Running head: EMDR

Chapter 5

Eye Movement Desensitization and Reprocessing

in the Treatment of Posttraumatic Stress Disorder

Louise Maxfield

Lakehead University, Canada

Contact information: Louise Maxfield. Psychology Department, Lakehead University, Thunder Bay, ON, Canada, P7B 5E3. <jlmaxfie@flash.lakeheadu.ca>

Abstract

Since EMDR was introduced twelve years ago (Shapiro, 1989a, 1989b) it has become the most researched treatment for PTSD and its efficacy has been widely recognized. EMDR is a comprehensive treatment protocol in which the client attends to emotionally disturbing material in short sequential doses while simultaneously focusing on an external stimulus (therapist-directed eye movements, hand-tapping, auditory tones). This chapter provides a overview of EMDR’s development and Shapiro’s (2001) Adaptive Information Processing model which hypothesizes that EMDR works by forging new links between elements of traumatic memories and adaptive information contained in other memory networks. The empirical evidence is examined, with summaries of 12 controlled studies: Civilian participants demonstrated a 70-90% decrease in PTSD diagnosis after 3 to 4 EMDR sessions, and combat veterans, a 78% decrease in PTSD diagnosis after 12 sessions. A concise explanation of the eight phases of EMDR treatment process is augmented with multiple client vignettes. Finally, a case illustration provides a detailed description of the application of EMDR in the treatment of PTSD.

Eye Movement Desensitization and Reprocessing

in the Treatment of Posttraumatic Stress Disorder

Overview of the Presenting Problem

Trauma is an experience of intense horror, or complete terror, or overwhelming helplessness (American Psychiatric Association, 1994). It is sudden and unexpected, and is perceived by the individual as nonnormative and as exceeding his or her ability to cope. It is catastrophic, destructive, and disruptive and can change the course and direction of a person’s life. Although most people move on toward health, reorienting values and goals, there are others for whom trauma creates lasting psychological and biological changes, resulting in posttraumatic stress disorder (PTSD).

Exposure to traumatic events is a common experience, with community surveys reporting rates of exposure from 62% to 69% (Breslau, Davis, Andreski, Peterson, & Schultz,1997; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Approximately 20% of those exposed will develop PTSD. It appears that posttraumatic stress may often be under-identified and under-treated (van Etten & Taylor, 1998). There are many other persons with subsyndromal levels of PTSD, who are so distressed by the trauma that their function is impaired (Maes et al., 1998).

Traditional Treatment Approaches

The National Comorbidity Survey found that persons with PTSD who received treatment recovered more rapidly than those without treatment, and that remission was most rapid within the first year (Kessler et al., 1995). After six years, however, treatment effects were minimal and almost 40% of both groups still met the diagnostic criteria for PTSD. This percentage was unchanged at 10 years post trauma. The fact that 40% of persons treated for PTSD were unable to find relief demonstrates the need for different and more effective treatments.

Cognitive Behavioral Therapy (CBT) is the psychological treatment most commonly used in the treatment of PTSD, and research has demonstrated its effectiveness (see Chapter 4: “Cognitive-Behavioral Approaches”). CBT often includes a “flooding” or “directed exposure” procedure that requires a concentrated chronological focus on the original trauma and elicits high levels of affective distress. Clients can find it difficult to endure the intense emotional arousal. CBT usually requires 12 to 16 sessions with daily homework assignments.

This chapter examines Eye Movement Desensitization and Reprocessing (EMDR). EMDR is a relatively new treatment that appears to be as effective as CBT and that may require less time and be less painful for clients. Researchers using both techniques remark that EMDR, with its alternating dosed exposure and client-directed focus seems to be better tolerated and preferred over exposure therapy by both clients and therapists (Boudewyns et al., 1994; Pitman et al., 1996). In a treatment process study comparing EMDR to exposure, Rogers et al. (1999) found that although clients rated both treatments equally, EMDR resulted in a rapid decrease in Subjective Units of Distress (SUD), whereas in the exposure group there was no decrease in SUD levels. This difference may contribute to the observation that EMDR is the more comfortable treatment.

In a meta analysis that compared the efficacy of treatments for PTSD, Van Etten and Taylor (1998) analyzed 61 treatment outcome trials from 39 studies of chronic PTSD. The treatments included pharmacotherapies, psychological therapies (behavior therapy, EMDR, relaxation training, hypnotherapy, and dynamic therapy), and control conditions (pill-placebo, wait-list controls, supportive psychotherapies, and non-saccade EMDR control). Although serotonin specific reuptake inhibitors (SSRIs) were effective, they were not well-tolerated: The high drop-out rate (36%) suggests that SSRIs may not be a treatment of choice for PTSD. Psychological therapies were more effective than drug therapies, and of these, CBT and EMDR were most effective. They showed generally equivalent effects on measures of PTSD, anxiety, and depression. The EMDR studies had significantly fewer treatment sessions than those using behavior therapy (4.6 vs. 14.8 sessions) and EMDR took significantly less time (3.7 vs. 10.1 weeks). It appears that EMDR may be equivalent in effectiveness to CBT and that it may be more efficient, producing more rapid recovery.

In 1995, the Clinical Psychology Division of the American Psychological Association initiated a project to determine the degree to which therapeutic methods were supported by solid empirical evidence. Using these criteria, independent reviewers (Chambless et al., 1998) placed EMDR, exposure therapy, and stress inoculation therapy on a list of “probably efficacious treatments;” no other therapies were judged to be empirically supported by controlled research for any PTSD population. In 2000, after the examination of additional published controlled studies, the Practice Guidelines of the International Society for Traumatic Stress Studies designated CBT and EMDR as effective for PTSD (Chemob, Tolin, van der Kolk & Pitman, 2000; Rothbaum, Meadows, Resick, & Foy, 2000).

Overview of EMDR

Brief Description

Described by originator Francine Shapiro as "a model, set of principles, procedures and protocols that together represent a new approach to psychotherapy" (1994a, p.155), EMDR is said to facilitate the accessing and processing of traumatic memories and to bring these to an adaptive resolution, indicated by desensitization of emotional distress, reformulation of associated cognitions, and relief of accompanying physiological arousal. EMDR is a therapeutic process in which the client attends to emotionally disturbing material in short sequential doses while simultaneously focusing on an external stimulus. Therapist-directed eye movements are the most common dual attention stimulus, but a variety of other stimuli, including hand-tapping and auditory tones, are often used (Shapiro, 1991; 1994b; 1995). This dual (external/internal) attention is combined with frequent brief periods of focusing on new associations as they arise, in a highly structured and client-directed process.

Shapiro (1995, 2001) maintains that EMDR, with its brief exposures to associated material, dual attention stimuli, and therapeutic protocol, is a distinctly different form of therapy, activating internal processes that move the individual toward healing. According to Hyer and Brandsma (1997) and Fensterheim (1996), EMDR is a complex multi-component, multi-staged process, blending many elements of other effective therapies into a comprehensive treatment protocol. It includes many features of CBT, including cognitive restructuring, anxiety desensitization, breathing, and exposure. EMDR also integrates elements of many other effective therapies such as psychodynamic, body-focused, person-centered, and interactional therapies (Bohart, in press; Brown, in press; Fensterheim, 1994; Lazarus & Lazarus, in press; Manfield, 1998; Wachtel, in press). Additionally it possesses a number of nonspecific therapeutic components, including therapeutic rapport, client empowerment, and expectations of positive outcome.

By far, the most unusual element of EMDR is the eye movement component. Primary research that studied eye movements in relation to thinking processes, dreaming, brain function, perception, and memory (e.g., Andrade, Kavanagh, & Baddeley, 1997; Antrobus, 1973; Antrobus & Singer, 1964; Christman & Garvey, 2000; Drake, 1987; Stickgold, 1998, in press), has provided indications that the clinical use of eye movements could be beneficial (see Shapiro 2001, in press; Shapiro & Maxfield, in press). There have also been dismantling EMDR studies in which eye movements were removed or modified to examine their effects (e.g., Montgomery & Allyon, 1994; Renfrey & Spates, 1996; Wilson, Silver, Covi, & Foster, 1996). Although these studies indicated that eye movements may contribute to clinical treatment outcome, the aggregate results are inconclusive because of the poor methodology typically used in these studies. While ongoing research is attempting to answer this question, it should be recognized that, as of yet, no psychotherapy, including CBT, has definitively identified or measured its active mechanisms (e.g., Jacobson et al., 1996; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998).

History

Francine Shapiro was a 38 year old Ph.D. psychology student when she made the “chance observation” (Shapiro, 1995, p.2) that resulted in the creation of EMDR. While walking in the park in May 1987, she noticed that the emotional distress connected to some old memories disappeared when she moved her eyes rapidly from side to side (Shapiro & Silk Forrest, 1997). Experimenting with friends and colleagues, she developed a procedure to facilitate eye movements and to expedite the processing of distress. She then administered this treatment to about 70 persons and standardized a procedure that was consistently successful. Since Shapiro’s primary goal was to reduce anxiety, and since she was, at this time, a behaviorist, she called her technique Eye Movement Desensitization (EMD).

Shapiro conducted a case study, and a controlled study for her doctoral thesis, which resulted in two published papers (Shapiro, 1989a, 1989b). The subjects were 22 individuals who were very disturbed by various traumas that had occurred an average of 23 years previously, and who had received an average of 6 years of unsuccessful treatment. Subjects were randomly assigned to one session of EMD or a modified flooding procedure (EMD without eye movement). The response of the EMD group was significantly superior to controls on SUD ratings and behavioral indicators. Results were independently corroborated at one and three-month follow-up, and replicated with EMD treatment of the controls. These findings were limited by the lack of standardized assessments and the multiple roles played by Shapiro. Such unprecedented treatment success generated both enthusiastic interest (e.g., Wolpe, in a footnote to Shapiro, 1989b) and critical skepticism (e.g., Acierno, Hersen, Van Hasselt, Tremont, & Mueser, 1994).

While working as a Research Fellow at the Mental Research Institute in Palo Alto, Calif., Shapiro observed that EMD appeared to result not only in desensitization, but also in the cognitive restructuring of memories and personal attributions. EMD became EMDR, renamed to capture the concept of Reprocessing (Shapiro, 1991). This conceptual development was accompanied by the development and refining of method protocols and procedures, and the formulation of Shapiro’s theory of Adaptive Information Processing (Shapiro, 1995, in press).

By 1991, an EMDR National Training Schedule was established, with training restricted to licensed clinicians. Training was controlled to ensure that all persons practicing EMDR received identical training, and were following the same protocols. When Shapiro published her book in 1995, the restriction on training was lifted. Presently more than 40,000 therapists worldwide have received EMDR training (Shapiro, 2001) and there are reports of more than 1,000,000 individuals treated with EMDR (EMDRIA, 2000). Twelve years after its inception, with the publication of over 100 case studies and 30 controlled studies, EMDR is becoming a recognized, established treatment (see Allen, Keller & Console, 1999; Chemtob, Tolin, van der Kolk, & Pitman, 2000; Maxfield, 1999; Shapiro, 1995, 2001; Shepherd, Stein & Milne, 2000). This recognition has been driven by research findings substantiating its apparent efficacy in the treatment of PTSD (Feske, 1998; Hembree & Foa, 2000; Lipke, 1999; Maxfield & Hyer, in press; Shalev, Foa, Keane, & Friedman, 2000; Spector & Read, 1999).

The Adaptive Information Processing Model

Shapiro (Shapiro, 2001; Shapiro & Maxfield, in press) has adopted the term "Adaptive Information Processing Model" to describe her theoretical model of information processing, and to distinguish this conceptual model from the treatment itself which is understood to be an "Accelerated Information Processing” treatment. Humans are assumed to have an inherent information processing system that is physiologically geared, and neurologically balanced, to process information to a state of mental health. Information is conceptualized as being stored in a system of memory networks, which are viewed as neurobiological structures containing related memories, thoughts, images, emotions, and sensations. During normal adaptive processing, connections are made to appropriate associations, emotional distress is relieved, experiences are used constructively, and learning takes place.

Pathology is thought to occur when information acquired at the time of a traumatic event is inadequately processed, and then is dysfunctionally stored with its sensory content in a state-specific form. It is held in an excitatory condition and may be more readily stimulated and triggered than other associations; the distressing intrusive re-experiencing symptoms of PTSD are a prime example. Recollecting the event appears to elicit the same negative self-attributions, affect, and physical sensations as those experienced at the time of the event.

The AIP model (Shapiro, 1995, 2001) postulates that adaptive resolution is achieved by activating the brain’s own information processing system, with its “inherent self-healing processes”. Adaptive reprocessing is understood to take place on a neurophysiological level. When the dysfunctional memory network links up with more adaptive information, insight and integration are achieved. Desensitization and cognitive restructuring are considered byproducts of this process. Adaptive reprocessing results in the elimination of maladaptive negative emotion, and in some kind of positive resolution. It may even include a positive schematic shift. For example, a person no longer sees himself as a victim, and instead claims his resiliency and strength.

EMDR is an Accelerated Information Processing treatment. It works directly with all the perceptual components of memory (cognitive, affective, somatic) to forge new associative links with more adaptive material. It is structured to rapidly and effectively access the dysfunctionally stored information and to directly mobilize the information processing system. A number of treatment elements (e.g., eye movements, free association, brief exposures) are specifically formulated to enhance information processing.

Empirical Evidence of the Effectiveness of EMDR

The level of evidence for EMDR is based upon 12 controlled studies that investigated the efficacy of EMDR treatment of participants with PTSD. The seven civilian studies, with one exception, all found EMDR to be efficacious in the treatment of PTSD: EMDR was equivalent to cognitive behavioral therapy, and superior to other control conditions. Four of the five studies with combat veterans addressed only one or two memories in this multiply traumatized population, and their findings were equivocal. The one combat veteran study that administered a longer course of treatment provides preliminary evidence that EMDR may be efficacious with that population. EMDR is a rapid treatment and appears to be well tolerated by clients, with effects being maintained at follow-up. Dismantling studies that examined the use of eye movements or other treatment components are not discussed here (e.g., Pitman et al., 1996) because their focus was on determining the mechanism of action rather than on assessing treatment efficacy.

EMDR with Civilian PTSD

EMDR was compared to wait-list conditions by Wilson et al. (1995; 1997) and Rothbaum (1997). Participants in the Rothbaum study were 18 adult female rape victims with PTSD who were randomly assigned to either a wait-list control group or three treatment sessions of EMDR. Results showed significantly greater improvement for the EMDR subjects, with scores on standardized measures moving to within normal range. At post-treatment, 90% of the EMDR subjects no longer met PTSD criteria. In the Wilson et al. study, participants were 80 civilian trauma survivors, 46% of whom had PTSD. Those subjects receiving EMDR treatment showed significantly greater improvement than the wait-list group. Scores on standardized measures moved to within normal range. After three-month follow-up, treatment was provided to the wait-list group, with results replicating the original findings. At 15-month follow-up (Wilson et al., 1997), 84% of those originally diagnosed with PTSD no longer met PTSD criteria. The wait-list design is limited: No comparison is made to other treatments, and it does not control for nonspecific factors such as therapeutic alliance, expectations, or placebo effects.

Two studies with civilian PTSD subjects compared EMDR to other treatments for which there is no established evidence of efficacy with PTSD. In an outpatient HMO, Marcus et al. (1997) randomly assigned 67 individuals to EMDR or to “Standard Kaiser Care” (SKC). SKC consisted of cognitive, psychodynamic, or behavioral therapies. Participants received an unlimited number of 50-minute treatment sessions. EMDR produced significantly lower scores than SKC for PTSD, depression, and anxiety symptoms. After three sessions, 50% of the EMDR participants no longer met the criteria for PTSD, compared to 20% of the SKC group. At post-treatment, 77% of the EMDR group no longer met criteria for PTSD compared to 50% of the SKC group. Even though the wide variety of treatments used in the control group accurately represents standard care in an HMO setting, there is no specific knowledge of their effectiveness for PTSD treatment; this limits the conclusions that can be drawn.

Scheck et al. (1998) compared EMDR to an active listening (AL) control with a group of 60 traumatized young women, 77% of whom were diagnosed with PTSD, and who were engaging in high-risk behavior such as sexual promiscuity, runaway behavior, or substance abuse. The women received two 90-minute treatment sessions, and had a homework assignment of journal writing. Both AL and EMDR resulted in significant reductions on all measures. The effects of EMDR were significantly greater than that of AL on all measures except a self-concept scale. Treatment gains were maintained at three-month follow-up for both groups. The results indicate that EMDR is superior to a condition that controls for some of the nonspecific effects of treatment such as attention, therapeutic rapport, and active listening.

EMDR has been compared to CBT for civilian PTSD in three studies. Vaughan et al. (1994) found relative equivalency for EMDR and CBT exposure and relaxation therapies. Thirty-six participants received three to five treatment sessions. All treatments led to significant decreases in depression and PTSD symptoms for subjects in the treatment groups compared to those on the wait-list. A comparison between treatment groups found a significantly greater reduction at post-treatment for the EMDR group on PTSD intrusive symptoms, and at follow-up for the relaxation group on self-reports of depression. At follow-up, 70% of the PTSD subjects no longer met PTSD diagnostic criteria. Lee and Gavriel (1998) randomly assigned 22 PTSD civilian subjects to EMDR or to Stress Inoculation Training with Prolonged Exposure (SITPE). Participants received seven 60-minute treatment sessions. Both EMDR and SITPE were found to be highly effective, with significant decreases on PTSD measures. EMDR was more effective on intrusion scales. At follow-up, 83% of the EMDR subjects and 75% of the SITPE subjects no longer met PTSD criteria. EMDR may be more efficient by not requiring homework assignments.

Devilly & Spence (1999) provided 23 civilian PTSD subjects with eight sessions of either EMDR or a CBT treatment package combining elements of CBT, Stress Inoculation Training, and Prolonged Exposure. Both EMDR and TTP were significantly effective on all measures and TTP was significantly more effective than EMDR on combined PTSD measures. At three-month follow-up, 58% of the TTP subjects no longer met PTSD criteria, compared to only 18% of the EMDR group. Although Vaughan et al. and Lee and Gavriel found EMDR and CBT exposure therapies to be relatively equivalent, this was not the finding of Devilly and Spence, who had uncharacteristically poor results with EMDR. When considering the wide variation in outcome of these three studies, methodological rigor should be considered. It appears that differences in outcome are related to differences in methodology, and that low ratings of methodological rigor predict low treatment effect sizes (Maxfield & Hyer, in press).

