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A recent BBC article discussed the use of EMDR (Eye Movement Desensitisation and Reprocessing) therapy for treating post-traumatic stress disorder (PTSD). It makes the claim, "Some are still sceptical about the treatment, although studies have shown that it works as well as, if not better than, many other therapies available for dealing with trauma. EMDR therapists now work in every defence community mental health centre." While the phrase "studies show.." is not refutable, the implication that EMDR is more effective than other therapies seems to be.

The Wikipedia article on EMDR lists studies that refute the effectiveness of EMDR, with a 2009 review study concluding "Trauma-focused CBT and to a lesser extent EMDR (due to fewer studies having been conducted and many having had a mixed trauma sample) are the psychological treatments of choice for PTSD, but further research of these and other therapies with different populations is needed."

This seems to claim CBT is a more effective treatment, further backed by a 2002 review titled "Review: eye movement desensitization and reprocessing is not better than exposure therapies for anxiety or trauma." This 2002 review makes the claim I am most interested in: that the eye movement is irrelevant to the effectiveness. I would very much appreciate more evidence regarding the effectiveness EMDR and, more specifically, of the eye-movement aspect, as I lack the expertise to do a proper literature review.

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    You've already found a literature review of 34 studies which shows that the eye movement is irrelevant. What more could an answer provide? – EnergyNumbers Feb 3 '13 at 10:20
  • I suppose you're right. I was doing research while typing the question and somehow didn't realize I had kind of answered it by citing that study. I still think it is quite possible more recent research refutes the 2002 review, which is why I was asking for more. – David Brenner Feb 8 '13 at 1:20
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After reviewing this further, it seems the 2002 study cited in the question does a good job of answering the question. Essentially, the eye-movement portion of the EMDR therapy is irrelevant.

Most insightful to me is a commentary on this study by Dr. Paul Salkovskis. I'm going to quote it here in its entirety.

EMDR had controversial origins as eye movement desensitisation (EMD). Early reports on EMD suggested that 1 session of treatment produced complete remission in PTSD. The treatment was trademarked. “Approved” training required participants to sign an undertaking that they would not train others. The treatment was elaborated to include 8 elements (mostly recognisable from CBT) and rebranded as EMDR. Longer treatments were advocated (a reversal of the trend in CBT). Unusual marketing strategies merged with apparently irregular scientific practices.[1] Notably, EMDR has no coherent theoretical basis.

Controversy has continued with apparently conflicting meta-analyses and commentary.[2] Davidson and Parker's well done meta-analysis manages convincingly to address 3 of the 4 key issues relevant to clinical science. (1) EMDR is found to be better than no treatment or placebo but no different than exposure. As a bonus, they found that the early reports of large effect sizes probably resulted from the use of process variables targeted directly in treatment sessions being used as primary outcome variables. (2) The training of therapists (whether or not it is approved by the EMDR franchising organisation) had no effect. It had previously been asserted that “treatment fidelity” was compromised in those studies that did not find positive results for EMDR. (3) The all important element of eye movements was found to be completely unimportant. The fourth question (whether evidence exists of specificity of treatment effects to disorders) was addressed, but unconvincingly given the number of studies and the way in which the analysis is conducted (in 4 categories rather than by specific disorder). If eye movements are not relevant to EMDR, then what remains is desensitisation and reprocessing—that is, CBT. EMDR has been assiduously marketed as a novel and effective treatment.

This meta-analysis, which is notable for the care with which it seeks to address the likely critique of those who advocate EMDR, firmly establishes that what is novel is not effective, and what is effective is not novel. Clinicians may wish to consider that the impressive paraphernalia of treatments such as EMDR is not, in the long run, a substitute for rapidly developing empirically grounded clinical interventions.[3]

[1] McNally RJ. EMDR and Mesmerism: a comparative historical analysis. J Anxiety Disord 1999;13:225–36.

[2] Rosen GM, Lohr JM, McNally RJ, et al. Power therapies, miraculous claims, and the cures that fail. Behavioural and Cognitive Psychotherapy 1998;26:99–101.

[3] Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther 2000;38:319–45.

