EMDR (Eye Movement Desensitization and Reprocessing)

How EMDR works (proposed mechanisms):

The mechanism is still debated. Leading theories:

1. Working Memory Hypothesis:

• Recalling trauma while doing eye movements taxes working memory
• Memory can't be held as vividly while attention is divided
• Reconsolidation stores a less distressing version
• Lee & Cuijpers (2013): Eye movements reduce memory vividness and emotionality

2. Memory Reconsolidation:

• Reactivated memories become temporarily unstable
• Bilateral stimulation during this window alters storage
• Memory reconsolidates with reduced emotional charge

3. REM Sleep Analogy:

• Eye movements mimic REM sleep patterns
• REM sleep processes emotional memories
• EMDR may activate similar processing mechanisms

4. Orienting Response:

• Eye movements trigger orienting reflex
• This activates parasympathetic system
• Reduces arousal while processing trauma

Key research:

• Shapiro (1989): Original controlled study showing PTSD reduction
• Bisson et al. (2013): Cochrane review - EMDR effective for PTSD
• Chen et al. (2014): Meta-analysis confirming EMDR efficacy

What the evidence shows:

• PTSD treatment: Strong evidence (WHO, APA, VA endorsed)
• Trauma-related anxiety: Strong evidence
• Phobias: Moderate evidence
• Depression (trauma-related): Moderate evidence
• Chronic pain: Preliminary evidence
• Performance anxiety: Some evidence

Comparison to other treatments:

• Comparable efficacy to trauma-focused CBT
• Often faster (fewer sessions needed)
• May be easier for those who struggle to talk about trauma
• Less homework than CBT approaches

Important: EMDR should be done with a trained therapist

The following is educational - not a self-treatment guide.

8 Phases of EMDR:

Phase 1: History & Treatment Planning

• Therapist gathers trauma history
• Identifies target memories for processing
• Assesses readiness and resources

Phase 2: Preparation

• Explains the EMDR process
• Teaches self-calming techniques
• Establishes "safe place" visualization
• Builds therapeutic alliance

Phase 3: Assessment

• Selects specific memory to target
• Identifies negative belief about self (e.g., "I'm not safe")
• Identifies desired positive belief
• Rates disturbance level (SUD scale 0-10)
• Rates validity of positive belief (VOC scale 1-7)

Phase 4: Desensitization (core processing)

• Hold target memory in mind
• Follow therapist's fingers (or other bilateral stimulation)
• Sets typically 24-36 back-and-forth movements
• Brief check-in: "What do you notice now?"
• Continue until disturbance level drops

Phase 5: Installation

• Strengthen positive belief
• Pair positive cognition with original memory
• Continue bilateral stimulation
• Goal: positive belief feels true (VOC 7)

Phase 6: Body Scan

• Hold memory and positive belief
• Scan body for residual tension
• Process any remaining physical sensations

Phase 7: Closure

• Return to calm state
• Use safe place or calming techniques
• Debrief the session
• Prepare for between-session experiences

Phase 8: Reevaluation

• Next session: check if gains maintained
• Address any new material that emerged
• Identify next target if needed

Types of bilateral stimulation:

• Eye movements (most researched)
• Tapping (alternating knees or shoulders)
• Auditory (tones alternating left/right ears)
• Tactile buzzers (held in hands)

Typical treatment course:

• Single trauma: 3-6 sessions
• Complex trauma: 12+ sessions
• Sessions: 60-90 minutes
• Frequency: Weekly or bi-weekly

Known risks:

• Temporary increase in distress during processing
• Vivid dreams or new memories between sessions
• Emotional intensity during sessions
• Incomplete processing if stopped prematurely

Contraindications:

• Active suicidality (stabilize first)
• Severe dissociation (requires specialized protocol)
• Psychosis (not appropriate)
• Lack of affect tolerance (preparation needed first)
• Medical conditions affecting eye movement

Precautions:

• Must be done with trained, certified therapist
• Requires adequate preparation and stabilization
• Not appropriate for everyone immediately
• May need to address dissociation first
• Pregnant individuals: consult with therapist

Self-EMDR concerns:

• Apps and self-help versions exist but lack evidence
• Risk of retraumatization without proper support
• May miss important preparation phases
• Cannot provide same containment as therapist
• Bilateral stimulation alone is not EMDR

Risk level: Low when done with trained therapist. Higher risk with self-administration or untrained practitioners.

Strong evidence for:

• Post-Traumatic Stress Disorder (PTSD)
• Single-incident trauma (accidents, assaults, disasters)
• Combat trauma (VA-endorsed treatment)
• Childhood trauma and abuse
• Complex PTSD (requires extended treatment)

Moderate evidence for:

• Phobias
• Anxiety disorders
• Depression (especially trauma-related)
• Grief and loss
• Performance anxiety

May be helpful for:

• Chronic pain with trauma component
• Addiction (trauma-related)
• Disturbing life experiences (not meeting PTSD criteria)
• Negative self-beliefs stemming from experiences

Good candidate signs:

• Specific traumatic memories causing distress
• Intrusive thoughts, flashbacks, nightmares
• Avoidance of trauma reminders
• Negative beliefs about self linked to experiences
• Previous talk therapy hasn't resolved trauma

May need other approaches first:

• Currently in crisis (stabilize first)
• Severe dissociation (specialized treatment needed)
• Active substance abuse (address first or concurrently)
• No specific trauma memories (may need different approach)

