Eye movement desensitization and reprocessing (EMDR) has fascinated the public and polarized the mental health community for years. Perhaps it’s the unusual bi-lateral stimulation that’s fundamental to its protocol, or the claims of rapid and dramatic relief of client symptoms that have caused this psychotherapy method to be a lightning rod for controversy and skepticism since its inception more than two decades ago.
However, as the years pass, the research builds, and the number of clients experiencing relief from a variety of trauma-based disorders grows, EMDR’s critics and skeptics are falling to the wayside. Today, tens of thousands of highly trained clinicians are practicing EMDR around the world, and it is being found effective for an increasing number of conditions which have trauma as an underlying contributor.
California Southern University sat down with two of EMDR’s leading expert practitioners—Susan Brown, LCSW, BCD and Sara Gilman, MFT—to learn more about this intriguing and highly effective psychotherapy method.
CalSouthern: For those who aren’t familiar with the history of EMDR, who is credited with originating this psychotherapy method and when was it developed?
Sara Gilman: In 1987, Dr. Francine Shapiro developed the beginnings of what we now know as EMDR. After receiving some disturbing news that was emotionally upsetting to her, she went out for a walk. While walking and gazing from side to side, she noticed, as she moved her eyes, a change in the emotional charge that she was feeling. From there, she began experimenting with this phenomenon with colleagues. She wondered if she had stumbled upon a way to activate the brain’s processing system and began to find similar results with other people, as well. Those were the very beginnings, affectionately referred to in the EMDR community as “The Walk in the Park.”
CalSouthern: Was EMDR accepted and put into practice relatively quickly?
Gilman: Not at all. While we are now in EMDR’s 24th year and there are more than 60,000 trained clinicians in 45 countries worldwide, it’s been a very long journey of gaining credibility and gathering research.
CalSouthern: What is it about EMDR that creates skepticism? Is that even a fair question?
Susan Brown: EMDR has met with skepticism and generated controversy since its inception. I think it has to do with the use of bilateral eye movements, taps, or tones, which are rather odd components of a treatment approach. It looks unconventional (to say the least) to those unfamiliar with the therapy. It was a paradigm-shifting experience to have a structured protocol with these unusual aspects to it along with pretty fantastic claims being made about its effectiveness; it garnered quite a bit of negative attention from the onset—and skepticism.
I had been a therapist for 15 years before I was trained in EMDR and had to be dragged to the training because I thought it looked ridiculous. Fortunately, a respected colleague mentioned that it was not like me to be so closed-minded and that I needed to learn more about this extremely effective treatment.
CalSouthern: If EMDR was initially met with skepticism, what were some of the factors that eventually led to its broad acceptance?
Gilman: There was such significant and efficient relief of client symptoms that those of us who were trained in the early years of EMDR—before the research was completed—were very excited and moved forward with it despite the criticism of the treatment.
Brown: It’s true; our excitement about results we were seeing in our clinical practices transcended our initial skepticism.
Also, some very prominent individuals in the trauma field, for example Bessel van der Kolk and Daniel Siegel, were trained in EMDR early on and quickly became some of its most vocal and public proponents. Robert Stickgold, a renowned sleep researcher from Harvard, also became very involved in EMDR, speculating that there might be a connection between the induced eye movements used in EMDR and REM sleep as a mechanism of action for the effectiveness of the therapy.
These people—and others like them—were so universally respected, that when they came on board, it gave EMDR an enormous boost in its credibility and research base.
CalSouthern: Could you give a brief description of how the treatment is administered?
Brown: EMDR’s protocol is comprised of eight phases and three prongs. Phases one and two are focused on history-taking, assessment, treatment planning, and stabilization The trauma reprocessing phases (which is what most people have in mind when they refer to EMDR) occurs in phases three through six, with phases seven and eight being closure and re-evaluation of a session.
EMDR is based on the “Adaptive Information Processing” model, described by Francine Shapiro. The theory is that earlier, undigested traumatic experiences (both major traumas like physical, emotional, and sexual abuse as well as the more ubiquitous disturbing life experiences such as divorce, bullying, death of a loved one, etc.) form the basis of present-day symptoms such as PTSD, depression, panic disorder, substance and behavioral addictions, and other trauma-based disorders. The theory predicts that once the earlier traumatic contributors are “desensitized and reprocessed” (the “DR” in EMDR), the current symptoms will diminish or resolve. Then, desired, more positive and adaptive thoughts, feelings, and behaviors are rehearsed and deepened with bilateral stimulation sets. These three “prongs” form the backbone of case conceptualization in EMDR, guide treatment and predict treatment outcomes.