EMDR with combat veterans with PTSD.

Five controlled studies have examined the efficacy of EMDR with combat veterans. This research area has suffered from poor methodology. In four studies (Boudewyns et al.,1993; Boudewyns & Hyer, 1996; Devilly, et al., 1998; Jensen, 1994), the participants were receiving adjunctive concurrent treatments, confounding the effect of the experimental conditions, and making it impossible to determine unique effects. Also, subjects in these four studies were provided with only two or three treatment sessions, or addressed only one or two of multiple traumatic memories. Other methodological limitations include poor treatment fidelity and lack of blind independent assessors. Although some changes in diagnostic status were found (Boudewyns & Hyer, 1996; Devilly et al, 1998), because of the methodological limitations, these four studies provide no clear evidence of the effectiveness of EMDR with combat PTSD.

In the fifth study, Carlson et al. (1998) provided 35 Vietnam combat veterans with an adequate course of treatment (12 sessions). EMDR was compared to wait-list and to biofeedback relaxation, and resulted in significantly lower scores on measures of PTSD and self‑reported symptoms. Both treatment groups and the wait-list control showed significant improvement on physiological measures, with no differences between groups, and with the decrease in physiological arousal maintained at three-month follow‑up. At nine-month follow-up, 78% of the EMDR subjects no longer met diagnostic criteria for PTSD.

Assessment and Treatment: The Eight Phases of EMDR

EMDR consists of eight phases, each considered essential for effective application (Shapiro, 1995; Shapiro & Forrest, 1997). EMDR utilizes a direct holistic approach, with attention to ongoing affective and physiological changes throughout the session. Clinical evidence indicates that application of the full protocol may be essential for optimal outcome, and that truncating the procedure by eliminating various procedural elements can result in poorer outcomes. Shapiro (1999) and colleagues reviewed EMDR phobia outcome studies and determined that those using fewer than half of the required elements had poorer outcomes than those which used more than half of the protocol elements.

Patient History and Treatment Planning

During the first phase, the therapist takes a full history, assesses the client’s suitability for EMDR, and develops a treatment plan. The therapist evaluates aspects such as diagnosis, comorbidity, existing support system, suicidality, life stability, presence of current stressors, physical health, and substance use. Although the obtaining of a full history is a procedure followed in most psychotherapies, in EMDR it has additional theoretical importance. It is understood that earlier traumas may underlie current presenting symptoms, and that the processing of related memory networks will activate such prior incidents. Therefore an effort is made to identify these, so that both client and therapist are aware of the material that may be accessed during processing.

“Trina” was the first person to arrive on the scene after a car had crashed on a deserted road and rolled into a river. She rescued those passengers who were still alive. Afterwards, she blamed herself for the deaths of the non-surviving passengers. While processing this with EMDR, she realized how closely this related to the drowning death of a younger sibling when she was 5 years old. Her parents had accused her of being responsible for the tragedy. This earlier incident had fueled her emotional response to the current event. (Note: Trina’s story and subsequent clinical vignettes are based on actual clients, with names and minor details changed to protect confidentiality).

The therapist also wants to ensure that the client can tolerate the intense affect that can arise during EMDR sessions. EMDR activates the memory network and clients can feel like they are reexperiencing the physical, emotional, and cognitive elements of the trauma. For example, during the Vitenam war, “Sam” had been viciously attacked and his arm almost severed with a knife. During the EMDR process, he felt severe pain in his arm. Additionally, the processing of material can continue after the session is over, with other memories and emotions surfacing. The therapist must ensure that the client can handle the despair, anger, fear, or other emotions associated with the memory before stimulating the memory network. Therefore client assessment must include an evaluation of the client’s ability to self soothe, regulate affect, and relax. If the client lacks such skills, these resources are enhanced in Phase Two, before beginning the processing of the event.

Preparation

Preparation for EMDR includes education about the EMDR process and ensuring that the client has adequate impulse control and affect management skills. For clients without deficits in these areas, this phase of treatment is often brief, and EMDR is typically used to enhance “safe place” visualization. This involves adding eye movements, according to certain interactive clinical guidelines, while the client imagines a past memory or fantasy that evokes a feeling of safety. Client reports indicate that EMDR amplifies the sensory content and somatic experience of the visualization.