What therapists measure:

• SUD (Subjective Units of Disturbance): 0-10 scale for memory distress
• VOC (Validity of Cognition): 1-7 scale for positive belief
• PCL-5 or IES-R: PTSD symptom questionnaires
• PHQ-9 or GAD-7: Depression/anxiety screens

What you might track:

• Frequency of intrusive thoughts/flashbacks
• Nightmare frequency and intensity
• Avoidance behaviors
• Overall anxiety/depression levels
• Sleep quality
• Trigger reactivity

Timeline:

• Session 1-2: Assessment, preparation, possibly begin processing
• Sessions 3-6: Core processing of target memories
• Often significant relief within 3-6 sessions for single trauma
• Complex trauma: 12-20+ sessions

Signs it's working:

• Memory becomes less distressing to recall
• Fewer intrusive thoughts
• Reduced avoidance behaviors
• Nightmares decrease
• Negative self-beliefs shift
• Can think about event without emotional flooding

Finding a therapist:

EMDR International Association (EMDRIA):

• emdria.org - Find certified EMDR therapists
• Look for "EMDRIA Certified" credential
• Ensures adequate training and supervision

What to look for:

• Licensed mental health professional (psychologist, LCSW, LPC)
• Completed EMDRIA-approved training
• Experience with your type of trauma
• Consultation/supervision (especially for complex cases)

Cost factors:

• Individual session: $100-250 typically
• May be covered by insurance (check coverage)
• Some therapists offer sliding scale
• Intensive formats available (multiple hours/day)

Self-help tools (limited evidence):

• EMDR apps - Light bars for bilateral stimulation
• Bilateral music - Audio with alternating tones
• Tapping tappers - Vibrating devices

Note: Self-help tools are not a substitute for therapist-guided EMDR. Use only as adjunct or for general calming, not trauma processing.

Cost: $100-250/session

Typical treatment costs:

• Single trauma (6 sessions): $600-1,500
• Complex trauma (12-20 sessions): $1,200-5,000
• Intensive format (weekend): $1,500-3,000

Insurance:

• Often covered as psychotherapy
• Check mental health benefits
• May require preauthorization
• Some plans limit sessions

Reducing costs:

• Training clinics (supervised students): Lower rates
• Sliding scale therapists
• Community mental health centers
• VA (for veterans): Free
• Some nonprofits offer low-cost trauma therapy

Cost-per-benefit assessment:

High upfront cost but potentially excellent ROI for trauma. Fewer sessions typically needed than traditional talk therapy. Consider: cost of untreated PTSD (lost work, health issues, relationships) vs. treatment cost.

Founder:

• Francine Shapiro, PhD (1948-2019) - Developed EMDR in 1987, founded EMDR Institute

Key researchers:

• Bessel van der Kolk, MD - Trauma researcher, author of "The Body Keeps the Score," EMDR advocate
• Roger Solomon, PhD - EMDR trainer, law enforcement trauma specialist
• Robin Shapiro, LICSW - EMDR author and trainer (no relation to Francine)

Organizations:

• EMDR International Association (EMDRIA) - Professional organization
• EMDR Institute - Training organization founded by Francine Shapiro
• EMDR Europe - European association

Related trauma researchers:

• Peter Levine, PhD - Somatic Experiencing founder
• Pat Ogden, PhD - Sensorimotor Psychotherapy
• Stephen Porges, PhD - Polyvagal Theory

Clinical recognition:

• World Health Organization: Recommended for PTSD
• American Psychological Association: Strong recommendation
• Department of Veterans Affairs: First-line treatment
• International Society for Traumatic Stress Studies: Endorsed
• UK NICE Guidelines: Recommended for PTSD

Common positive reports:

• "Finally processed trauma I'd carried for decades"
• "Faster than years of talk therapy"
• "The memory doesn't trigger me anymore"
• "Felt strange but worked"
• "Wish I'd done this sooner"

Common concerns:

• "Worried about reliving trauma" (therapist helps contain it)
• "Sounds too weird to work" (mechanism debated but outcomes clear)
• "Expensive" (often fewer sessions needed)
• "Hard to find a good therapist" (use EMDRIA directory)

Why it's controversial to some:

• Mechanism not fully understood
• Originated from personal observation, not theory
• Eye movements seem arbitrary
• Some question if bilateral stimulation adds anything
• However: outcomes research is robust regardless of mechanism debate

Pairs well with:

• TRE - Somatic complement to EMDR's cognitive approach
• Mindfulness Meditation - Helps with between-session regulation
• Progressive Muscle Relaxation - Self-calming skill for preparation
• NSDR - Recovery after intense sessions

Treatment sequencing:

• Stabilization first (grounding skills, nervous system regulation)
• EMDR for trauma processing
• Integration and maintenance after

Supporting practices:

• Daily: Grounding exercises, self-care
• After sessions: Rest, gentle activity, journaling optional
• Between sessions: Notice what comes up, use coping skills
• Avoid: Major decisions, intense activities right after sessions

Complementary modalities:

• Somatic therapies (Somatic Experiencing, sensorimotor)
• Yoga or gentle movement
• Vagus nerve practices
• HRV training for regulation

Not recommended to combine:

• Multiple trauma therapies simultaneously (too activating)
• Intensive EMDR with major life stressors
• Processing while in crisis