After history and assessment are completed, the therapist and client collaboratively determine the target to be worked on for that session. (There’s a sequential plan for targeting upsetting material, assuming it’s not a single incident.) During the session, the client is asked to identify the most distressing part of the memory or issue, along with an irrational, negative self-referencing belief that the client currently associates with it. (This is a belief that the client knows intellectually is not true, but which feels true anyway, at a gut level.)
Then the client identifies a more positive, adaptive, and true belief that they would prefer to hold in relationship to that memory (one that even though they know it intellectually to be true, it does not feel so, again at the gut level.)
The client is then asked to rate how true the more adaptive belief feels as they currently hold the memory in mind. They’re also asked to identify the emotions they feel at that moment, and to rate the degree of distress they feel. Finally, they are asked to identify where in their body they feel that distress.
So, for example, a military veteran might be processing a combat experience where a buddy was killed and he was spared. The worst part of the memory might be seeing his friend blown up in front of him. The negative belief could be something like, “I should have done something.” The more adaptive belief might be, “I did the best I could; there things that occur in combat that are beyond one’s control.” The emotions might include guilt, shame, anxiety, or sadness. Body sensations could include chest tightening and nausea or twisting in the gut.
Once the target has been identified and set up to reprocess, as described above, bi-lateral (side-to-side) stimulation sets are initiated: eye movements, tapping, or tones. The client is then asked to mindfully “just notice” what happens as the sets progress. Between the sets, the client briefly reports to the therapist what they are experiencing at that moment.
The therapist doesn’t interfere with or interpret what is happening organically with the client’s process. That’s not our job. This is one component of EMDR that differentiates it from other therapies. The counselor simply facilitates the process to ensure client safety and to progress into more adaptive, positive territory. We only assist if the client’s natural processing gets stuck or blocked in some way. It’s essentially a client-centered experience where they client’s own brain is presumed to be intrinsically capable of healing itself and is doing all the work.
CalSouthern: Once the bi-lateral stimulation begins, what is happening? Are you leading or initiating a conversation about the traumatic event?
Brown: No. As one of our colleagues often says, “If your hand is moving, your mouth is not.”
During the bi-lateral stimulation, the client has been asked to drop into their internal landscape and simply notice what thoughts, feeling, images, or body sensations come up. If we were to stop and talk about this in any length, as we do in traditional talk therapies, the client would likely fall out of their own processing.
Gilman: I like to call EMDR a “whole-brain & whole body therapy”; it simultaneously works with different parts of the brain, and the brain’s connection to the body’s memory. We store memory in different parts of our minds and in our bodies, (the gut actually has memory neurons, and your heart even has muscle memory). EMDR therapy appears to activate the natural healing process and reprocesses the memories at every level.
As a therapist, it’s fascinating to move your hand to direct the eye movements and watch the innate wisdom of your client’s mind and body as they process where the memory needs to go.
CalSouthern: I understand there’s no consensus as to why EMDR works. Do you endorse or favor a particular theory?
Gilman: As a clinician who has observed thousands of hours of EMDR therapy, it seems to me that it replicates rapid eye movement sleep in a waking state. We’ve seen brain scans before and after EMDR and know that there are changes in the brain that occur. It’s almost as though we’re “jump-starting” the brain’s organic healing process. Sometimes information gets stuck or frozen in the nervous system. Once the information is activated and can move and re-file itself, it results in a more adaptive state of the brain with more adaptive functioning, thinking, and behavior in everyday life. The more neuroscientists learn about our information processing system and memory storage, the more this seems plausible.
Brown: I also think it’s important to stress that no one really knows how any psychotherapy works. It’s funny how EMDR has been singled out for this criticism—that if we can’t figure out why it works, it must be bogus.
Sara mentioned the REM sleep hypothesis. There are others, too, including the working-memory hypothesis. While I am not an expert in neurobiology, my basic understanding of this hypothesis is that when you undergo EMDR with eye movements, you are setting the brain up to focus on two things at the same time: the distressing memory and the bi-lateral eye movements. This divides the attention and “working capacity” of the brain’s information processing system. It’s believed that in doing so, the level of distress and arousal about the experience is reduced, with treatment effects maintained over time. There is current research to suggest this theory has merit, as there is to support the REM theory and several others. A full review of current EMDR research can be found on the website www.emdria.org, www.emdr.com, or the Francine Shapiro Library available online.