For clients with deficits in these areas, brief treatment is not recommended, and this phase of treatment may be extensive. Therapists can use a form of EMDR to assist in the development of resources and strengths, and to establish client safety and stabilization (Korn & Leeds, in press). This resource enhancement work combines relaxation, imagery, and EMDR to assist the client in developing new skills and strengths.

Assessment

In the third phase, the client and therapist select which specific memory to target, and the client identifies the most distressing visual image connected to that event. The therapist helps him to identify the current negative belief about himself that is related to the target memory. Negative cognitions are beliefs such as “I’m powerless,” or “I am worthless.” Next the client develops a potential positive cognition, which expresses a desired sense of empowerment and agency, such as “I’m competent,” or “I have value as a person.” He rates the accuracy of this positive belief on the Validity of Cognition Scale (VOC), where 1 represents “completely false” and 7 represents “completely true”.

The articulation of the cognitions can take substantial work, and may constitute a “significant piece of cognitive therapy” (Allen & Lewis, 1996, p. 246). The development of these positive and negative cognitions serves to identify the irrationality of the negative belief attached to the traumatic memory. These cognitions tend to cognitively anchor each end of the EMDR process (Boudewyns & Hyer, 1996). For example, “John”, a man abused by his mother, chose for his target image a mental picture of his mother’s angry face, and the belief “I’m unlovable.” Combining those two elements elicited powerful emotions, and the recognition of how deeply his sense of self had been rooted in early experiences with his mother.

The client next identifies the emotions that are elicited when the visual image is combined with the negative belief. He rates the level of distress on the Subjective Unit of Disturbance (SUD) scale, where 0 is “calm” and 10 is “the worst possible distress” and identifies and locates the body sensations accompanying the emotions. The therapist’s simple acceptance of the client’s low VOC and high SUD scores indicates to the client that there are no expectations, and shows an acceptance of the client in his present state.

Desensitization

During the fourth phase, the client focuses on the visual image, the identified negative belief, and body sensations, while experiencing eye movements in sequential dosed exposures. The client holds all these elements in mind while simultaneously moving his eyes from side to side for 15 or more seconds, following the therapist’s fingers as they move across the visual field. Alternative dual attention stimuli such as hand‑tapping or auditory tones can replace the eye movements (Shapiro, 1991; 1994b; 1995). After the set of eye movements the client is told to take a deep breath, and then is asked what material was elicited in the process. Generally this material (image, thought, sensation, or emotion) then becomes the target of the next set of eye movements. This cycle of alternating focused exposure and client feedback is repeated many times and is accompanied by shifts in affect, physiological states, and cognitive insights (e.g., Vaughan et al., 1994). If the processing stalls, specialized interventions are worded and timed in a specific manner to facilitate processing. The SUD level is usually not reassessed until emotional, physical, and cognitive resolution is apparent. A SUD rating of 0 or 1 generally indicates completion of this phase.

It is during this phase that the client is exposed to the traumatic material, with exposure occurring in brief segments. Because EMDR uses a non-directive free association method, clients may spend very little time exposed to the details of the presenting trauma. Instead they may move sequentially through related material. When “Margie” started processing the emotional distress related to physical assaults by her ex-husband, she found that her focus shifted to childhood experiences of harsh parental criticism. When she had resolved the pain related to parental rejection, the distress related to abuse by the ex-husband resolved rapidly.

Installation of Positive Cognition

In the fifth phase, the therapist invites the client to pair the previously identified, or an emergent, positive self-statement with the original traumatic image, using eye movements. The therapist encourages the client to continue until strong confidence in the positive cognition is apparent, and a VOC of six or seven is achieved. This phase allows for the expression and consolidation of the client’s cognitive insights. For many clients it involves a profound shift in self-concept, integrating self-acceptance with new positive and realistic perceptions of the self. When “John” (the man abused as a child) paired his positive belief “I deserve love” with the targeted image of his mother’s face, he noticed that the image no longer had any power, and that he could make this statement with great confidence.

Body Scan

In phase six, the clinician asks the client, while thinking of the image and the positive cognition, to notice if there is any tension or unusual sensations in his body. Because emotional distress is also often experienced physiologically, processing is not considered complete until the client can bring the traumatic memory into consciousness without feeling any body tension. Any sensations found in the body scan are targeted with more eye movements; this continues until the tension is relieved. Sometimes such body sensations are linked to aspects of the memory network that have not yet been processed. For example, “Melinda” had apparently finished processing the trauma of a rape. When the therapist asked her to scan her body for any discomfort, she reported that her wrists hurt. This sensation was then targeted, and Melinda remembered how the rapist had gripped her wrists, holding her hands above her head, and how powerless she felt. After this aspect of the rape was targeted, the pain in her wrists disappeared and Melinda felt free and able to reclaim her own power.

