Keywords: PTSD, therapy, depression
Overview and Procedure
Eye Movement Desensitization and Reprocessing, or EMDR, was developed by Francine Shapiro in 1989 as a treatment for PTSD. Since that time, over 30 randomized controlled clinical trials have been conducted to identify the effectiveness of this treatment. Results show it to be effective, with a 36-95% reduction in symptoms of PTSD. It is also effective at treating PTSD with co-morbid illnesses such as depression.
When EMDR was initially promoted as a treatment for PTSD, it was met with skepticism because of the unusual procedure used. As stated in its name, eye movements are thought essential to help desensitize patients as they recall traumatic memories. Are the eye movements necessary? How does this differ from traditional “talk” therapy?
According to Rodenburg et al., the steps for EMDR sessions follow this pattern:
- A history is taken (first session).
- Client focuses on traumatic memory via direct questioning from therapist.
- Client gives negative dysfunctional cognition related to the trauma and then creates a positive cognition.
- Client focuses on emotion connected to the memory and where in the body the physical symptoms are felt.
- Client focuses on the memory, the dysfunctional cognition, emotion, and physical sensations during bilateral stimulation (e.g., eye movement).
- Level of disturbance is repeatedly measured on a 10-point scale until the level reaches zero (desensitization has occurred).
- The memory is connected to the functional or positive cognition, measured with a 7-point scale during stimulation. Continues until a 7 is reached which means installation has occurred.
- Physical sensations are checked followed by positive closure and re-evaluation.
The number of sessions depends on type of trauma and severity of psychopathology.
Citation: Rodenburg, R., Benjamin, A., De Roos, C., Meijer, A. M., & Stams, G. J. (2009). Efficacy of EMDR in children: A meta-analysis. Clinical Psychology Review, 29, 599-606.
Are Eye Movements the Key Ingredient?
2012 Review of Literature:
Moving the eyes back and forth, typically horizontally but sometimes vertically, is an unusual but important component of this treatment. Without it, you are simply engaging in “talk therapy.” New versions of EMDR involve tapping the hands back and forth on the desk, or even hearing tones through headphones that move between left and right ears.
Can you get the same results simply by recalling the traumatic events without orchestrated eye movements? Research comparing treatment with and without horizontal eye movements has proven that eye movement is the most effective component of treatment. In fact, the results are equivalent using horizontal as well as vertical eye movements. Binaural stimulation (beeps played alternately in left and right ears) has been studied, but beeps are less effective than visual stimuli. However, mindfulness breathing also works as a substitute for eye movement.
Recalling traumatic memories during EMDR serves to reduce the intensity of the memory, thus leading to desensitization. It can achieve the same effect when recalling positive memories: they become less intense as a result of EMDR. The method works not only on memories but also on disturbing thoughts about potential future events (so-called “prospective” memory).
Citation: Van den Hout, M. A., & Engelhard, I. M. (2012). How does EMDR work? Journal of Experimental Psychopathology, 3(5), 724-738.
2013 Meta-analyses:
A 2013 article presented results of two meta-analyses which compared eye-movement vs. non-eye-movement effects on outcomes. The first meta-analysis included only clinical trials of patients in treatment for PTSD and other anxiety disorders; the second meta-analysis consisted of laboratory studies of participants recalling an autobiographical memory.
Fourteen clinical (therapeutic) studies compared eye-movement vs. non-eye-movement conditions for 452 patients receiving treatment. This meta-analysis resulted in effect sizes proving that inclusion of eye movements in therapeutic treatment yielded significant results.
Ten non-therapy laboratory studies of 397 participants were meta-analyzed for differences in outcomes between eye-movement and non-eye-movement protocols. This analysis found a medium to large effect for the eye-movement condition’s effect on the vividness and emotionality of a memory.
Citation: Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44(2), 231–239. https://doi.org/10.1016/j.jbtep.2012.11.001
Is EMDR Effective at Treating PTSD?
This meta-analysis drew upon randomized-controlled trials (RCTs) published between 2008 and 2018 using all psychological therapies for treating PTSD. These RCTs compared the effectiveness of therapies against other therapies, psychosocial support, or a control group. A total of 114 studies with 8171 participants were subjected to meta-analysis. Twenty-nine therapeutic interventions were assessed across these studies, including individual and group therapy. The cause of the PTSD trauma included combat, car accidents, sexual assault, terrorism, crime, and others.
EMDR and CBT-T (trauma-focused Cognitive Behavioral Therapy) had the largest effect sizes (showing the greatest efficacy compared to the control). To a lesser extent, there was support for non-trauma-focused CBT and Present-Centered Therapy (PCT). According to the authors, “the psychological therapies with the strongest evidence of effect should be those prioritized for clinical use when available and acceptable to the patient” (p. 15).