CalSouthern: How quickly do clients tend to get relief? Is it permanent?
Gilman: If it’s a single traumatic incident—like a dog bite, a car accident or sports injury—the client is focusing on, it may take just a few sessions. If it’s a more complex trauma, where you have layers of trauma dating back to early childhood and multiple disorders—perhaps addictions—the process can be much slower, with more time needed for stabilization, and more required for follow up, as well.
Brown: I’d like to give you an example. A woman heard about EMDR and came to me for treatment. She had been an addict, an alcoholic, for 40 years. Her drinking began at the age of 18 with a rape. That particular experience set her on a trajectory that eventually spun her totally out of control.
This was one of the targets we decided to re-process because of the obvious connection between the trauma and the onset of the addictive behavior. She carried so much guilt, shame and responsibility for that experience—that she had somehow caused it, leading this guy down a path of expectation. And that was “let go” in a 90-minute session. She just collapsed in relief, sobbing, finally realizing that she was just an 18-year-old kid who had been led into a field by a 56-year-old man and raped. To be able to let go of the inappropriate responsibility for an incident that was held for 40 years in a single session—we then solidified this progress in subsequent treatment sessions—speaks to the heart of EMDR’s efficiency and effectiveness: it was not enough for her to “know” she was not responsible; this had to “feel” true in her gut.
Gilman: This does not mean that EMDR is a quick fix, though. It is a comprehensive, deliberately delivered psychotherapy. Although relief and a turning point can happen in a session—or appears to—a lot has gone into that. Susan is a very highly trained clinician with specialized and constantly updated experience in EMDR. We deliver it in the way that it was intended to be delivered and that’s why these results are produced.
CalSouthern: The therapy does appear—in some ways—to be deceptively simple.
Gilman: Oftentimes, when the public sees a presentation about EMDR, they just see the eye movements, the tapping, or the tones. What doesn’t get adequately conveyed is that we are working with the complicated neurophysiology of the brain and the body, which has many layers to its understanding. Success is shown in these short clips, and that’s illusory—there’s a succession of interventions and stages to the protocol. Certified trained clinicians must complete an extensive specialized training to become EMDR-certified.
Brown: Yes, it is deceptively simple looking. Complex trauma work is very delicate and EMDR is particularly evocative as a therapy, especially once bi-lateral stimulation is initiated. This is good news in that it gets the distressing material that’s been stuck—sometimes for decades—activated and moving, giving the brain a chance to digest it more adaptively. But when you initiate the protocol, people can move very quickly into their distressing material. As a clinician, you must be prepared to handle the state of distress your client might get into. You have to be skilled enough to ride out that storm with the client, keeping them as stable as possible in the process as you go along. You never know what reprocessing is going to open up.
CalSouthern: So in certain cases, you don’t have to be able to identify the trauma in order to process it?
Gilman: That is one of the beauties of EMDR, in my opinion. I do a lot of work with athletes and others focusing on performance-enhancement. I was working with a competitive cyclist not too long ago. He wanted to improve his cornering—he had noticed some slight hesitation when he approached corners. He was a very healthy individual, both mentally and physically, without a lot of childhood trauma. We decided to do some EMDR over whatever this cornering issue was. We began with the current problem of hesitation and slowed speed. As we proceeded into the processing phase, the root event popped up. That’s what so cool about EMDR—we had no idea going in what it was, and as a therapist, I wasn’t required to figure it out.
As it turned out, when he was eight years old, he was happily riding his bike and as he approached a corner, a car was coming the other way. He didn’t see it or feel in any danger, but his mother saw it from across the street. From her angle, it looked like they were going to collide. So she let out a blood-curdling, maternal scream, which he still had stored in his nervous system. As we proceeded with EMDR, he literally cringed and broke into a sweat as he re-lived the event and heard his mother screaming.
We processed that memory and came to a resolution, then rehearsed his desired performance. The next time he was cycling and approached a corner, he experienced no hesitation and actually smiled and let out a breath of relief. He and I had no idea whatsoever that this was the causal event that was stuck in his nervous system, but it was revealed—and processed—through EMDR. I could tell you story after story like that.
CalSouthern: For what types of conditions and populations is EMDR appropriate?