Closure

In phase seven, the therapist assesses that the material has been adequately worked through, and if not, assists the client with self‑calming interventions. These are the skills and techniques that have been developed and strengthened in Phase Two. Clients are also asked to keep a journal to note any material that emerges after the session. During the week after the session in which she processed memories of the rape, “Melinda” began thinking about her parents’ refusal to believe that this has happened to her. This new material became a treatment target in a subsequent session.

Reevaluation

Reevaluation takes place at the beginning of every subsequent EMDR session. The therapist checks with the client to assure that the treatment gains have been maintained, via SUD, VOC and body self‑report measures. These reevaluations assist the therapist in continuing to direct the treatment to achieve maximum benefit for the client. The goal of EMDR therapy is to produce the most substantial treatment effects possible in the shortest period of time, while simultaneously maintaining client function and preventing emotional overload. Therefore thorough ongoing evaluation of reprocessing, stability, behavioral change and integration within the larger social system is essential.

The eight phases of treatment may be completed in a few sessions or over a period of months, depending upon the needs of the client and/or the seriousness of the pathology. “Melinda” required only three treatment sessions to eliminate the PTSD that followed a rape, whereas “John” required more extensive therapy to deal with child abuse issues. For most persons, EMDR appears to accelerate treatment and to result in thorough and complete processing. “Susan” sought EMDR treatment after ten years of various therapies (CBT, group, feminist, art therapy, etc.) had failed to resolve PTSD resulting from extensive childhood physical, emotional, and sexual abuse. Susan had been unemployed for 12 years following the onset of PTSD, her relationship with husband and children was compromised by her daily rages, and she dissociated frequently. After ten weeks of EMDR, Susan no longer met diagnostic criteria for PTSD, her rages were eliminated, and her dissociation was markedly reduced. Susan continued in treatment for about a year. Her life was transformed on multiple levels. In addition to mental and emotional change and growth, Susan improved her relationships with husband and children, reconciled with her parents, developed a social life, and found employment in a highly satisfying position.

Application of EMDR to PTSD and Trauma Related Disorders

EMDR is formulated to expedite the accessing and processing of traumatic memories, by forging new links between the memory and adaptive information contained in other memory networks. EMDR takes a three-pronged approach to ensure that all past, present, and future aspects of the clinical picture are thoroughly addressed. In addition to targeting the traumatic events, the current conditions that elicit distress are processed to eliminate sensitivity, and a template for appropriate future action is incorporated to enhance positive behaviors and skill acquisition.

Although EMDR has recognized efficacy only in the treatment of PTSD, published case reports indicate that it can be successfully used to treat other trauma related disorders, such as phobias. For example, “Angela” almost died when she was trapped in a crevice while mountain climbing. Subsequently she developed a phobia about being in any enclosed space. This phobia became disabling and prevented her from sitting in restaurants or traveling on airplanes. When EMDR was used to target the near death experience, her phobia was eliminated and she was able to resume her active and adventuresome lifestyle. Future research is needed to evaluate such applications of EMDR.

Case Illustration

Session 1

“Frank” was a 45-year-old man who had been in a severe car accident 18 months previously. He had collided at high speed with three horses on a rural highway. The horses were dismembered, and lay on the road screaming, while he sat, waiting for help, with a broken arm and leg, and multiple lacerations. Although Frank recovered adequately from his physical injuries, he was immobilized by his PTSD. He could not sleep for more than 90 minutes before horrific nightmares replayed the accident. He avoided driving a vehicle because this was accompanied by severe anxiety. Frank had withdrawn from all his previous activities and never saw any of his friends. His attempts to return to work since the accident had been unsuccessful. Now his wife “Joan” had delivered an ultimatum, “Get help and get better, or get out!” She was determined to leave with their three children if he did not improve. Frank sobbed throughout the session as he explained what brought him to the therapist’s office. He felt like he had lost everything: his emotional stability, his health, his ability to work, and now, his family.

The therapist and Frank briefly reviewed his life history, and determined that there were no earlier severe traumas. Although it was apparent that Frank’s current sadness and fears were primarily related to the possible loss of his wife and children, Frank and the therapist decided to start by targeting the accident, because the accident was the precipitating event.

Session 2

The therapist asked Frank to identify the most disturbing visual image or scene connected with the accident. Frank said that the moment of impact was the most distressing and stated that this visual image was exceptionally clear and vivid. As he talked about it, his eyes filled with tears, and he gripped the arms of the chair.

“I can still see the horses caught in my headlights, and then an instant later, crashing into the windshield and smashing over the roof of my car!”

