EMDR: Looking Past the Pain

Today we're going to unravel a specific type of psychotherapy, and it's one that presents the researcher with formidable walls to scale of both support and criticism. Some psychotherapists are firm believers; some are firm detractors. The therapy is called EMDR, Eye Movement Desensitization and Reprocessing. It is controversial as the day is long, and yet it enjoys broad recommendations in most of the world's major guidelines. It also has plenty of criticism of its effectiveness. And it has a wildly unscientific origin story, which never bodes well for any kind of treatment. So now let's dive in and find out if EMDR is for real or phony.

EMDR is one of a number of treatments for Post-Traumatic Stress Disorder (PTSD), a potentially serious and debilitating condition in which certain traumatic memories can trigger anything from nightmares and anxiety to an uncontrollable emotional breakdown to a complete dissociative episode. The idea is to reduce the emotional distress associated with traumatic memories, and when used as an adjunct to other therapies, EMDR does this by attempting to get the brain to reprocess those memories via bilateral stimulation. Whether bilateral stimulation can actually do that is mainly where the controversy around EMDR lies. The stimulation is usually guided eye movements back and forth, but can also be tactile or auditory: tapping or holding a buzzer in each hand, or hearing tones played through headphones alternating between left and right. A typical EMDR session would include the patient recalling and talking about their traumatic memory while the therapist moves a pointer from side to side in front of them, for the patient to follow with their eyes. If you were uninitiated and saw this happening, you might well be inclined to wonder what kind of freaky woo you had just walked into.

The American Psychological Association (APA) is the authority for standards of care in psychology in the United States. Their recommended treatments for PTSD are cognitive behavioral therapy, cognitive processing therapy, cognitive therapy, and prolonged exposure therapy. There are also three conditionally recommended therapies, and among these is EMDR. However, based on studies published between 2012 and 2016, the APA has said that they expect to move EMDR up from "conditionally recommended" to "strongly recommended," and the panel is currently convened to update those guidelines.

Despite this encouraging news, it's important to point out that EMDR had a very inauspicious origin, like most pseudosciences, and that puts us on kind of a rocky start. Its creator was Francine Shapiro — a high school English teacher with a masters degree in English literature, not in psychology. The story goes that she was walking in a park one day in 1987, going over some old unpleasant memories, and moving her eyes back and forth. She noticed that when doing so, the negative memories were less distressing.

On the strength of this alone, Shapiro decided to switch careers. She acquired a doctorate in psychology from an unaccredited diploma mill in San Diego called the Professional School of Psychological Studies in 1988. At the time, the California board of psychology did grant licenses to people whose degrees were unaccredited, though that's no longer the case today. She still had to go through the required 3,000 hours of supervised internship, so she would have had a solid foundation in psychotherapy. But although she's often referred to as "Dr." Francine Shapiro, she never had a valid doctorate. Once she was licensed she began conducting her own trials and publishing extensively on EMDR.

Why had she been moving her eyes back and forth during her walk in the park? The reason is some goofy nonsense in which she was also a firm believer. In addition to teaching high school English and promoting EMDR, Shapiro taught Neuro-Linguistic Programming (NLP), an aggressive self-help program from the 1970s promising to make you a "Super Achiever". (There's a complete Skeptoid episode on NLP, episode #155.) Among its tenets is the claim that you can tell what's going on in someone's head by the way they move their eyes. She was also a devotee of self-help pitchman Tony Robbins, who sold NLP seminars accompanied by firewalking with the claim that it was only made possible by purchasing his courses and becoming a Super Achiever. Tony Robbins' skills as a huckster turned out to be more than a little influential on Shapiro.

It gets worse. Two of Shapiro's major advocates for EMDR were Robert Welch and Gerald Puk, who both published articles in her defense. Neither disclosed that they had both been married to her (though not at the same time); Puk even served on her dissertation committee while secretly her husband, a clear ethical violation.

So the fact is that EMDR descends from NLP, which has more in common with high-pressure sales than it does with science, and certainly has nothing to do with psychotherapy. So as far as EMDR being a topic for Skeptoid goes, it's got as bad a start as any topic I've ever covered. However, we're going to proceed as we always do: not to judge EMDR based on guilt by association, but rather to look at the testing and see if it actually does work or not. Because you never know; maybe Francine Shapiro got lucky. 99 times out of 100, the answer to that would be "no" — wild conjectures developed by people working outside of a profession are rarely correct.