Citation: Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. (2020). Psychological therapies for post-traumatic stress disorder in adults: Systematic review and meta-analysis. European Journal of Psychotraumatology, 11, 1-22.
In a review of literature at the 30-year anniversary of the development of EMDR, the authors reviewed research findings evaluating the effectiveness of EMDR at treating PTSD, the condition for which it was initially developed. Since 1989, there have been more than 30 randomized controlled trials evaluating the effectiveness of EMDR for adult patients suffering from PTSD. Of note, almost all of the patients had non-combat-related PTSD. These trials compared EMDR with other treatment modalities, including various therapies, pharmacotherapy, and waitlisting. Results of these studies found that EMDR significantly reduced PTSD symptoms (ranging from 36-95% reduction) including reduction of symptoms of co-morbid conditions.
Caution is warranted in interpreting the results of these meta-analyses as some studies have been poorly designed, leading to the possibility of bias in reported findings.
The authors included a summary of EMDR recommendations by various health organizations, including WHO, APA, VA/DOD, ITSS, and NICE.
For adults with non-combat-related-PTSD, EMDR is as effective as CBT and may require fewer sessions, giving it a distinct advantage. More evidence is needed to determine if EMDR is comparable to CBT in treating vets and children with PTSD.
Citation: De Jongh, A., Amann, B. L., Hofmann, A., Farrell, D., & Lee, C. W. (2019). The status of EMDR therapy in the treatment of post-traumatic stress disorder 30 years after its introduction. Journal of EMDR Practice and Research, 13(4), 261-269.
Can Children and Adolescents Benefit from EMDR?
A review of literature published in 2018 collected studies of EMDR treatment of PTSD in child and adolescent populations. The selected studies focused on pure EMDR treatments with all components included and excluded combined approaches (EMDR with other treatments). In the 13 studies with control conditions, PTSD symptoms were significantly reduced for the child and adolescent participants. Five studies compared EMDR to TF-CBT and found no significant differences in outcomes between these two approaches. Three of these studies found less time was needed to complete EMDR compared to TF-CBT.[1]
Meta-analyses comparing treatment effectiveness of EMDR with children and adolescents show that it can effectively treat various types of trauma (e.g., physical and sexual abuse, car accidents) and may be slightly more effective than CBT.[2] Is EMDR the most effective treatment for PTSD? This question has not been answered definitively. Both EMDR and Trauma-focused CBT (TF-CBT) are superior to other treatments for PTSD.[3] Children with trauma symptoms, rather than full-blown PTSD, are more likely to improve as a result of EMDR therapy.[4]
[1] Beer, R. (2018). Efficacy of EMDR therapy for children with PTSD: A review of the literature. Journal of EMDR Practice and Research, 12(4), 177-195. https://doi.org/10.1891/1933-3196.12.4.177
[2] Rodenburg, R., Benjamin, A., De Roos, C., Meijer, A. M., & Stams, G. J. (2009). Efficacy of EMDR in children: A meta-analysis. Clinical Psychology Review, 29, 599-606. https://doi.org/10.1016/j.cpr.2009.06.008
[3] John-Baptiste Bastien, R., Jongsma, H., Kabadayi, M., & Billings, J. (2020). The effectiveness of psychological interventions for post-traumatic stress disorder in children, adolescents and young adults: A systematic review and meta-analysis. Psychological Medicine, 50(10), 1598-1612. https://doi.org/10.1017/S0033291720002007
[4] Lewey, J.H., Smith, C.L., Burcham, B. et al. (2018). Comparing the Effectiveness of EMDR and TF-CBT for Children and Adolescents: A meta-analysis. Journal of Child and Adolescent Trauma, 11, 457–472. https://doi.org/10.1007/s40653-018-0212-1
Is EMDR effective for Vets with PTSD?
In an overview of published studies, the authors explained that both TF-CBT and EMDR are evidence-based therapies and have long track records of effectiveness in treating PTSD in members of the general population. Thus far, there is less evidence for EMDR effectiveness with the military population. In fact, combat-related PTSD is different from other types because of the prolonged and repeated exposure to traumatic events.
The authors culled studies of EMDR therapeutic effectiveness published between 1987 and 2012. After removing non-relevant studies of EMDR among patients with combat-related PTSD, four studies (with 60 patients) were deemed relevant and subjected to meta-analysis. This meta-analysis found no support for the effectiveness of EMDR with combat-related PTSD. There were several potential explanations for these findings including: the patients may have had more severe symptoms, there were not enough studies/patients included in the meta-analysis, and there were too few EMDR sessions to result in long-term treatment effectiveness.
