Dawn Beazer

Critical Examination of Efficacy of Counselling Intervention A critical look at EMDR (eye movement desensitization and reprocessing) By Dawn Beazer adamlld00@uleth.ca

For Professor Blythe Shepard CAAP 6615: Counselling Strategies and Interventions Master of Counselling Program University of Lethbridge

Assignment Due Date: June 8, 2011 Assignment Submitted: June 8, 2011

Dawn Beazer

A critical look at EMDR (eye movement desensitization and reprocessing) Before I began the Master of Counselling course at the University of Lethbridge, I had an interest in EMDR. In fact, during my interview for the program, I expressed my interest in this counselling intervention. I was told that I would not receive training in this particular intervention. Therefore, over the different courses thus far, I have looked for opportunities to explore this technique. This semester, I was able to review a few websites and research focusing on EMDR. I found one website in particular very informative: http://www.emdr.com. It was developed by the EMDR Institute, Inc. which was founded by Francine Shapiro and contains information on EMDR, research, training, and the client experience. I have been encouraged with the overall impressions I have had about EMDR regarding efficacy and drastically increased treatment time. However, I decided that I should take a deeper and more critical look at these claims. The purpose of this paper will be to examine what EMDR is, to review recent research on EMDR, its efficacy, any contraindications, and to conclude with my impressions of this counselling intervention based on the research. EMDR is used for treating chronic post traumatic stress disorder (PTSD) and old trauma memories (Shapiro, 2009) EMDR is a therapy focusing on information processing and contains elements of various effective psychotherapies including psychodynamic, cognitive, behavioural, interpersonal, experiential, and body-centered therapies. EMDR uses eight phases, attending to past experiences contributing to pathology, current situations triggering dysfunctional emotions, beliefs and sensations, and positive experiences enabling future adaptive behaviour and mental health. During treatment, structured procedures and protocols are followed. A critical procedure is dual stimulation which involves using bilateral eye movements, tones, or taps. Prior to each set, the clinician draws the clients attention to appropriate material. During the reprocessing phase, the client focuses momentarily on past experience, current triggers, or anticipated future events while attending to the external

Dawn Beazer

stimulation. Insight, changes in memory, or new associations are usually experienced at this time. (EMDR Insitute, Inc.) EMDR includes eight phases. The first phase includes history taking, assessment of readiness for EMDR and developing a treatment plan. Together the client and therapist identify potential targets for EMDR processing. During the second phase, the therapist determines whether the client is in an adequately stable state, has appropriate methods of dealing with emotional distress and good coping skills. In phases three to six, an identified target, such as a vivid visual image related to traumatic memory or a negative belief about self is processed using EMDR. Additionally the client reports a positive self belief. The client rates the validity of the positive belief and the intensity of negative emotions. Next, the therapist directs the client to focus on the image or negative thought, and body sensations while simultaneously providing bilateral stimulation (such as eye movement, auditory tones, or tapping) for 20-30 seconds or more, depending on client need. The client is to simply notice what happens, then to let their mind go blank and notice any though, feeling, image, memory, or sensation comes up. Then a new client-directed focus is chosen and the process repeated numerous times over the session. Once the client reports no distress related to the target, the therapist directs the client to focus on the positive belief and the target simultaneously while also experiencing bi-lateral stimulation. Eventually clients will usually report increased confidence in the positive belief. If the client experiences negative body sensations, these are also processed the same way. Finally, phases seven and eight involve closure and processing. History of the research done on EMDR is divided into three phases. First, demonstrating the effectiveness of EMDR in treating PTSD. Second, demonstrating the effectiveness of EMDR compared to other trauma-focused interventions for PTSD. Third, focusing on understanding EMDRs underlying mechanisms. In the first phase, strong evidence demonstrated that EMDR was consistently superior to

Dawn Beazer

wait-list or delayed treatment controls. In the second phase, four randomized controlled trials evaluated the effectiveness of EMDR compared to nonspecific therapies for PTSD, finding that EMDR was consistently the more effective treatment. Compared to other exposure-based therapies, EMDR was equally effective with greater efficiency and quicker reduction of symptoms with fewer required sessions. (Schubert & Lee, 2009) Currently, the third phase of research is focusing on understanding underlying mechanisms of EMDR. The role of eye movements is the focus of controversy with critics arguing that they are unnecessary to the treatment. Presently more research is required to determine whether eye movements enhance the processing of memories leading to physiological dearousal, or whether the physiological effects of the eye movements facilitate the processing of memories. At this point, there is no empirically supported model capable of explaining precisely the underlying mechanisms of EMDR. (Gunter & Bodner, 2009, Shubert & Lee, 2009) In further studies, EMDR has been found to have established efficacy in 16 published controlled, randomized studies when compared to antidepressant medication, cognitive behavioural therapies, and other treatment methods. EMDR is comparable to other effective treatments such as exposure therapy, in reducing symptomatology of PTSD. When EMDR is integrated into phase-orientated treatment of trauma the two approaches are found highly complementary in regard to their strengths and weaknesses. Additionally, the rates of dropout with EMDR are considerably low across studies, and lower than the rates reported for exposure therapy. A noted benefit of EMDR is the level of control that clients have over their treatment and the exposure is experienced in small increments rather than a prolonged style as in exposure therapy. (Korn, 2009) EMDR has received the highest category of effectiveness for treatment of PTSD with several independent bodies. The International Society of Stress Studies ranked EMDR as a level A, evidence-

Dawn Beazer

based treatment. The American Psychiatric Association and the U.S. Department of Veterans Affairs and Department of Defence rated EMDR in the highest category of research and support. The U.K. National Institute for Clinical Excellence and the Australian Centre for Post-traumatic Mental Health acknowledge EMDR as an evidence-based treatment for PTSD. (Schubert & Lee, 2009) In other studies, concerns are raised. In one study, it was found that with eight sessions of EMDR, individuals with childhood trauma history had less promising results than those with adult onset. PTDS diagnosis was lost in 100% of adult-onset participants post-treatment, compared to 75% of the child-onset participants. I was concluded that early trauma onset predicted poorer end state functioning, and that eight weeks of therapy was not sufficient to resolving long standing trauma. In another study, mixed results were found and conclusions were made that for combat PTSD, increasing the number of sessions resulted in significantly more positive outcomes. (Korn, 2009) One case study found that a good therapeutic relationship prior to engaging in EMDR was possibly a key factor to the success of EMDR. Another study found that the symptoms of PTSD do not improve until the point that trauma-focused exposure work is introduced. (Korn, 2009) Based on research reviewed I feel very confident in the efficacy of EMDR. However, I am cautioned in particular elements of its use. As Korn (2009) found that results were less promising in individuals with child-onset trauma, I would be hesitant to use EMDR with this client base, and more likely to use it with adult-onset trauma. As it was also suggested that more sessions resulted in better results, I would ensure that I did not stick to eight sessions as a general rule, and would consider extending treatment to 12 or more sessions as needed by individual clients. Additionally, I would introduce EMDR after trauma focused exposure, as suggested by Korn (2009). Through an examination of Korns research, I was particularly interested in the finding that a good therapeutic relationship prior to initiating EMDR was important. I highly value the therapeutic alliance and this makes sense to me. If I

Dawn Beazer

am ever to receive proper training with EMDR and be given the opportunity to use it with clients, ensuring a strong therapeutic relationship before engaging in EMDR will be one of my main goals. Overall, the research and evidence of EMDRs efficacy is very strong and promising. Of the concerns raised, I believe that they are ones that can be managed while providing a client with a highly efficacious and efficient treatment experience. Based on research, the many benefits of EMDR far outweigh the limited number of criticisms. It is my hope that I will eventually be able to receive training in EMDR for work with clients enduring PTSD. I feel confident in my review of research, which confirms my original impressions that EMDR is both efficacious and does decrease treatment time. If there is a drawback to my research, it would be that all of my articles came from the same journal. I did not notice this until after I had begun reading them. I would feel more confident in the research findings if they had come from a variety of sources.

Dawn Beazer

References EMDR Institute, Inc. (2011). What is EMDR?. Watsonville, CA: EMDR Institute, Inc. Retrieved from: http://www.emdr.com Gunter, R.W. & Bodner, G.E. (2009).EMDR works...but how? Recent progress in the search for treatment mechanisms. Journal of EMDR Practice and Research, 3, 161-168. doi: 10.1891/19333196.3.3.161 Korn, D.L. (2009). EMDR and the treatment of complex PTSD: A review. Journal of EMDR Practice and Research, 3, 264-278. doi: 10.1891/1933-3196.3.4.264 Schubert, S. & Lee, C.W. (2009). Adult PTSD and its treatment with EMDR: A review of controversies, evidence, and theoretical knowledge. Journal of EMDR Practice and Research, 3, 117-132. doi: 10.1891/1933-3196.3.3.117 Shapiro, E. (2009). EMDR treatment of recent trauma. Journal of EMDR Practice and Research, 3, 141-151. doi: 10.1891/1933-3196.3.3.141