And yet we see the APA probably moving EMDR from "conditionally recommended" to "strongly recommended" based on the published research — at the same time we see skeptical authors asserting that EMDR adds absolutely nothing to the conventional cognitive therapies it is given alongside. Well, here's an interesting tidbit that may explain why EMDR can actually play a useful role.

REM sleep, which stands for Rapid Eye Movement, is the most important part of our night's sleep. There are a number of things thought to happen during REM sleep, chief of which is the formation of long-term memories. This is when the brain processes the day's events, and that's a lot. It takes the things we learned that day and stores them. It takes emotional experiences from the day and processes them, drawing any lessons like emotional stability and resilience. Creative connections and insights are drawn during this period. Although we dream throughout our sleep, REM sleep is when the dreams are most vivid, and those dreams are also the ones we're most likely to remember when we wake up. This may be because REM sleep is when we're storing long-term memories.

One question that's not fully understood is why the eyes move during REM sleep. There are a number of theories; they're all related, and they may all be true to some extent. One is that since this is a period of exceptionally vivid dreaming, the eye movements may simply reflect what we're looking at in the dream. Another is that we're strengthening and developing cognitive processes during REM sleep, and vision is a big part of cognition — this is supported by experimental data finding that congenitally blind people have much less eye movement during REM sleep than sighted people; the cognitive processes and memories their brains are storing are less visual in nature. This supports another theory for why the eyes move, and that's that our brains may be reliving the experiences that are being memorized. Taken altogether, eye movements — at least in sighted people — are strongly correlated with the brain's processing of experiences, and obviously this would include deeply emotional and/or traumatic experiences. Theory to explain how and why this happens is far from solid, but the correlation is definitely there.

So the interesting question this raises is whether this can work in reverse. If the processing of traumatic events causes the eyes to move involuntarily, can deliberately moving the eyes back and forth (or other bilateral stimulation) prompt the brain to reprocess the memories you're currently thinking of?

We can say for sure that it's not as simple as that. We can also say that there's sound theory underlying that it might play a role. We do know from REM sleep that eye movements are associated with processing memories. So let's find out what the research has shown.

One of the largest and most-often cited studies is from 2006 and was published in Psychological Medicine. This was a literature review of 16 years of published studies comparing the effectiveness of EMDR to the standard treatment, cognitive behavioral therapy. It found both equally effective, with neither treatment demonstrating superiority over the other. However, it concluded "What remains unclear is the contribution of the eye movement component in EMDR to treatment outcome."

Another study, published in 2007 in the Journal of Clinical Psychiatry, compared EMDR to drug treatment using an SSRI called fluoxetine, and also to a placebo. This one found that EMDR was superior, but mainly for adult-onset trauma patients (75% asymptomatic) compared to child-onset patients (33% asymptomatic).

The APA is not the only organization in town that recommends EMDR. Few places treat as many PTSD patients as the US Department of Veteran Affairs, and the VA lists EMDR among their "strongest recommendation" therapies. They find that weekly 90-minute sessions over about 3 months produce moderate to strong effects in PTSD symptom reduction and loss of PTSD diagnosis. In fact, most of the world's major guidelines also include EMDR among their highest recommended therapies, including the International Society for Traumatic Stress Studies, the UK's National Institute for Health and Clinical Excellence, and the Australian National Health and Medical Research Council.

Even the most skeptical of critics acknowledge that EMDR is as effective as the previously recommended therapies, CBT and so forth. The example I offer of this is an op-ed in Scientific American by Hal Arkowitz and Scott Lilienfeld, who has been a reference in many Skeptoid episodes. They largely dismiss EMDR as being nothing more than conventional psychotherapy with the bilateral stimulation being nothing more than a superfluous ornamentation, giving the quote "What is effective in EMDR is not new, and what is new is not effective." But in their otherwise very downbeat article, the worst they can manage to say about EMDR is that it is not superior to the other recommended treatments.

Luckily, many psychotherapists are fluent and trained in multiple treatments for PTSD, and in any decent patient-therapist relationship, whatever works best is what they'll go with. No two patients' cases are the same and no two people will react the same to any given therapy; and EMDR offers one more tool that can be tried. There's no guarantee that any of them will successfully treat a person's PTSD, and also no reason that any one of them can't. There are many medical and psychological interventions in the marketplace for which we don't have complete explanations for the mechanisms, so that shouldn't stop anyone who's interested from trying EMDR.

By Brian Dunning
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