A discussion about the beliefs associated with this image revealed that Frank felt completely powerless. He had been helpless to prevent the accident, and this sense of impotence had continued. When he combined the statement “I am a capable person” with thoughts of the accident, the statement did not feel true, and he gave it a VOC of 2. Next the therapist asked Frank to look at the image of the accident, to say “I’m powerless,” and to notice his feelings. He reported that he felt “helpless and sick, like crying.” He gave this a SUD rating of 10, and mentioned feeling tightness in his chest and stomach.

Processing started with the therapist asking Frank to look at the image, to think the words “I’m powerless”, and to notice the sensations in his body, while he followed her fingers with his eyes. After the first set of eye movements (EMs), she told Frank to take a deep breath and to let his mind go blank, and then to just notice what came up for him. Frank said, “I see the horses standing there, frozen.” The therapist then said, “Go with that” and started another set of EMs. After this next set, he reported, “I can see the light shining in their eyes.” The therapist responded “Just go with that,” and did another set of EMs. Frank continued to process the most distressing elements of the incident, including the arrival of the police, and his mixed feelings of guilt and relief when they put the horses down.

At the session end, the therapist asked Frank to think of the original target and to report a SUD rating. He reported a low SUD rating, and the positive belief “I am a capable person” was installed, with a VOC of 7.

Session 3

When Frank arrived a week later for the following session, he reported that he had not had one graphic or gory nightmare since the EMDR. He related that he was happy and relieved. He had been out visiting his old friends, for the first time since the accident, and had been very talkative and social. In reviewing his journal and the material that had emerged over the week, Frank said,

“Although I feel so much better, I still feel very frustrated; I can’t do anything; Joan is still upset; I’m still not back at work.”

This session targeted an image of Frank waiting for help to arrive, sitting beside the deserted highway, listening to the horses cry. As processing progressed, Frank realized that his primary emotion at the time of the accident had been anger.

“I just realized – when I saw that I couldn’t avoid hitting those horses, I was furious. And you know, I’ve been angry ever since; I don’t think that I ever stopped being angry!”

He recognized how this anger had affected his relationship with Joan. Processing resulted in a dissipation of the anger and a feeling of calm acceptance at the end of the session. The positive belief installed was “I’m okay now,” with a VOC of 7.

Session 4

Frank reported that the PTSD symptoms were almost entirely eliminated, he had arranged to return to work, and the marital situation was much improved. However, at times he would feel overwhelmed with sadness. For this session, the targeted image was the “blood everywhere,” the beliefs were “I can’t protect myself” and “It’s okay to be vulnerable,” and the emotion was sadness. During the collision, Frank had thought that he was going to die. As he processed this with EMDR he remembered feeling great grief about dying and never seeing his wife and children again. As Frank worked through this, he recognized that his feelings of vulnerability during the accident were similar to those that he now felt about his current life situation. A future template was targeted, in which Frank imagined feeling both vulnerable and confident. At session end, Frank experienced no distress connected to the accident. He expressed a strong commitment to his family and a calm readiness to cope with life’s uncertainties.

Three Month Follow-up

After the first session of EMDR, Frank never had another nightmare about the accident. At three-month follow-up, he was back at work and doing well, and the marital relationship was stronger and more enjoyable than it had been prior to the accident. Frank continued to be free from PTSD symptoms and the driving phobia was completely gone.

Six-Year Follow-Up

Frank is now the supervisor at work, with multiple responsibilities that he performs well. No further symptoms of PTSD have ever surfaced. Frank and Joan continue to enjoy a rich and satisfying life.

Summary

EMDR appears to facilitate the accessing of disturbing memories, and to activate the information processing system. During EMDR the client focuses on an external stimulus while simultaneously attending, in brief sequential doses, to emotionally disturbing material that is elicited through free association. These treatment elements (e.g., eye movements, free association, brief exposures) are specifically formulated to enhance information processing and are embedded in a comprehensive eight-stage protocol. The protocol seeks to ensure that all past, present, and future aspects of the clinical picture are thoroughly addressed.

.The Adaptive Information Processing model posits a physiologically-based information processing system that has a tendency to move towards health by processing information to a state of adaptive resolution. It is hypothesized that EMDR works by forging new links between the traumatic memory and adaptive information contained in other memory networks. Complete reprocessing is evident in the desensitization of triggers, elimination of emotional distress, elicitation of insight, reformulation of associated beliefs, relief of accompanying physiological arousal, and acquisition of desired behaviors

Currently, EMDR has been found efficacious in the treatment of PTSD. Civilian participants have shown a 70-90% decrease in PTSD diagnosis and a substantial improvement in reported symptoms after 3 or 4 EMDR sessions. The only combat veteran study that provided a full course of treatment revealed EMDR to be efficacious with a 78% decrease in PTSD diagnosis after 12 sessions.

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