Commentary on Evid Based Mental Health 2002;5:13 doi:10.1136/ebmh.5.1.13 by Paul Salkovskis, MPhil, PhD, C Clin Psychol, FBPsS

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    These are old articles and quite out of date. McNally, in particular, was almost vituperative about EMDR prior to numerous studies, reviews and official endorsements that rate it the equal of prolonged exposure therapy as a first-line treatment for PTSD. He really has egg on his face now, but has not spoken up publicly since being proven wrong. Also, recent reviews have supported the efficacy of eye movements in EMDR. See my response below for details. – David Lewis Dec 22 '13 at 5:40
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Summary

EMDR is one of only two systems widely endorsed as highly effective, first-line therapies for PTSD, the other being TFCBT (prolonged exposure). As such, EMDR is superior to all other researched systems than TFCBT, to which it is roughly equal.

That said, EMDR is demonstrably gentler than TFCBT, requiring much less painful exposure to distressing traumatic material. It is therefore less prone to dropout. EMDR is also probably faster than TFCBT. There is some research and widespread anecdotal evidence for EMDR's relatively low drop-out rate and speed.

As for eye movements, the latest meta-studies and reviews judge EMDR's eye movements to be essential to its effectiveness and theoretically justified. There is much more to EMDR than eye movements, however, and the eye movement component arguably acts as a catalyst that makes the entire system faster and more effective.

Full answer

First, in answering questions about EMDR, it's best not to rely on meta-studies and reviews prior to about 2003, since a lot happened after that to change the scientific view of EMDR, all in the positive direction. Even an important 2007-8 report is now out of date (see below).

Next, you are correct to say that eye movements or other bilateral stimulation (BLS) techniques are an aspect of EMDR. There is indeed much more to EMDR than BLS. (See Hyer & Brandsma, 1997; Rozelle & Lewis, 2014). But for that reason you cannot compare eye movements to other therapies -- that is compare a technique that is a part of a therapy to other complete therapies -- it is an ill-formed question.

Therefore, I assume you are really asking one or both of two related questions: (a) Is EMDR as effective (or more effective) than other therapies? (b) how important to EMDR's effect is BLS? Both these questions are addressed in the scientific literature.

The answer to (a) is well-established by numerous studies and judgments of professional bodies such as the International Society for Traumatic Stress Studies (ISTSS, the major international professional society concerned with PTSD) and national bodies in many countries (for example, the US Veterans Administration) -- EMDR is one of two highly recommended, first-line therapies for PTSD, the other being what's called trauma-focused (or exposure-based) cognitive-behavioral therapy (TFCBT) of which there are several forms. And between EMDR and TFCBT, neither is preferred based on the evidence. See Spates, etal (2010), pp. 279-301 for a summary of the evidence on EMDR published by the ISTSS, bearing in mind that the section on the efficacy of eye movements is out of date (see below). But on EMDR as a whole, this ISTSS report says "Based an on this review of seven new controlled efficacy/effectiveness studies of EMDR and seven new meta-analytic investigations of this technique, we assigned EMDR for treatment of adult PTSD and AHCPR rating of Level A." and that it is "equally effective as exposure-based therapies" (p. 298). In fact, "recent investigations... suggest the possibility that the dosed exposure, along with postexposure 'mindfulness' features comprising EMDR, might confer advantages over conventional prolonged exposure to trauma memories. However, this hypothesis requires substantially more research to test its validity." (p. 300)

As an example, Nijdam, etal (2012), a recent rigorous study with high n (140), concluded "EMDR and brief eclectic psychotherapy [BEPP, a form of TFCBT] had equal effects in terms of reduction of self-reported and clinician-rated PTSD symptoms, depressive symptoms and general anxiety symptoms when statistically controlling for pre-treatment differences. Across all outcomes, the response pattern was significantly different for EMDR and brief eclectic psychotherapy when accounting for baseline differences, indicating that EMDR led to faster symptom decline and brief eclectic psychotherapy to more gradual improvement." Not only was this an exceptionally rigorous and large study with controls against bias, it was conducted by the group at the University of Amsterdam that developed BEPP. So if there is any bias it would have gone against EMDR! This study is openly available at http://bjp.rcpsych.org/content/200/3/224.long. By the way, in this study EMDR worked approximately twice as fast as BEPP.

The only significant dissenting body is the US Institute of Medicine (IOM). IOM's 2007-8 report did not cast any explicit doubt on EMDR's efficacy, but simply excluded it from the top rank because it did not have enough studies that met the topmost criterion for rigor. But that extremely high bar for studies did not bother the other bodies, particularly ISTSS. Also, there are quite a few more studies on EMDR since the IOM's report, all positive. For a detailed discussion of the controversies surrounding all the institutional assessments of EMDR, see Forbes, etal (2010), pp. 550-551.

As for (b), the latest meta-study on the contribution of eye movements to EMDR's effect is Lee & Cuijpers (2012). They found (p. 231) "The effect size for the additive effect of eye movements in EMDR treatment studies was moderate and significant (Cohen’s d = 0.41). For the ... laboratory studies the effect size was large and significant (d = 0.74)." They also found methodological flaws in two major earlier meta-studies on eye movements, Davidson & Parker (2001) and Devilly (2002), and updated them with the considerable subsequent research.

Jeffries & Davis (2013) reviewed the literature on eye movements in EMDR and concluded "the results suggest support for the contention that EMs are essential to this therapy and that a theoretical rationale exists for their use. Choice of EMDR over trauma-focused CBT should therefore remain a matter of patient choice and clinician expertise; it is suggested, however, that EMs may be more effective at reducing distress, and thereby allow other components of treatment to take place."

One interpretation (in Rozelle & Lewis, 2014 forthcoming) of the recent results on eye movements in EMDR is that BLS is actually a kind of catalyst that enhances the actual core process of EMDR, that being information processing via mostly silent free association (Solomon & Shapiro, 2008, p. 321). Thus EMDR can indeed work without BLS, but it works better, often much better with BLS. In practice, however, there is no reason not to use BLS when doing EMDR -- it does help, sometimes a lot, and has not, to my knowledge, been shown to have any problematic side-effects.

Some last thoughts. EMDR is still held in low esteem by some academics, mainly because its early claims for efficacy seemed excessive and early research was not very rigorous. Both of these are now put to rest, but academics, like everybody, hate to admit their mistakes in public, especially when their earlier assertions were so strongly worded, and some even vituperative. Also, in those days waving fingers in front of a client's face seemed, on the face of it (pun intended) to be just too weird to be respectable -- not a terribly scientific opinion, but it carried a lot of emotional weight. Now that various forms of meditation have gained significant currency in psychotherapy, however, especially Kabat-Zinn's Buddhist-inspired mindfulness techniques, perhaps it's time to rethink the weirdness objection to BLS. How much weirder, after all, is attending to a therapist's fingers going back and forth than attending to your own breath going in and out?! (In fact, there may well be a relationship between those two techniques.) To tell the truth, nobody really yet understands in a scientific reductionist sense, why or how either works (not to mention any psychotherapy system)... but they do!

References:

Davidson, P. R., & Parker, K. . C. (2001). Eye Movement Desensitization and Reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69(2), 305–316.

Devilly, G. J. (2002). Eye movement desensitization and reprocessing: a chronology of its development and scientific standing.The ScientificReview of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 1(2), 113-138.

Forbes, D., Creamer, M., Bisson, J. I., Cohen, J. A., Crow, B. E., Foa, E. B., Friedman, M. J., Keane, T. M., Kudler, H. S. and Ursano, R. J. (2010), A guide to guidelines for the treatment of PTSD and related conditions. J. Traum. Stress, 23: 537–552. doi: 10.1002/jts.20565

Hyer, L., & Brandsma, J. M. (1997). EMDR minus eye movements equals good psychotherapy. Journal of Traumatic Stress, 10(3), 515–22.

Fiona W. Jeffries, Fiona W. & Davis, Paul (2013). What is the Role of Eye Movements in Eye Movement Desensitization and Reprocessing (EMDR) for Post-Traumatic Stress Disorder (PTSD)? A Review. Behavioural and Cognitive Psychotherapy, 41, pp 290-300. doi:10.1017/S1352465812000793.

Lee, C. W., & Cuijpers, P. (2012). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44(2), 231–239. doi:10.1016/j.jbtep.2012.11.001

Nijdam MJ, Gersons BP, Reitsma JB, de Jongh A, Olff (2012). Brief eclectic psychotherapy v. eye movement desensitisation and reprocessing therapy for post-traumatic stress disorder: randomised controlled trial. British Journal of Psychiatry, 2012 Mar;200(3):224-31. doi: 10.1192/bjp.bp.111.099234. Epub 2012 Feb 9.

Rozelle, D. & Lewis, D (forthcoming in 2014). What can Buddhism and EMDR tell us about treating PTSD? In V. Follette, J. Briere, D. Rozelle, J. Hopper, & D. Rome (Eds.), Contemplative practices in trauma treatment: Mindfulness and other approaches. Guilford Press, forthcoming 2014.

Solomon, R. M., & Shapiro, F. (2008). EMDR and the adaptive information processing model: Potential mechanisms of change. Journal of EMDR Practice and Research, 2(4), 315–325. doi:10.1891/1933-3196.2.4.315

Spates, C. R., Koch, E., Cusack, K., Pagoto, S., & Waller, S. (2010). Eye movement desentization and reprocessing. In E. B. Foa, M. Keane, Terence, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 279–305). Guilford Press.

  • Can you add some links or direct quotes from the worked cited? – rjzii Dec 21 '13 at 1:51
  • @rob -- Did that. Enough? – David Lewis Dec 21 '13 at 2:41
  • Your answer to the question asked seems to have got lost in your volume of text, but I think it boils down to: "No, EMDR therapy is not more effective than other available therapies for treating trauma survivors". Is that correct? – EnergyNumbers Dec 21 '13 at 11:31
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    I've taken the liberty of including your summary in the answer. – Sklivvz Dec 22 '13 at 15:24
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    @DavidBrenner -- sorry for the long lapse -- got pulled away and forgot about this. The best reference for your question is the Lee & Cuijpers 2012 meta-study cited above. It shows medium effect size for eye movements in actual therapy -- hence sometimes much better. There's also some anecdotal evidence from professional psychologists who actually try EMDR on themselves that the eye movements lead to remarkable results in specific cases. – David Lewis Nov 6 '14 at 0:02
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EMDR has a lower drop-out rate in PTSD than the other two evidence-based treatments recommended by ISTSS. Unlike Cognitive Behavior Therapy (CBT), there's no homework. Unlike Prolonged Exposure Therapy (PE), one is not forced to relive the horrors of bad events without relief. There is excellent research now proving EMDR's efficacy and it is considered one of the three treatments of choice for trauma (along with CBT and PE) by organizations such as ISTSS (International Society for the Study of Trauma and Dissociation), American Psychiatric Assoc, American Psychological Assoc, Dept of Veteran Affairs, Dept of Defense, Departments of Health in Northern Ireland, UK, Israel, the Netherlands, France, and other countries and organizations. EMDR is a treatment approach which has been empirically validated in over 24 randomized studies of trauma victims. An additional 24 studies have demonstrated positive effects for the eye movement component used in EMDR therapy. For further information, please see the cited research http://www.emdr.com/index.php?option=com_content&view=article&id=12&Itemid=18

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    Hi, Patti, welcome to Skeptics. Can you directly cite some of the research in this answer, to prevent linkrot? – Sam I Am Feb 4 '13 at 16:53
  • Additionally, can you please cite literature that directly speaks to the effectiveness of the eye-movement aspects of EMDR? – David Brenner Feb 8 '13 at 1:16
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    @DavidBrenner It's worth bearing in mind that the EMDR Institute does have a commercial stake here? Even so, its own catalogue of the evidence is much more ambivalent than summarised above. – EnergyNumbers Feb 8 '13 at 7:06
  • Here's an April 2013 study on eye movements -- ncbi.nlm.nih.gov/pubmed/23485024. From the abstract: The simple act of repeatedly looking left and right can enhance subsequent cognition, including divergent thinking, detection of matching letters from visual arrays, and memory retrieval....The primary finding was that saccade [eye movement] execution increased the subsequent operation of the executive function network, which encompasses attentional control....the study establishes attentional enhancement as a potential mechanism by which saccades enhance other aspects of cognition. – David Lewis Dec 28 '13 at 1:40

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