Eye Movement Desensitization Reprocessing (EMDR) therapy is a short-term, experiential psychotherapy that alleviates anxiety. It works with the brain’s adaptive information processing system to change the emotional intensity of distressing experiences. It works well for many forms of anxiety, including phobias, performance, social situations, panic attacks, and OCD. Between two and 15 sessions are the ideal range for most conditions.
Central Concepts of EMDR
EMDR involves working with thoughts, behaviors, emotions and physical sensations similar to cognitive behavior therapy (CBT); however, EMDR is experienced in the moment using bi-lateral stimulation of the brain. According to Dr. Francine Shapiro, stimulating the adaptive information processing system in the brain produces positive cognitive and emotional changes by reprocessing memories.8 One of the major benefits of EMDR is that the clients do not have to talk in-depth about their painful experiences; instead they process through them using a standardized protocol.
When EMDR was first used, blinking light bars were used to move the eyes horizontally side to side to stimulate the brain (bi-lateral stimulation). It is thought that this bilateral movement replicates rapid eye movement (REM) sleep. It is during REM sleep that the limbic system (emotional part of the brain) is accessed and memories are processed.8 Other forms of bilateral stimulation (tapping and sounds) have become as effective at bilateral stimulation using lights.6
EMDR therapy is delivered using an eight-step system. These eight steps ensure a client’s safety and readiness for treatment. EMDR has some requirements that facilitate effective reprocessing. Clients must be able to maintain dual awareness—that is to keep attention equally on the present and on the past. Clients must also be able to manage emotional state changes, moving quickly from heightened emotions to a state of calm. A seasoned therapist will carefully work to preserve the clients’ abilities to effectively regulate their emotional reactions so they don’t get “stuck” in disturbing memories or painful emotions.
EMDR therapy initially focused on post-traumatic stress; however, there is a close relationship between trauma, which is related to an event or experience, and anxiety, which is a symptom or a state. The underlying characteristic of both is experiencing some level of distress, fear or threat.8
EMDR targets the information processing part of the brain that deals with memories associated with painful thoughts, emotions and body sensations. When the EMDR eight step protocol is applied to various fearful events, they can be reprocessed and changed to harmless memories. This relieves the anxiety, guilt, anger, fear and body tension brought on by negative experiences, beliefs, and thoughts.8
Research has found the following types of anxiety are treatable with EMDR therapy:1,2,3,8,9
- Generalized anxiety disorder
- Panic disorder
- Panic disorder with agoraphobia
- Fear of flying anxiety
- Phobias
- Obsessive-compulsive disorder
- Social Anxiety
- Performance anxiety in athletes and musicians
- Performance anxiety in general
- Pre-operative anxiety and other medical situations
- Caregivers’ anxiety
- Anxiety related to natural disasters
Traditionally therapists offered EMDR in a face-to-face, in-office setting. However, many people have adopted video-based, online EMDR at least partly in response to the inability to safely hold in-person sessions during much of 2020 and 2021.
Common EMDR Techniques for Anxiety Disorders
EMDR for anxiety is fundamentally the same as it is for posttraumatic stress. The therapist may change the initial sessions to include some mindfulness practice, meditation, yoga, or body relaxation training to supplement EMDR. It is also common for the therapist to work with clients using some cognitive behavior therapy for negative thinking before initiating EMDR for anxiety.
In some cases, the therapist may suggest medication for immediate symptom relief while using EMDR for long-term relief of the overall problem. It is up to the client and therapist to create an effective individualized treatment plan.
EMDR’s eight-step protocol is used after completing the agreed upon early treatment, if there is any. Since EMDR protocol is a manualized treatment, using specific guidelines, there is little deviation in the process when treating anxiety; however, the treatment targets will be unique to the client’s fears, worry, and anxiety producing situations. The focus will be on the past, present, and the future.8
Here are the eight steps of EMDR:
- Client history and treatment planning including history and goals.
- Preparation by learning calming and relaxing tools.
- Assessment requires selecting negative and positive thoughts, images and feelings.
- Desensitization by applying bilateral stimulation to reprocess negative experiences.
- Installation, which exchanges a negative thought with a positive, empowering thought.
- Body Scan means checking for the level of physical relief and relaxation.
- Closure helps with grounding and feeling a state of equilibrium before leaving.
- Reevaluation assessment takes place at the beginning of the next EMDR session.
EMDR Examples in Practice
Although EMDR is manualized, there may be some slight modifications of EMDR step three to fit the treatment needs of the individual with anxiety. Clients may have to process any barriers to effective treatment, such as emotional avoidance, or having dissociative episodes.
