An Unbelievable (But Real) Treatment for PTSD

Coming up with the idea was a walk in the park. Gaining acceptance for it was not. Still, Francine Shapiro persevered, inventing and refining Eye Movement Desensitization and Reprocessing (EMDR) into a treatment that now enjoys strong recommendations from the U.S. Department of Veterans Affairs, U.S. Department of Defense, and International Society for Traumatic Stress Studies for post-traumatic stress disorder (PTSD). [1, 2] (The American Psychiatric Association only “suggests” it as a treatment for PTSD.[3])

The idea really did come to her while walking in the park in the spring of 1987. Shapiro describes the event in her 2001 book, Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and Procedures:

While walking one day, I noticed that some disturbing thoughts I was having suddenly disappeared. I also noticed that when I brought these thoughts back to mind, they were not as upsetting or as valid as before… Fascinated, I started paying very close attention to what was going on. I noticed that when disturbing thoughts came into my mind, my eyes spontaneously started moving very rapidly back and forth in an upward diagonal. Again, the thoughts disappeared, and when I brought them back to mind, their negative charge was greatly reduced. At that point I started making the eye movements deliberately while concentrating on a variety of disturbing thoughts and memories, and I found that these thoughts also disappeared and lost their charge.[4]

Shapiro began to test this new technique, having people recall disturbing memories while moving their eyes back and forth, finding the best speed and direction of eye movements and other aspects of what would become the treatment. In about 6 months, she had worked with 70 people (friends, colleagues, and participants in a psychology workshop) and developed a standard procedure that she said “consistently succeeded in alleviating their complaints.”[4] After an initial controlled study that involved 22 victims of rape, molestation, or Vietnam combat, all of whom were suffering from traumatic memories, Shapiro published her first journal article on the procedure. [5]

Not surprisingly, there was some resistance. Some critics claimed EMDR was hypnosis by another name; others said it was the same as exposure therapy, with some mumbo-jumbo hand-waving (literally) thrown in. By the early 2000s, however, there had been multiple controlled studies that supported EMDR, and it began to make its way into the mainstream[6]. By 2015, reviews and meta-analyses of all the relevant studies found it was definitely effective in treating PTSD, rating it just a little better than Cognitive Behavior Therapy (CBT)[7]. Shapiro founded the EMDR Institute in 1990, training psychologists all over the world on the technique. It was even taken on the road to disaster areas including Southeast Asia after their tsunami and war-torn Bosnia, where it continued to prove itself[6].

EMDR is applied in eight phases, though the number of therapist-led sessions varies. According to the EMDR Institute’s website: “After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist’s hand as it moves back and forth across the client’s field of vision. As this happens, the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level. For instance, a rape victim shifts from feeling horror and self-disgust to holding the firm belief that, ‘I survived it and I am strong.’”[8] Some implementations use other ways to engage the brain in a side-to-side fashion in place of eye movements. They might involve an audio tone in one ear or the other, or having the patient tap his/her fingers on alternating hands. But that bilateral involvement of the brain is necessary for the treatment.

There are a few theories about how EMDR works, based on a model of PTSD in which traumatic memories are not fully processed. Normally, memories of an event are broken into component parts that are stored in different locations in the brain – the sights involved might be stored in one location; the sounds in another – and when we recall an event, the brain reconstructs the memory. Over time, each component will likely be associated with other, neutral or even positive, memories, weakening the impact of the recall. In PTSD, however, it is as if the traumatic event is encapsulated in the mind, with the physical sensations – sights, sounds, smell, pain – the traumatic memory, the lead-up and consequences all secure in their little bubble. Trigger any part of it, and you get the whole, explosive mess back in your mind, as if it were happening right there. The memory doesn’t get fully processed[9].

So, how does EMDR change that? One theory proposes that the eye movements of EMDR mimic Rapid Eye Movement (REM) sleep, during which emotional memories are processed – broken apart, stored, and associated with other memories. In this theory, REM sleep was failing – it was not effectively processing the traumatic memory “bubble” on its own – but the side-to-side eye movements are able to get those processes started. Another theory is that the side-to-side brain activity is a distraction while someone is holding some aspect of the traumatic event in their working memory, so that the brain just can’t keep the integrity of that memory “bubble” together[6]. Either way, or through some other, unsuspected mechanism, what an amazing (and drug-free) treatment for PTSD.

Of course, if this works for PTSD, what else can it do? EMDR has been adapted for for many other conditions, and studies show positive outcomes in areas involving pain, anxiety, mood and stress[10]. Amazing. And it all started with that walk in the park, and with a woman who turned what she was feeling and doing in that moment into a positive good in the world.

References:

[1] Management of Post-Traumatic Stress Working Group [Online]. VA/DOD clinical practice guideline for management of post-traumatic stress disorder and acute stress disorder. Washington (DC): Department of Veterans Affairs, Department of Defense; 2017. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf.

[2] International Society of Traumatic Stress Studies (ISTSS) [Online]. (2018, November 26). New ISTSS prevention and treatment guidelines. Retrieved from http://www.istss.org/treating-trauma/new-istss-guidelines.aspx.

[3] Courtois, C. A., et al. (2017, February 24). Clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. American Psychological Association. Retrieved March 29, 2023, from https://www.apa.org/ptsd-guideline.

[4] Shapiro, F. (2001). Eye movement desensitization and reprocessing (EMDR): Basic principles, protocols, and procedures. Guilford Press.

[5] Shapiro, F. (1989). Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20(3), 211-217.

[6] Oren, E. M. D. R., & Solomon, R. (2012). EMDR therapy: An overview of its development and mechanisms of action. European Review of Applied Psychology, 62(4), 197-203.

[7] Chen, Y. R., Hung, K. W., Tsai, J. C., Chu, H., Chung, M. H., Chen, S. R., ... & Chou, K. R. (2014). Efficacy of eye-movement desensitization and reprocessing for patients with posttraumatic-stress disorder: A meta-analysis of randomized controlled trials. PloS one, 9(8), e103676. and

Chen, L., Zhang, G., Hu, M., & Liang, X. (2015). Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: systematic review and meta-analysis. The Journal of nervous and mental disease, 203(6), 443-451.

[8] EMDR Institute, Inc. (2020). What is EMDR? EMDR. Retrieved March 29, 2023, from https://www.emdr.com/what-is-emdr/.

[9] Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of clinical psychology, 58(1), 61-75.

[10] Scelles, C., & Bulnes, L. C. (2021). EMDR as treatment option for conditions other than PTSD: A systematic review. Frontiers in Psychology, 12, 644369.