In the past decade, the popularity of a therapeutic technique called EMDR has exploded. EMDR, or Eye Movement Desensitization Therapy, was first used to treat PTSD. It is currently endorsed by the American Psychological Association, The Department of Defense, and the World Health Organization as a quick and effective intervention for anxiety, depression, and eating disorders. Researchers claim that its success rates are as a high as 90-100%. For people with eating disorders, this kind of success rate seems nothing short of miraculous. We are all too familiar with the dismal statistics about eating disorder recovery in more “traditional” treatment modalities (such as CBT and DBT), so why would we not jump at the chance to try a new and exciting therapy that could actually cure us? Additionally, eating disorders are hugely co-morbid with PTSD and EMDR seems like it could tackle both at once. Apparently, all we would have to do to start feeling better is follow someone’s finger.
EMDR is a relatively brief therapeutic intervention centered on eye movement as a way to change psychological function. The EMDR Institute claims that, to date, over 100,000 clinicians have been trained in the technique. Do its claims sound a bit too good to be true? Perhaps unsurprisingly, many researchers argue that they are. Let’s take a dive into this complex and controversial therapy.
EMDR was developed in the 1980s by a psychologist named Francine Shapiro (EMDR Institute). Dr. Shapiro published a small study she had done testing the effects of an eye movement procedure on patients diagnosed with PTSD, and found that she could reduce their distress without actually exposing them to their anxiety-provoking stimuli (Shapiro, 1989). Shaprio said she discovered that her own distressing thoughts went away when she moved her eyes in a “multi saccadic pattern.” She further claimed that only one session was “sufficient to desensitize completely the subject’s traumatic memories and dramatically alter their cognitive assessments” (Shapiro,1989). Her assertions are certainly surprising given that PTSD often presents with co-morbid disorders like depression or anxiety and with differing responses to Cognitive Behavioral Therapy and Exposure Therapy among veterans compared to sexual assault victims, making treatment outcomes complicated (Rauch, Eftekhari, & Ruzek, 2012). We might remember Carl Sagan’s saying that extraordinary claims require extraordinary evidence to prove them.
Does EMDR measure up?
Practitioners of EMDR say it works by recalling traumatic memories while making horizontal eye movements. These eye movements can be guided by a finger or by intermittent lights or beeps (Van den Hout, Engelhard, 2012). Dr. Shapiro says that EMDR enhances someone’s information processing ability and that it frees the brain to reach resolution after trauma, though she is not sure whether the brain’s chemistry and activity is somehow changed by the eye movements, or if the movements allow someone to enter a more receptive emotional state (Shapiro, 2001). Trying to put together a simple summary of her ideas and findings is admittedly tricky, but the basic idea is that psychopathology results from dysfunctional storage of memories, kept “frozen” in a neuro network (Shapiro’s own term), and that therapeutic progress can be made when those memories are moved into a more adaptive processing network (Shapiro, 2001). Eye movements result in a transmutation of memory and also in lowered physiological arousal.
There are several studies of EMDR that find it equally effective for PTSD treatment as the “gold standard” treatment of Cognitive Behavioral Therapy (Siedler & Wagner, 2006). EMDR in these studies began by asking the patient to imagine the traumatic event as vividly as possible before starting bilateral stimulation, usually through the therapist’s finger movement. CBT began similarly, with the patient reliving the event in session, but then practicing continual exposure to that event by listening to video recordings of their narrative after every session. While the authors of the meta-analysis for these studies say that posttreatment symptom differences were comparable for the EMDR and CBT groups, they mention that EMDR may just be another form of exposure therapy and that it is impossible to tell if eye movements made any contribution. Additionally, they remark that the sample sizes in these studies were quite small, with each treatment group having under twenty participants. I was unsure what to make of their concluding statement that “A limitation of this paper is the relatively small number of studies available that directly compare EMDR and CBT. It therefore did not seem advisable to include only those studies that satisfy high methodological standards” (Siedler &Wagner, 2006).
In order to come to any conclusion about EMDR’s efficacy, it is necessary to isolate the eye movement as the variable of interest, because it is what makes EMDR different than other exposure therapy. Researchers at an Australian university conducted an experiment on students with distressing memories, assigning some to a group of EMDR with eye movements according to a fixed protocol, others to a group of EMDR with random, varied eye movements, and others to a group of EMDR with no eye movements at all. They found that the groups who received EMDR with eye movement had lower self-reported ratings of distress and lower physiological signs of distress like skin conductance than the group who simply talked through their experience (Schubert, Lee &Drummond, 2011).