Gilman: Early in my career, I was trained in and focused on addiction, and you quickly learn that almost everyone associated with addiction—the addict, as well as affected family members—suffers from some sort of underlying trauma. And this is true of many other disorders: depression, anxiety, panic disorder—so many of them have traumatic material at their foundation. Post-traumatic stress happens to be where most of the research for EMDR is, but the treatment is appropriate for many disorders that have this underlying trauma which EMDR is so effective at processing.
CalSouthern: You mentioned that there is significant research showing EMDR’s effectiveness as a treatment for PTSD. Is it accepted and fully utilized by the military?
Brown: The Veterans Administration and the Department of Defense recommended EMDR as an effective treatment for PTSD back in 2004, along with CBT (CPT and exposure therapy), but that did not cause the doors to be opened wide for EMDR.
In the 2004 report, it was noted that exposure therapy might not be appropriate in the treatment of guilt, anger, or shame. EMDR is often more easily tolerated by those who are having difficulty engaging in other therapies, and there’s a prospect of obtaining significant improvement in just a few sessions.
Material being worked on is processed internally by the client, who does not have to reveal details about the traumatic event for it to be effective. This makes it particularly compelling for military personnel, because they experience such high levels of guilt and shame regarding events they witness or participate in as part of standard wartime experience. I’ve done entire sessions where I don’t really know what exact event we are working on. But having said that, I know that there are some VA mental health supervisors who prohibit their EMDR-trained staff from using it, which I find quite troubling.
Gilman: It was only last year that TRICARE—the military’s health care program—officially approved EMDR as a reimbursable therapy. That’s an indicator of the resistance. How many approved therapies are not reimbursed?
CalSouthern: What’s the reason for the resistance?
Gilman: Change is difficult, especially in large organizations. Cognitive behavioral therapy, exposure therapy and others have had the lion’s share of the work, contracts, training, and research dollars. EMDR has had to prove itself time and again. We don’t seek to replace these therapies, but rather to have EMDR used in conjunction with them, where appropriate.
We have had some phenomenal military support though, from every rank—people using EMDR, perhaps even at some risk, to prove its effectiveness with active duty military, as well as veterans. We’ll see one VA with one or more EMDR-trained therapists on staff, and another where it’s prohibited. It’s very inconsistent.
CalSouthern: What’s the current landscape like in terms of acceptance and utilization, outside of the military?
Brown: We’re seeing more and more research regarding the relationship between trauma and adverse childhood experiences in a variety of disorders: depression, substance abuse, domestic violence, smoking, suicide…the list goes on and on. EMDR’s utilization should be increased in accordance with what the research is suggesting about the impact of trauma across all these disorders, not just PTSD. My hope is that EMDR will be used as a core adjunctive treatment with addictive disorders. I think the need for integrative treatments in addiction is critical at this time worldwide, and the rarity of its use (and other effective trauma treatments) is strictly due, in my opinion, to the lack of awareness and education regarding the link between trauma and addiction, although awareness is growing by the day.
Gilman: I think EMDR is reaching a tipping point. If you look at trainings, for example, the numbers are steadily increasing. Clients are calling in and asking for it specifically. The research is solid. The public is talking about it. There is a rapidly growing global community of EMDR organizations and humanitarian efforts offering trainings throughout the world. I really think we could be nearing a breakthrough. It’s our hope that mental health providers will continue to become educated about and trained in EMDR Therapy—and utilize it within a whole host of environments and with a variety of disorders.
Susan Brown and Sara Gilman are noted authorities and sought-after speakers on the subject of eye movement desensitization reprocessing. Brown has presented nationally and has published numerous articles on the topic, including an article co-authored with Dr. Francine Shapiro—founder of EMDR in 1987—on its use in the treatment trauma and Borderline Personality Disorder. She also co-authored a book chapter on EMDR, Mental Health and Substance Abuse. She is an approved consultant with the EMDR International Association, having served on its Standards and Training Committee and the International Conference Committee. She is also a designated facilitator for EMDR training with the EMDR Institute and EMDR’s Humanitarian Assistance Program.
In addition to holding fellowship status with the American Academy of Experts in Traumatic Stress, Gilman is an EMDR-approved consultant and a past president of the EMDR International Association. She—along with Brown—is a principal investigator in a research study piloting an Integrated Trauma Treatment Program combining EMDR and Seeking Safety for co-occurring trauma and substance abuse in an adult drug court program. An acclaimed lecturer on the topic, Gilman has also appeared on national television addressing EMDR.