Eye movement desensitization and reprocessing (EMDR) is a helpful psychotherapy technique used to treat PTSD, anxiety, depression, addiction and other conditions. Most people can expect some calming effect after engaging in one 90 minute session. Additional weekly 60 – 90 minute sessions are needed to relieve intense emotions from disturbing experiences. Treatment is generally short-term, taking six to eight sessions and can be done in-person or via video-based therapy with a therapist trained in online EMDR.
Effective EMDR therapy requires a skillful therapist trained through an EMDR International Association (EMDRIA) approved program.
Central Concepts of EMDR
EMDR works by diverting attention through directed eye movements as the initial means of stimulating the brain’s neural network to reprocess trauma. In the past, therapists used blinking lights to help move the eyes back and forth, side to side (bi-lateral stimulation). Over time, various other sources of bi-lateral stimulation such as tapping, sound, or handheld vibrating disks have been proven to be just as effective. All types of bi-lateral stimulation work with the brain to reduce the emotional intensity of negative experiences.
EMDR has some requirements that help with effective memory reprocessing. Clients must be able to maintain dual awareness—that is to envision a difficult memory and also be able to return immediately to the present. Clients must also be able to manage emotional state changes, moving from heightened emotions to a state of calm within seconds.
A seasoned therapist will work within a client’s personal window of tolerance (how much emotion can be managed). This precaution carefully preserves the client’s ability to effectively regulate their emotional reactions without getting stuck in a painful memory. A qualified therapist will use an eight-step protocol to deliver EMDR therapy. These eight steps ensure a client’s safety and readiness for treatment.
The Eight Phased EMDR Protocol
The therapist will direct a client through each phase of protocol, one at a time. The length of time spent in each of the eight phases is guided by the therapist with input from the client.
The eight essential phases in EMDR treatment are:
1. Client History and Treatment Planning
The therapist and client will discuss the client’s history and goals for therapy. This also includes an evaluation of the client’s emotional stability and a conversation about current circumstances that might influence treatment effectiveness.
2. Preparation
The EMDR process is explained to the client with particular attention paid to the possibility of emotional upset. The therapist will teach the client relaxation tools to ease distress during and after treatment.
3. Assessment
A target negative event and image are chosen. The client states a negative thought about him or herself related to the event, then creates a positive thought that can replace the negative. The image and negative thought are combined to identify the emotions surrounding the event, and a measure of distress (called standard units of distress or SUD) is taken by using a 0 to 10 point scale. The client then notices the physical body sensations brought on by recalling the negative image, thought, and emotions.
4. Desensitization
Some form of bi-lateral stimulation (BLS), such as eye movements, tapping, or using headphones with sounds, is used to engage the brain in processing. BLS takes place in sets, with pauses for deep breathing and measuring distress in between sets. Distress can increase, decrease, or remain stationary during the sets. The therapist will continue sets until the SUD is at or near zero, which indicates relief. This is known as memory reprocessing.
5. Installation
The focus in this phase is on strengthening the positive thought that the client chose to replace the negative thought. A client’s SUD should be near or at 0 on the distress scale for installation to occur. The client will think of the positive thought while BLS is used in very short sets.
6. Body Scan
While noticing each area of the body, the client holds the target event in mind. Any lasting body tension is targeted with sets of BLS, and the tension generally decreases or goes away.
7. Closure
Closure occurs at the end of a session even if the target has not been fully reprocessed. The client is brought back to a state of equilibrium. There is usually a feeling of being grounded, peaceful and calm. The client is reminded that it is normal for images, memories, negative thoughts, or dreams to arise after treatment. Keeping a journal of this phase is helpful for phase eight.
8. Reevaluation
This assessment takes place at the beginning of the next EMDR session and will determine the next steps in treatment, as well as help to identify other negative experiences that need reprocessing.
EMDR therapy will be complete when the client feels emotional relief from the targeted negative experience. The client will notice that when recalling the event, it is just a faint memory. It has been reprocessed and is no longer a defining life experience. The symptoms associated with the event have been resolved.
What Can EMDR Help With?
25 years of research have found EMDR to be an effective front-line treatment for post-traumatic stress disorder.4
There is also evidence that EMDR can be used to effectively treat other problems, including:
- Anxiety and panic attacks
- Depression
- Addiction related to alcohol, drugs or smoking
- Social Anxiety
- Chronic pain
- Eating disorders
- Fears related to natural disasters
- Assault (violent and sexual)
- Sleep problems
- Dissociative disorders
- Recovery from critical illness
- Complex grief
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EMDR Examples
Since EMDR can be used to treat several different types of mental health problems, here are some examples of what the process looks like for people coming in with a variety of concerns:
Acute Trauma
Sheila, who had been suffering with anxiety and depression, came to see me one day after she experienced a drive-by shooting at her house. A car pulled up and stopped in front of her house. The driver, whom she did not know, pointed a large pistol at her home and started shooting until the magazine was empty.
Shelia was still shaky, tearful and scared when she sat down in my office. She said, “I can still see his eyes like black holes, scary and deep. I thought I would die.” Tears rolled down her checks into her trembling hands.
Using the eight phase EMDR protocol, the worst part of Shelia’s trauma memory was targeted for reprocessing. Sheila’s tears increased and then subsided; the emotional intensity and frightening thoughts were resolved during one 90 minute session. Sheila’s end response was, “I’m fine. I’m safe. I understand what happened, but I am okay.” She was calm and relaxed when she left. I saw her for two more months, but that incident did not bother her again.
Post Traumatic Stress Disorder
A lifetime of domestic violence and complicated grief brought Margaret to therapy with PTSD; she was age 72. Margaret had been hospitalized many times in her life due to severe assaults resulting in serious injuries and broken bones. She was a devout Catholic and had been freed from her torment only after her husband died three years prior.
Margaret had tried many medications and psychotherapy, but they had not helped her. Thinking that it would take a year of intense therapy to find some relief, Margaret was prepared for the long-haul.
Surprisingly, in the first 90 minute EMDR session, Margaret found a profound sense of peace and calm, stating that it was a spiritual experience for her. She processed through her complex trauma during two months of weekly sessions. By the end of treatment she was deeply changed; even her physical countenance was different. Her face was open, softened, relaxed, and her furrowed brow was smooth. Margaret carried herself with dignity and strength, upright, not hunched over as she was the first day we met.
In our last session, Margaret told me that she had begun the process of throwing away the physical remnants of her past. For her, this seemed like a miracle as her children had implied she was a hoarder. To both of our surprise, Margaret enjoyed the most remarkable, lasting transformation of all my encounters in therapy.
Anxiety
Jennifer and her husband saved enough money for a 10-day cruise. This was a problem for Jennifer because she was terrified of being on a cruise ship. She had struggled through a short four day cruise on their honeymoon, which meant she stayed in her cabin enduring uncontrollable, intermittent panic attacks and vomiting. Jennifer was determined to overcome her fear and have a good time.
Initially, Jennifer worked with CBT to challenge her negative thoughts, especially the thought “I am trapped and I’m going to die.” After several CBT sessions, homework, and practice, EMDR therapy was instituted. Four 60-minute EMDR sessions resolved Jennifer’s fears. Being skeptical, she still packed her “emergency kit” full of naturopathic remedies, relaxation tapes, and acupressure bracelets to take on her trip.
After the cruise, Jennifer happily reported she didn’t even open her emergency kit. She didn’t need to. She was too busy enjoying every entertainment and activity the ship had to offer.
Sleep Problems with Nightmares
Sarah had been raped as a teenager; she was 42 when she came to EMDR therapy. EMDR resolved the intense emotional memories relieving all of her PTSD symptoms, except for a recurring nightmare.
She chose a scary image from the dream. Using EMDR phases three through eight she processed through the fear and terrible thoughts. Sarah found relief after two EMDR sessions and using some guided imagery to “rewrite” the ending. She was glad to be rid of the emotional burden of an awful event and find some peace.
How to Find an EMDR Therapist
Finding an EMDR therapist is fairly easy. There are many qualified EMDRIA-approved therapists, who generally publish their education and training on their professional websites. Their credentials and proof of training also appear when they list themselves on various searchable websites, like online directories, the EMDR Institute, or on the EMDR International Association’s website. Searching can be done by provider’s name, or simply by location.
Cost of EMDR
Clients can choose a private pay therapist and pay an hourly rate set by the therapist. The national average rate is $60 to $120 per 45 – 50 minute session. There is substantial price variability when you pay out of pocket because there are no set rates. Sessions can cost between $20 to $300 per session.
Location, type of practice, experience, training, education, and reputation all play a part in the cost of therapy. Open discussion about payments will take place either in the initial telephone screening or at the first session.
Generally, insurance companies that provide mental or behavioral health care benefits will pay for EMDR therapy. Some insurance plans may have an annual deductible that must be met first, and a copay at time of service. This information will be available from the insurance company, so it is important to contact them first. Be aware that insurers often have limitations on the number of sessions available in a given year.
What to Ask Your Therapist Before Beginning EMDR
Some questions to ask your therapist before beginning EMDR therapy include:
- What is your training and experience with EMDR therapy?
- Have you treated someone with symptoms similar to mine, and was it effective?
- Will we need 90 minute sessions as opposed to 60 minute?
- Can you estimate the number of sessions that may be needed?
- How will I know that I can safely engage in EMDR?
- What if EMDR doesn’t work for me—then what?
- How will I know when the therapy is complete?
What to Expect at Your First Appointment
Hopefully, the therapist has all the necessary forms easily available online so they can be completed and brought to the first meeting. The therapist will review the client’s concerns, questions, and treatment goals with the client. All financial information, policies, and consents will also be explained and signed.
The therapist will provide brief information about EMDR, including how it works, the treatment process, and potential outcomes. Often therapists will send the client home with some reading material so they can have a more in depth understanding of what to expect after EMDR therapy. Finally, the therapist will discuss all the safety factors involved in EMDR treatment. Phase one will begin at the next session.
Is EMDR Effective?
Several reputable organizations recognize the effectiveness of EMDR therapy, including the American Psychiatric Association, the World Health Organization, and the International Society for Traumatic Stress Studies.
Several studies have been conducted, citing the effectiveness of EMDR for various mental health issues:
The Effectiveness of EMDR for PTSD
The bulk of EMDR research centers on post-traumatic stress disorder in adults and children. There are a significant number of worldwide studies examining EMDR’s effectiveness for treating PTSD related to combat, domestic violence, natural disasters, violent crimes, exposure to war, childhood and adult sexual abuse, accidents, illnesses, complicated grief, and the breakdown in childhood attachment. There is wide consensus that EMDR is an effective, short-term treatment for PTSD.4,8,9,10
EMDR for Anxiety
CBT and EMDR are shown to be equally effective treatment for anxiety (general anxiety, panic attacks, and social anxiety); however, research also indicates that anxiety medication provides the most relief.1 EMDR or CBT are often combined with medication and provide very good results.
EMDR for Depression
Episodic and long-term depression responds well to a number of treatments, including EMDR.6,9,12
EMDR for Addiction Disorders
There is evidence that EMDR can reduce cravings, vivid imagery and memories related to smoking, as well as food, drug, and alcohol addictions.3
EMDR for Chronic Pain
A small number of studies indicate the efficacy of EMDR in treating chronic pain, particularly if it is related to a history of trauma.11
EMDR for Grief
Several studies have shown that EMDR is as effective as other treatments for complicated grief.2,10 EMDR doesn’t eliminate grief, but allows for greater inner peace during the mourning process.10
Risks of EMDR
There are some risks associated with EMDR therapy. It can be difficult to contend with disturbing memories of events that were emotionally overwhelming when they happened. This may be particularly true if one has spent a lifetime trying to keep memories contained or cut off.
EMDR therapy targets those very memories that it feels best to avoid. Clients are asked to recall their history of traumatic episodes, and then envision the very worst part of the experience along with the accompanying emotions. While processing may take only minutes, for some people the emotion can be unbearable.
It is possible the session may result in what Dr. Francine Shapiro calls an abreaction, or “the reexperiencing of stimulated memory at a high level of disturbance.”10 This can lead to a dissociative episode, which can be an unpleasant feeling like being out of one’s body watching the event. This can be managed by a skilled therapist.
Critiques of EMDR
Not everyone has confidence in EMDR therapy. There are critics voicing their opinions about Dr. Francine Shapiro’s adaptive information processing (AIP) theory of reprocessing emotionally intense memories to resolution. Dr. Shapiro developed EMDR and first published her method in 1989. Since then, research on the brain has proliferated and helped to provide some validity to her theory.
Neuroscience is providing new information rapidly, so matching initial theories to current science is challenging. Brain functions like neural processing, consciousness, emotions, and memory are indeed complex. There is always more to learn, but there is enough worldwide research validating the adaptive information processing theory underlying EMDR that it will continue to be widely used.
Other critics state that EMDR is not an evidence-based treatment. Drs. Peterson and Rouanzoin called it a pseudoscience and not an evidenced based therapy in a 2004 validation study.7 Nowill questioned if it was too narrow and inflexible, or if it was just another form of exposure therapy.5 However, the majority of research has demonstrated that it is an equally (or more) effective treatment for PTSD and other disorders. It is accepted worldwide as an empirically supported treatment.
How Is EMDR Different from Other Therapy?
EMDR is similar to cognitive behavioral therapy (CBT) and prolonged exposure (PE) therapy in that exposure to negative memories provides a way to transform them. CBT requires working to change thoughts, behaviors, and emotions using skill-building and homework. Prolonged Exposure therapy is similar to EMDR, as the client must confront fears head on, but PE also includes thought, behavior, and emotional changes. EMDR does not require skill building and behavioral change. The therapist may ask a client to keep a journal after each session; it is helpful, but not required.
Compared to most therapies, including talk therapy, EMDR can provide some immediate relief with additional relief in each session. Talk therapy can take many years to resolve trauma. EMDR also focuses on adapting to future events after reprocessing the difficulties of the past and present. Finally, troubling, intense, emotionally negative memories that have been resistant to treatment will often resolve using EMDR therapy.
History of Eye Movement Desensitization and Reprocessing
Whether myth or reality, there is a story that Dr. Francine Shapiro took a walk in the park while upset and found relief by looking left and right as she walked. This led her to imagine using back and forth, side to side, eye movements to reprocess negative thoughts and experiences in order to relieve distress.10
After extensive research and experimental trials, Dr. Shapiro presented eye movement desensitization and reprocessing therapy to the public in 1989 in her book by the same name. Since then, there has been substantial research with adults and children to test the effectiveness of EMDR treatment for PTSD, as well as, many other mental health problems.
To learn more about the history of EMDR and Dr. Francine Shapiro, visit her website. Dr. Shapiro provides many resources related to EMDR, as well as providing her own history of developing this life changing therapy.