The evidence is compelling, but there was no difference between the group with fixed eye movements according to the typical EMDR protocol and the group with random eye movements. So, is it possible that eye movements serve merely as a sort of distraction and relief from the distress, not unlike how mindful breathing or muscle relaxation might be used in therapy? In addition, it is worth asking questions about the study’s sample, a group of psychology students who were not actually diagnosed with PTSD. These students were receiving credit for their major for participating. It is possible they might have shown demand characteristics, an effect that occurs when participants catch on (or think they catch on) to what the experimenter is trying to measure. These students might have been studying EMDR themselves and wanted to try to “assist” the researchers in proving their hypothesis. We cannot know for sure, but it is worth entertaining the possibility.
Relaxation therapy may be the best control to choose for EMDR, since it involves doing small activities to reduce symptoms of hyperarousal and is also often employed to treat PTSD (Taylor et al., 2003). EMDR, while effective in these trials, did not show greater effects than relaxation therapy, and the greatest symptom reduction was in exposure therapy, still considered the standard for treatment (Taylor et al., 2003). The authors of this study concluded that EMDR’s efficacy was due to the imaginal exposure, not the eye movements.
Media coverage of EMDR often does not paint the full and nuanced picture of what actually makes it effective. It’s easy enough to understand why popular news sources might include some missteps in evaluating its claims, since descriptions of how the therapy works are seriously complicated. Psychology Today, a source the public often turns to in order to better understand therapy and mental health, actually gives a valiant effort at presenting both sides of the EMDR debate. A 2014 article titled “Why are Deepak Chopra and Sanjay Gupta important for science and life?” pointed out how EMDRs claims like efficacy for conditions from anxiety, to cancer, to eating disorders, along with its obscure language and shifting standards of proof, make it a prime example of pseudoscience (Kashdan, 2014).
While Kashdan’s criticism was valid, I worry that his tone might have been a little strong to handle a delicate topic like trauma therapy. I doubt anyone who supported EMDR or was currently receiving it as a treatment would be convinced that a therapy that can alleviate devastating symptoms is totally pseudoscience. Most other articles on Psychology Today focusing on EMDR support its claims seemingly unconditionally, so I also have doubts that people would weigh the information they find on that site equally.
For all its claims as a “paradigm shift” for therapy, EMDR is a disappointment. It is effective at reducing symptoms of PTSD, but meta analyses consistently show that its effects are not different than exposure therapy, and that eye movements make no impact on symptom reduction (Davidson &Parker, 2001). It doesn’t actually introduce anything new at all to PTSD treatment, since we know imaginal exposure is already part of exposure therapy. It does meet criteria for pseudoscience, like proponents who fall back on ad hoc hypotheses, claiming faulty methods when EMDR studies don’t prove their points (Kashdan, 2014). I also was unable to find studies that prove its efficacy against a control group for the incredible range of mental and physical illnesses it claims to treat. Shapiro even claims EMDR can be used for two year olds (Shapiro, 2001). There don’t seem to be any boundary conditions.
All this considered, we have to remember who the real audience of this research is. It is not enough to write off EMDR as pure pseudoscience and denounce its practitioners as quacks. We would likely just ruffle some feathers (pardon that awful pun) and further the gap that already exists between research and therapists who are trying to alleviate suffering. PTSD is a debilitating illness, and EMDR can alleviate its symptoms. Trauma is such a sensitive issue, and it doesn’t seem helpful to tell people they are healing in the “wrong” way. Rather, we might do a better job at publicizing results of valid, controlled studies of EMDR and disseminating that information to the people who are seeking help. The causes and boundaries of its efficacy are just simply not what it claims. Knowledge is power, and hopefully people could use that knowledge for healing, too.
References:
Davidson &Parker. (2001).EMDR: A meta-analysis. Journal of Counseling and Clinical Psychology. 69(2).
Kashdan. (2014). Why are Deepak Chopra and EMDR important for life and science? Psychology Today.
Rauch, Eftekhari, & Ruzek. (2012). Review of exposure therapy: a gold standard for PTSD treatment. Journal of rehabilitation research and development 49, (5). 679-87.
Schubert, Lee, &Drummond. (2011). The efficacy and psychophysiological correlation of dual attention tasks in Eye Movement Desensitization and Reprocessing. Journal of Anxiety Disorders 25(1). 1-11.
Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20(3), 211–217.
Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. Guilford Press.
Siedler, Wagner. (2006). Comparing the efficacy of EMDR and trauma focused cognitive behavioral therapy in the treatment of PTSD: a meta-analytic study. Psychological Medicine 36, 1515-1522.
Taylor, Thordarson, Federoff, Maxfield, Lovell, &Ogrodnizcuk. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clincial Psychology. 71(2), 330-338.
Van den Hout, Engelhard. (2012). How does EMDR work? Journal of Experimental Psychopathology? 3(5), 724-738.