Here are some treatment examples:
EMDR for a Phobia
Jennifer had been in therapy for post-traumatic stress disorder with my colleague when I first met her. She made excellent progress and found relief of her PTSD symptoms; however, she had a phobia of seeing pictures of, or actual, unloved, injured, killed, or lost animals. She had severe panic attacks if she saw a picture of an injured pet, or noticed a dog she thought was lost. It was especially disturbing if she saw any kind of dead animal on the roadside, which is common in the rural, remote area where she lived. Jennifer’s anxiety would last for several days after an event. It left her sleepless, feeling panicky, sick to her stomach, and gave her nightmares. She had flashbacks of the images that she was trying to avoid and the panic would return.
Jennifer’s therapist asked me to work with her using EMDR for her PTSD. At the first session, Jennifer was so sensitive that the anticipation of talking about her phobia sent her into panic. Before we began the eight step protocol for EMDR, I provided some psychoeducation about the brain’s limbic system and the impact of fear on body functions. Following the education session, I worked with Jennifer to improve her breathing and relaxation to counter her stress response. She practiced these skills at home daily. These first two pre-EMDR sessions and “homework” helped prepare Jennifer for EMDR.
During EMDR step one, taking a history, we stopped frequently to use breathing and relaxation to help Jennifer stay within her window of tolerance (the amount of disturbance one can manage without going into severe distress). I reminded Jennifer to notice how well she was able to manage her anxiety with the tools she had learned. This built her confidence and thus increased her window of tolerance. We were able to move on to EMDR step two and install additional resources, such as calm place imagery and present place mindfulness.
Before Jennifer began EMDR step three, we discussed the value of bringing her therapy dog into the session. The dog went with her everywhere, but usually stayed in the car. We agreed to try having the dog present, which turned out to work well. We were able to complete EMDR steps three through seven while the dog laid on the floor next to her, relaxed and quiet. Jennifer had her foot barely touching the dog, but that added level of reassurance allowed her to complete six additional EMDR sessions without ever experiencing an abreaction (getting stuck in a painful emotional state), or a panic attack.
Jennifer’s phobia changed dramatically almost without her noticing. At first, she found that she was able to talk about a beloved dog that had died from cancer. Then she found that she didn’t have to turn away from T.V. shows, the news, or Facebook stories that mentioned or showed pictures of animals that may have been in distress or injured. By the last session, eight weeks later, Jennifer still felt deep love and empathy for all animals, but she was no long paralyzed or terrified by thoughts that see might see an animal that might be abused, injured, or just unloved.
Side note: I often recommend that clients bring something to session that they find comforting. Soft shawls, sweaters, or blankets, a special pillow, or a stuffed animal all work well to provide some soothing comfort. Trained therapy dogs can be helpful if they are indeed trained to provide a calming presence. If the dog takes on a client’s anxieties, or becomes disturbed by a crying client, the treatment fails because focus moves to the dog’s discomfort. The use of therapy animals must be openly and frankly discussed with the therapist, and possibly with her agency or office colleagues.
EMDR For Performance Anxiety
Jessie worked with me to address substance use disorder and PTSD. She was hard working and found relaxation and enjoyment in performing in community theatre. Jessie had been an active member in three different theatre groups and had become well known for her powerful performances. She was sought after by local directors.
After a few months of treatment, both cognitive behavior treatment and EMDR for PTSD, Jessie told me that she was having trouble with an upcoming play. There were several circumstances that added pressure on her to perform her best. Using EMDR eight step protocol, we processed a few past experiences of Jessie making mistakes and feeling embarrassed and foolish. This work went well. Jessie noticed that the emotion around those events dissipated, so we moved to focus just on the present and future.
Jessie’s anxieties of failing in the upcoming play were out of portion to reality. Jessie had years of experience, she was always well prepared, she acted with integrity to the role, and she was loved by audiences and her fellow actors. We used EMDR step 5, the installation process, as a stand-alone treatment for one session. Bilateral stimulation created a new pathway for her brain to access her positive beliefs about her achievements and increase her positive sense of self.
The eight stage protocol was very helpful in alleviating Jessie’s anxiety of past, present and future performance fears. Jessie became more confident and relaxed overall. It was the focus on installing positive beliefs based on Jessie’s real accomplishments and positive characteristics that made the most significant difference. Jessie told me that during rehearsals and on opening night, she found a quiet place to do her preparation. Jessie brought her positive beliefs to mind while using some bilateral tapping interspersed with deep breathing. She said that her positive self-assurance grew inside her like a bright light and made her feel vibrant, while her anxiety faded away.
Jessie’s success was due to her own hard work both in therapy and in her everyday life. She was highly motivated, never missed a session, and practiced the coping and soothing skills she learned. Most important, Jessie took the EMDR sessions seriously, even when they were very emotionally painful before the relief came. Success in therapy only happens when the client and therapist are working collaboratively at the same pace with equal effort.