Citation: Verstrael, S., van der Wurff, P., & Vermetten, E. (2013). Eye movement desensitization and reprocessing (EMDR) as treatment for combat-related PTSD: A meta-analysis. Military Behavioral Health, 1, 68-73.
What Treatment is Recommended by the APA?
In their 2017 publication, “Clinical Practice Guideline for the Treatment of Post-Traumatic Stress Disorder (PTSD) in Adults,” the American Psychological Association conditionally recommends EMDR, but fully recommends CBT and other cognitive therapies (see p. 91). Their systematic review included English-language studies published between 1980 and 2012, and focused only on research on adults with PTSD. They did not give recommendations for combat-related PTSD as this is considered a sub-group. Their recommendations pertaining to all therapies studied can be found starting on p. 39 of the publication.
You can access the APA’s treatment guideline here:
https://www.apa.org/ptsd-guideline/
Is EMDR effective at treating other conditions?
Depression:
Two meta-analyses were conducted to answer this question. Both meta-analyses examined studies that compared EMDR to other treatments (therapies and medication) as well as other control conditions, such as waitlisting. This comparison is important because it goes beyond simply stating that patients who completed EMDR got better. Controlled comparison studies prove whether EMDR is effective relative to other treatment modalities.
A comprehensive meta-analysis conducted using relevant English-language studies published between 1994 and 2019 compared EMDR with other treatments for primary and secondary depression. In included studies, EMDR was compared with other therapies, pharmaceuticals, and waitlisting. A total of 39 studies met criteria and were meta-analyzed. The authors found that “EMDR significantly improved depression compared to all control types” (p. 6). More specifically, “we found that EMDR is an effective treatment for adult depression, irrespective of age, sex, type of depression, treatment duration, or intake of psychotropic medication” (p. 12).
Citation: Sepehry, A. A., Lam, K., Sheppard, M., Guirguis-Younger, M., & Maglio, A. (2021). EMDR for depression: A meta-analysis and systematic review. Journal of EMDR Practice and Research, 15(1), 1-16.
Another meta-analysis compared 9 studies with 373 patients for treatment effectiveness. All studies were controlled studies in which EMDR was compared with another therapy or waitlist condition. Results found that EMDR was effective at treating depression compared to control conditions. A dose-response relationship was not found, meaning effectiveness was not determined by the number/length of sessions. However, results must be interpreted cautiously as a high risk of bias was evident in some studies.
Carletto, S., Maladrone, F., Berchialla, P., Oliva, F., Colombi, N., Hase, M., Hofmann, A., & Ostacoli, L. (2021). Eye movement desensitization and reprocessing for depression: A systematic review and meta-analysis. European Journal of Psychotraumatology, 12, 1-15.
Other Psychological Diagnoses:
At the time of this publication, the authors claimed that no other meta-analyses had been published regarding EMDR’s effectiveness at treating psychological conditions other than PTSD. Therefore, their focus was on identifying studies of EMDR with all ages in the treatment of both PTSD and non-PTSD psychological disorders.
Effect sizes were calculated for the EMDR outcomes compared to the control intervention. Seventy-seven randomized trials of 3,309 patients were meta-analyzed. Treatment diagnoses consisted primarily of PTSD, anxiety, and depression (68 studies), with other diagnoses in the remaining studies.
There was no significant association between effect size and number or duration of treatment sessions. When compared to other psychological interventions for PTSD, EMDR had significantly greater effect sizes (better outcomes), however bias was a potential problem in these studies. When the biased studies were eliminated there was no significant difference in outcomes for EMDR compared to other therapies. Studies with 3-month follow-up data revealed a significant positive effect for EMDR post-treatment.
A few studies focused on anxiety and other disorders. However, due to bias in the studies, EMDR could not be validated as the preferred treatment. “Dismantling” studies in which a particular component of EMDR was removed for comparison were included in the analyses. Typically, this involved removal of the eye movements from EMDR. Results showed a high risk of bias in these studies and non-significant differences.
In summary, the authors noted: “EMDR may be effective in the treatment of PTSD in the short term and possibly have comparable effects as other treatments. However, the quality of studies is too low to draw definite conclusions” (p. 176).
Citation: Cuijpers, P., Van Veen, SC., Sijbrandij, M., Yoder, W., & Cristea, I. A., (2020). Eye movement desensitization and reprocessing for mental health problems: A systematic review and meta-analysis. Cognitive Behavior Therapy, 49(3), 165-180.
Reviews authored by Jennie Dilworth, Ph.D
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