A new method for treating post-traumatic stress disorder was born in 1987 when California psychologist Francine Shapiro, Ph.D., observed that moving her eyes rapidly from left to right eased her disturbing thoughts. More than 10 years later, the effectiveness of this technique remains controversial among psychiatrists.
Proponents say Eye Movement Desensitization and Reprocessing (EMDR) therapy in patients with post-traumatic stress disorder gets the same if not better results in less time than standard exposure therapies, while critics question the method's scientific validity.
Shapiro, now a senior research fellow at the Mental Research Institute in Palo Alto, Calif., told Psychiatric News that she has since added several phases to the eye movement component of the therapy, such as treatment planning and cognitive restructuring of the patients' beliefs about themselves.
The eight phases are drawn from behavioral, cognitive, psychodynamic, body-based, and systems therapies. "Specifically, what is useful is learned and stored with appropriate affect, and what is useless, such as the negative emotions, irrational self-assessments, and physical sensations, is discarded," according to Shapiro's chapter on EMDR in Innovations in Clinical Practice: A Source Book, published this year by Professional Resource Press.
Bessel van der Kolk, M.D., a clinical researcher specializing in memory and trauma and a professor of psychiatry at Boston University, told Psychiatric News that he has found EMDR extremely useful in treating patients with PTSD.
"It helps patients retrieve details associated with a traumatic event, process them, and lay them to rest," he noted.
Van der Kolk said he uses a modified version of Shapiro's eight phases and noted that processing seems to occur instantaneously when memories surface.
He commented that clinicians may be resistant to using EMDR because "it runs contrary to the twin pillars of psychotherapy, which are the therapeutic relationship and the ability to articulate one's experience. With EMDR, we barely know each other and use a minimum of words."
Nonetheless, van der Kolk's brain-scan research shows promising results in patients traumatized by a single incident including rape or assault. Van der Kolk remarked that after patients had experienced three or four 90-minute sessions with EMDR, "the increased activation in the frontal lobes and cortex was striking."
Moreover, the anterior cingulate, which integrates cognitive and emotional aspects of experiences, was activated. "I believe people after treatment are more capable of distinguishing between a real threat and a reminder of the threat," he said.
Van der Kolk noted there was no control group in the study, which has not been published.
Kenneth Adam, M.D., a professor of psychiatry at the University of Toronto Medical Center and director of a psychological trauma clinic at Mount Sinai Hospital in Toronto, told Psychiatric News, "I have used EMDR in my practice for the past three years and have found it to be an effective treatment for PTSD. EMDR is probably as effective and works more quickly than prolonged exposure therapy, based on my reading of the literature."
He plans to do the first direct controlled study comparing EMDR with prolonged exposure, considered by some psychiatrists and psychologists as the standard treatment for PTSD.
"Because EMDR involves exposure to traumatic memories, some critics claim it's simply another exposure treatment and the eye movements do not add anything," said Adam.
"My response is that EMDR is a complex procedure involving cognitive elements, exposure to the traumatic event by imagining it, and eye movements. It's impossible to meaningfully separate these aspects."
Skeptics include psychiatrist Roger Pitman, M.D., coordinator of research and development at the Veterans Affairs Research Service in Manchester, N.H. He believes that the eye movement component serves no real purpose.
Pitman, who is also an associate professor of psychiatry at Harvard Medical School, told Psychiatric News that the results of his study of 17 Vietnam combat veterans with chronic PTSD published in the December 1996 issue of Comprehensive Psychiatry showed that after patients were given six sessions with standard EMDR or EMDR without the eye movements, partial emotional processing occurred in all patients. The comparison group stared straight ahead and tapped their fingers.
"The therapy's success, which is based on eye movements, is muted by our findings," said Pitman. "There may be some mystical element in the therapist's hand-waving similar to a shaman."
Shapiro responded that she discovered after naming the procedure in 1989 that tones and finger taps, like eye movements, can produce bilateral stimulation in the brain. More research, however, is needed in this area, she said.
Shapiro also said Pitman's results were not statistically significant because he used too few subjects and not enough sessions of EMDR in subjects who have been traumatized multiple times. She referred to the results of a study of 35 combat veterans in the January issue of The Journal of Traumatic Stress showing that "combat veterans with PTSD who received EMDR treatment improved significantly on cognitive and behavioral measures and on anxiety and depression compared [with] veterans in routine clinical care or in biofeedback-assisted relaxation."
The subjects were treated with 12 sessions of EMDR or biofeedback-assisted relaxation. The control group received routine clinical care.
Shapiro claims that EMDR has more published case reports and controlled research to support it than any other method used in the treatment of trauma. As evidence, she provided copies of six recent controlled studies, including five published in the last year, and references to other controlled studies.
Shapiro also disavowed the idea that EMDR is another form of exposure therapy because EMDR operates differently and the research on EMDR shows better results in less time.
"In flooding or prolonged exposure, the patient holds in mind a disturbing element for a long time with no distraction or interruption. In contrast, in EMDR, the patient thinks about the disturbing element and then is directed to follow the therapist's fingers with his or her eyes, which is a distraction. The mind then can wander anywhere, and the level of intensity of the disturbance drops in the first five minutes, compared with a minimum of 25 minutes or longer for exposure therapy."
She said EMDR achieved an 80 percent reduction in PTSD symptoms after the equivalent of about five hours in one study, compared with 50 hours of imagining the traumatic event and live exposure required for the same results in another study.
EMDR has also made it onto the American Psychological Association's 1998 list of probable treatments for civilian PTSD along with exposure and stress innoculation treatment. To meet the well-established treatment criteria, the effects of the therapy must be clearly superior to an alternative treatment or placebo or equal to another well-established treatment.
Shapiro refers to the "probably efficacious" designation as further legitimacy of the once-experimental treatment.
The demand for EMDR continues to grow. Shapiro's EMDR institute in Pacific Grove, Calif., founded in 1990, has trained about 22,000 mental health practitioners internationally, according to a brochure. EMDR workshops are held regularly in several cities in the United States and abroad.
Shapiro also established a humanitarian assistance program after the Oklahoma bombing incident in 1995 to train local therapists in EMDR so that they could help relieve the suffering of trauma victims.
She has also has published two books on her technique: one for clinicians, Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures, and one for the general public, EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma.