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PTSD and Evidence-Based Practices

EMDR

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EMDR
Additional Information

EYE MOVEMENT DESENSITIZATION AND REPROCESSING

(EMDR)

 

  • EMDR was discovered by Francine Shapiro, Ph.D.,  in 1987.  While taking a walk in the park, she noticed that recurring and disturbing thoughts were unexpectedly resolved by rapidly moving her eyes from side to side.  This led to the development of EMDR.  

 

  • EMDR is a psychotherapy that was originally designed to alleviate the distress associated with traumatic memories.  

 

  • EMDR facilitates the accessing and processing of traumatic memories to bring them to an adaptive resolution.

 

  • EMDR is a complex multicomponent and multistaged process that integrates elements of many traditional psychological orientations into a comprehensive treatment protocol. 

 

  • EMDR is a dual stimulus intervention.

 

  • EMDR contains many effective components which are thought to contribute to treatment outcome.

 

There are 5 Treatment Elements of EMDR:   

 

  1. The client simultaneously focuses on the image of the traumatic event, the associated negative belief and the intended physical sensations may serve to forge initial connections among various elements of the traumatic memory, initiating information processing.

 

  1. Mindfulness is encouraged by instructing clients to “just notice” and let what ever happens, happens.

 

  1. During processing, clients are asked to report on any new insights, associations, images, emotions, and sensations that emerge into consciousness.  This may create associative links between the original targeted trauma and   other related experiences and information contributing to the processing of traumatic material.

 

  1. The brief exposure of EMDR provides clients with repeated practice with controlling and dismissing disturbing internal stimuli.  This can provide clients with a sense of mastery, contributing to treatment effects by their ability to reduce or manage negative interpretations.

 

  1. Eye movements and other dual attention stimuli.

 

Even though each client is unique, there is a standard 8 phase approach that clinicians should follow which will result in high treatment fidelity:

 

  1. The clinician takes a complete history, assesses the client for suitability for EMDR and develops a treatment plan.   
  2. The clinician prepares the client by educating them and, teaching the client self-control techniques and effective management skills.  This phase may take several sessions and includes the development of resources and client strengths and the establishment of client safety and stabilization.  
  3. The client identifies the target and chooses the most distressing visual image connected with the event.  The client then identifies the emotions that are elicited when the visual image is combined with the negative belief.  The client then identifies and locates the body sensations accompanying the emotions.  
  4. This is the desensitization phase where the client focuses on the visual image, the identified negative belief, emotions, and body sensations, while experiencing bilateral stimulation in sequential doses.  The client holds these elements in mind while simultaneously moving their eyes from side-to-side for 15 seconds or more following the clinician’s fingers while they move across the visual field.  Hand tapping or oral stimulation can replace the eye movements.  After this set of eye movement desensitization, the client is asked what material was elicited in the process.  This material then becomes the target of the next set of eye movements.         
  5. The clinician asks the client to pair the identified or emergent positive self-statement with the original traumatic image using bilateral stimulation.  
  6. While thinking of the image and the positive cognition, the clinician asks the client to notice if there is any tension or unusual sensations in their body.  Since emotional distress is often experience physiologically, processing is not considered complete until the client is able to bring the traumatic memory into consciousness without feeling any body tension.  If the client experiences body sensations, eye movements are repeated until the tension is relieved.  
  7. This is the closure phase where the clinician assesses that the material has been adequately worked through.  If not, the clinician assists the client with self-calming interventions.
  8. On-going reevaluation assists the clinician in continuing to direct the treatment to achieve maximum benefit for the client.

 

  • A new form of therapy usually becomes established in 3 stages:  clinical innovation, followed by scientific validation and then dissemination to practitioners and the public.  EMDR skipped the first stage and went to the third stage.  EMDR has never been scientifically validated.
  • Goals of EMDR

     

    • EMDR has been found to reduce PTSD symptoms.

     

    • It was also found to be faster in terms of reduction in these symptoms.

     

    • It was also better tolerated by study participants.

     

    • It has also been found to be an efficacious treatment for civilian PTSD.

     

    • After the use of EMDR, the traumatic event loses its negative charge and no longer maintains its destructive hold.

     

    • This event becomes another event in the history of the survivor’s life.

     

    • Progress of this intervention is typically tracked by other research studies.

    Supporting Evidence

     

    Ironson, G., et al, 2002

     

    • SAMPLE – 22 individuals who experienced a single trauma, past spousal abuse or who were adult survivors of sexual abuse without dissociation.  Ages ranged from 16 – 62; 9 in their 20s; 5 in their 30s; 4 in their 40s; 2 younger than 20 and 2 older than 50.  17 were women and 5 were men.  Diverse races INCLUDED:  Caucasians, African-Americans, Caribbean Blacks, Hispanics and 1 Syrian individual.
    • INTERVENTION –Session 1 consisted of informed consent, a discussion of confidentiality, clinical intake measures and baseline assessment measures.  Session 2 and 3 included a discussion of reactions to trauma and a development of an in vivo list used to structure in vivo homework. These sessions also included a breathing exercise and a taped relaxation exercise.  In session 4, 5 and 6, participants received active treatments either EMDR or Prolonged Exposure (PE) and a session at a 3-month follow-up.
    • RESEARCH DESIGN – RCT
    • MEASURES - PTSD Symptom Scale (PSS-SR), a self-report measure of post-traumatic symptoms corresponding with the criteria from the DSM III-R, Beck Depression Inventory, The Dissociative Experience Scale (DES) and Subjective Units of Distress Scale (SUDS).
    • RESULTS – Both EMDR and PE were effective in reducing symptoms of PTSD and depression.  EMDR was better tolerated based on the drop out rates.  Only 1 of the 10 EMDR participants dropped out during an active session.  In the PE group, 6 of the 12 participants dropped out; 3 between session 1 and 3, and 3 between sessions 4 and 6.  After the first active session, distressed levels as measured by SUDS were lower with EMDR than PE. 

     

    Lee, C., et al., 2003

     

    • SAMPLE - Participants were recruited from a clinical psychology section of a large general hospital, the psychology department of a government defense service or a sexual assault referral center.  This study consisted of 24 participants; 13 males and 11 females.  Twelve participants were given EMDR and 12 were given Stress Inoculation training and Prolonged Exposure (SITPE).  The participants were assigned in alternate order.  The first participant was assigned via a coin toss.   
    • INTERVENTION - One group received EMDR and the other group received SITPE.  The participants were their own wait list.  Each treatment program involved 7 90-minute sessions on a weekly basis. 
    • RESEARCH DESIGN – RCT
    • MEASURES - Structured interview for PTSD, PTSD-SR, Hamilton Depression Scale and the Hamilton Anxiety Scale.  Subjective measures were supplemented by a set of standardized objective measures.  These included: Keane' PTSD Scale, Impact of Event Scale and the Beck Depression Inventory.
    • RESULTS - The groups appear to be equivalent on major variables.  Also, there were no significant differences between groups on any of the global measures immediately after treatment.      

    Power, K., Et al., 2002

     

    • SAMPLE –Participants were referred by general practitioners and psychiatrists in central Scotland.  These participants were between the ages of 18-65 and were randomly allocated as follows:  39 in the EMDR group; 37 in the Exposure (E) + Cognitive Restructuring (CR), and 29 in the waitlist (WL) group. Drop out rates consisted of 12 (31%) EMDR, 16 (43%) E_CR and 5 (16%) WL.
    • INTERVENTION - EMDR, E, CR and WL. Ten 90-minute sessions on a weekly basis.  Participants in the EMDR and E_CR group were assessed at the midpoint, end of treatment and on average a 15-month follow-up.  
    • RESEARCH DESIGN – RCT
    • MEASURES – Clinician Administered PTSD Scale; the Impact of Event Scale and a Self-Report of the SI PTSD Checklist. For depression and Anxiety , Montgomery Asberg Rating Scale,  the Hamilton Anxiety Scale and the Hospital Depression and Anxiety Scale. 
    • RESULTS – EMDR and E+CR are effective treatments for PTSD.

     

    Taylor, S., et al., 2003

     

    • SAMPLE - 60 participants entered treatment and 45 completed treatment.  75% were women and 77% were White. 97% of the 60 participants had chronic PTSD.
    • INTERVENTION - Participants were randomized to 8 90 minute individual sessions of EMDR, Exposure therapy or Relaxation training. Detailed treatment manuals for each treatment were used. 
    • MEASURES - DSM IV-TR criteria for PTSD, Clinician Administered PTSD Scales, Self-Report questionnaires, from the PTSD Severity Scale, and Beck Depression Inventory.     
    • RESULTS - All 3 treatments were associated with reductions in PTSD symptoms. These treatments were also efficacious to various degree in reducing PTSD.  PTSD treatments were associated with reductions in depression.

    Level of Evidence

     

    • The level of evidence for this intervention is B.  The studies are well designed but have an absence of placebo groups.  When informed consent is given then randomization takes place.

     Additional Research

     

    • There needs to be additional studies investigating EMDR.

     

    • Research is needed to investigate whether the use of EMDR sustains the effect of client factors. 

     

    • There needs to be more research studies done using placebo groups.

     

    • A measure of treatment fidelity needs to be developed with good inter-rater reliability. 

     

    • To date there has been no research done on EMDR and individuals with schizophrenia, bipolar or other serious and persistent mental illnesses. 

    Amber Hursh, Justin Reimenschneider, Justine Tedesco
    RSSW 705 Evidence-Based Practice in Mental Health
    Dr. Zvi Gellis, SUNY Albany, Rockefeller College of Social Work