networks. The client often spontaneously accesses related thoughts, images, emotions, sensations, and memories. As the process continues, he or she usually reports cognitive insights and shifts in affect and physiological states.
For example, during processing, John recalled other incidents of peer bullying and humiliation. His emotional state shifted as different memories surfaced; he experienced a number of insights, including the realization that as an adult he instantly responded with rage whenever he felt criticized. The therapist did not dialogue with John during this process; instead she simply encouraged John to “just notice” as he continued with the sets of eye movements and internal focus. If John’s processing had stalled, the therapist would have used specialized interventions worded to reactivate processing.
As processing continues, with associations being forged to more adaptive information, there appears to be a shift in how the memory is stored. The client will often report a change in his or her perception of the memory. For example, John realized, “It was only some children who were mean to me; there were others who were actually quite friendly.” He then remembered a number of positive social interactions with his classmates.
Phase 5—Cognitive installation
The fifth phase occurs after the targeted issue is resolved and no further distress is reported when the memory is accessed (i.e., the SUD rating is 0). At this point, the client focuses simultaneously on the targeted memory and the PC, while engaging in sets of eye movements. This PC could be the belief developed in Phase 3, or another PC that emerged during Phase 4. The purpose is to incorporate and increase the strength of the PC until strong confidence is apparent (i.e., VOC of 6 or 7). Often processing continues to consolidate the changes in the memory network. For example, as John worked on installing his PC of “I’m a socially competent adult” he stated, “You know, it is the bullies who have no social skills!” He also realized that there were various responses that he could use when he felt criticized. He felt quite energized as information related to his social value and skills was incorporated from other memory networks.
Phase 6—Body Scan
Phase 6 occurs after the successful completion of Phase 5. The clinician asks the client to focus on the incident and PC and to notice if there is any tension or unusual sensation in the body. Because body sensations can indicate unprocessed aspects of the memory network, an assessment of these sensations is used to detect any residual material. Any identified sensations are targeted with eye movements until the tension is relieved.
This phase occurs at session end. The therapist determines whether the memory has been adequately processed and, if it has not, assists clients with the self-calming interventions developed in Phase 2. The client is told that processing may continue after the session and is asked to maintain a journal to record any new material that arises.
Reevaluation takes place at the beginning of every EMDR session following the first. In this phase, the therapist evaluates the memory targeted in the previous session by collecting the SUD rating and assessing the PC. If the work is incomplete, processing of that incident continues. If the work on a specific memory is complete, the therapist will then shift the focus to other related memories. Once these have been processed, current triggers that are activating the memory network and creating distress are targeted. With John, for example, after successful resolution of the past childhood experiences of peer bullying, the focus shifted to the present conflict with his supervisor. The target was assessed using memories of specific incidents (using Phase 3), and processed (using Phases 4 through 8). Finally a future template was developed to assist John in handling future situations in which he might feel criticized or humiliated, and the template was processed according to the protocol. Attending to all past, current, and future aspects ensures that the entire memory network is successfully processed.
As John’s childhood memories of peer bullying were resolved, he began to experience himself as a socially competent, vital, and dynamic individual, capable of high functioning in many life domains. The change in the way that the memories were stored in the brain resulted in a profound shift in his self-perception with alterations in cognitive schemas, behavior, and interpersonal interactions. John was now able to choose from various options in responding to his employer’s criticisms and was able to resolve those issues in a mature manner.
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