EMDR For Fear of Driving
Jeff had an unusual personality disorder and one of the symptoms was anxiety. One of his biggest fears was driving. He would say to me, “What if I get in an accident, or I get lost? What will I do?” For most of us, this is not a debilitating possibility, but is was for Jeff. For days before his appointment, he would be panicked and sick with anxiety over having to drive the short distance to the office.
We settled on EMDR for his fear of driving. Throughout his therapy, we had worked on relaxation, breathing and addressing negative thinking using Acceptance and Commitment Therapy. He felt safe enough to address his driving anxiety after about 4 weeks in treatment.
Since he was prepared, we went straight to step three of the EMDR protocol. Interestingly, Jeff had never been in a car accident, or even witnessed an actual accident. We worked with imagery of a potential worst case and connected it to his negative thoughts, feelings and body sensations. At the end of that first session, he left my office very grounded and calm.
What happened the following week was surprising. When he sat down to reevaluate his previous session, Jeff calmly said, “I got into a fender bender on my way here.” I was floored by his statement and his demeanor, but didn’t show my surprise. Jeff went on to tell me that he had accidently bumped into the car in front of him when it stopped at a crosswalk. He said that he didn’t feel any panic, he just got out of the car, saw there was no damage and apologized to the driver. The other driver was not particularly distressed and waved him off without exchanging any insurance information. Jeff got back in his car and drove to his appointment, even arriving on time.
My response was, “Jeff, how do you account for your behavior?” He simply told me he didn’t understand it and he seemed confused. Smiling, I went straight to discussing his last session using EMDR. Without much emotion, he said, “Huh…I guess it worked.” This led us to a meaningful discussion about how his anxiety and panic “helped” him, what we call secondary gains. One EMDR session had not only helped with his driving fear, but it opened the door to a profound discovery that became one of the core features of his ongoing therapy.
We returned to EMDR to address other fears. Jeff successfully processed through his agoraphobia. However, due to the impact of his personality disorder, he never became very comfortable around people, but he learned to better manage his emotions and behaviors.
Is EMDR Effective for Treating Anxiety?
The short answer is yes. Dr. Francine Shapiro, who discovered EMDR and wrote the EMDR manual, published a second book called, EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma. Her years of clinical experience, experimentation, and research have shown that EMDR can change the impact of single incident trauma and effectively treat other problems related to fear, distress and threat.6,8
Subsequent research investigated EMDR therapy for issues like chronic pain, autism, psychosis, cancer, and medical issues, and the results indicate that EMDR is not an effective treatment for every problem.8,9
Twenty-five years after EMDR’s introduction there are still naysayers in the psychotherapy community when it comes to EMDR treatment; however, their voices are growing faint due to the mounting research on EMDR effectiveness.1,2,5 Working with a well-trained, competent therapist makes a difference in treatment outcomes when using EMDR. A skillful therapist will not only know the basic methods, but will be well informed about current research on both the effectiveness and the limitations of EMDR therapy.
All of the following reputable organizations recognize the effectiveness of EMDR therapy and provide information and resources:
- American Psychiatric Association
- International Society for Traumatic Stress Studies
- World Health Organization
- Substance Abuse and Mental Health Services Administration
- National Center for PTSD, U.S. Dept. of Veterans Affairs
- EMDR International Association
How to Find an EMDR Therapist
There are many qualified EMDR therapists who have received EMDRIA-approved training. Any master’s degree level licensed therapist, or healthcare professional, can be trained to provide EMDR. The training includes at least 10 hours of in-class instruction, 10 hours of supervised practicum and 10 hours of consultation by a certified practitioner. EMDRIA regulates the training of EMDR to maintain its integrity over time. While EMDRIA approved training does not guarantee the skillfulness of clinicians, it does ensure that their training meets all the criteria for good practice.
Finding an EMDR therapist is fairly easy. Therapists generally publish their education and training on their professional websites. Their credentials also appear when they list themselves on various searchable websites, like Anxiety and Depression Association of America, EMDR Institute, or the EMDR International Association. Searching can be done by provider’s name or simply by location.
Here are some questions to ask your therapist before beginning EMDR therapy for anxiety:
- What is your training and experience with EMDR therapy for anxiety?
- Have you treated someone with symptoms similar to mine and was it effective?
- Will we need 90 minute sessions as opposed to 60 minute? How often?
- Can you estimate the number of sessions that may be needed?
- What if EMDR doesn’t work for my anxiety, then what?
- How will I know when the therapy is complete?
- Will my insurance cover the sessions?
Additional Resources for EMDR for Anxiety
Here are more helpful resources related to EMDR therapy for anxiety:
