Eye Movement Desensitization and Reprocessing (EMDR) - Detailed Report

The essential components of EMDR include:

• EMDR is based on Adaptive Information Processing (AIP) theory which postulates that symptoms arise from maladaptively stored memories that include the thoughts, beliefs, emotions, body sensations, and sensory experiences that were stored at the time of the traumatic event.
• EMDR taps into that information system, activating the traumatically stored information, and, through reprocessing, helps move the traumatically stored information to adaptive resolution. As an integrative psychotherapy driven by Adaptive Information Processing (AIP) theory, EMDR integrates and is compatible with elements of other treatment interventions.
• When working with child clients, EMDR integrates play therapy and other efficacious treatment tools for working with children. With the theoretical underpinnings of AIP and the therapeutic relationship, case conceptualization with appropriate target assessment and reprocessing are all enacted throughout the complete eight-phase integrative psychotherapy of EMDR. Therefore, even though some elements of the goals and objectives of the phases of EMDR may be evident in other treatment modalities, it is the aggregate of the theory, case conceptualization and accurate implementation of this integrative psychotherapy that truly defines EMDR.
• EMDR consists of 8 phases of treatment with specific goals and objectives for completion of each phase.
• The first phase is Client History and Treatment Planning during which the therapist assesses the clinical landscape, evaluates the client's readiness for EMDR, and develops a treatment plan.
• Afterwards, during the Preparation Phase the therapist ensures that the client has adequate methods of handling emotional distress and self-soothing and calming skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on developing these needed skills for continuing with trauma reprocessing. During this phase, the therapist also teaches the mechanics of EMDR and reviews informed consent to assess for any forensic issues.
• In phases three through seven, a target memory (or image) is identified with the client identifying the image that represents the worst part of the target memory, the negative cognition associated with the image and a positive cognition (PC) that the client would like to believe instead (which is the goal for this phase of therapy) and the PC is then measured on the Validity of Cognition (VoC) Scale of 1-7 with 1 being completely false and 7 being completely true. Once the clinician has assessed the client’s current feelings about the VoC, the client is asked to identify the emotions associated with the target and then to measure the disturbance associated with the emotions on a Subjective Units of Disturbance Scale (SUDS) ranging from 0 being no disturbance to 10 being the most disturbing. Then the client is asked to identify where the client feels any disturbance in the body sensations associated when bringing up the target. After the client is guided through these series of questions, the client is then asked to hold together the target and the negative cognition along with the body sensations and the therapist starts sets of bilateral stimulation. This Desensitization Phase of EMDR continues until the disturbance is assessed by the client to be a SUDS rating of zero. Although eye movements are the most commonly used external form of bilateral stimulation, therapists often use auditory tones, tapping, or other types of tactile stimulation especially with children. The client is instructed to just notice whatever happens.
• The clinician then instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report, the clinician will facilitate the next focus of attention and restart bilateral stimulation. In most cases, a client-directed association process is encouraged. Client-directed association refers to following what the client responds to after doing the eye movements. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume reprocessing. Parents can be included in sessions and taught to assist children between sessions with symptoms and cuing children to use self-soothing and calming techniques and skills.
• When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements.
• In phase seven, closure, the therapist reminds the client of the client’s self-soothing and calming skills and to note any targets, images, cognitions, emotions, and/or sensations (TICES) that arise between sessions, and then to report these to the therapist at the next session. For children, parents and caregivers are asked to assist in identifying any progress or new symptoms that the child might evidence between sessions.
• In phase eight, re-evaluation of the previous work, and of progress since the previous session, takes place.
• EMDR treatment ensures processing of all related historical events, current incidents that elicit distress and future scenarios that will require different responses. Re-evaluation continues through each session as targets are reprocessed and the treatment plan is followed toward discharge planning.

Eye Movement Desensitization and Reprocessing (EMDR) is rated a "1 - Well-Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least two rigorous randomized controlled trials with one showing a sustained effect of at least 1 year. For more information on the rating of a "1 - Well-Supported by Research Evidence," please see the Scientific Rating Scale.

Greenwald, R. (1998). Eye Movement Desensitization and Reprocessing (EMDR): New hope for children suffering from trauma and loss.Clinical Child Psychology and Psychiatry, 3(2), 279-287.

Type of Study: Case Study
Number of participants: 1
Population:

Age Range: 10 year old girl
Race/Ethnicity: Not Specified
Status (e.g., foster care, CW): Not Specified

Location/Institution: Not Specified
Summary: (To include comparison groups, outcomes, measures, notable limitations) Case study involving a 10-year-old girl who was diagnosed with posttraumatic stress disorder. She had one introductory and five treatment sessions over a 2 month-period, and was reassessed at 2 months after the end of treatment and was assessed with the Parent Report of Post-traumatic Symptoms (PROPS), the Child Report of Post-traumatic Symptoms (CROPS), the Subjective Units of Distress Scale (SUDS), and the Problem Rating Scale (PRS).
Length of post-intervention follow-up: 2 months.

Puffer, M., Greenwald, R., & Elrod, D. (1998). A single session EMDR study with twenty traumatized children and adolescents. Traumatology-e, 3(2), Article 6. Retrieved on May 17, 2010, from. http://www.fsu.edu/~trauma/v3i2art6.html

Type of Study: Two-group pre-/post-test design
Number of participants: 20
Population:

Age Range: 8-17 years
Gender: Not specified
Race/Ethnicity: Not specified
Status (e.g., foster care, CW): Participants from several small Midwestern towns were recruited through newspaper publicity as well as therapist referrals.

Location/Institution: Michigan
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were evenly split into treatment and delayed-treatment groups. Participants were each treated for a single traumatic memory with a single session of Eye Movement Desensitization and Reprocessing (EMDR), though those in the delayed-treatment group received treatment one month later than those in the regular treatment group. Measures used in the study included the Children’s Manifest Anxiety Scale (CMAS), which is a broad-spectrum anxiety scale, as well as the Impact of Events Scale (IES), which measures post-traumatic stress symptoms. Also used was the Subjective Units of Distress Scale (SUDS), which measures the intensity of subjective distress in response to a particular stimulus, such as a traumatic memory. Over half of the participants moved from Clinical to Normal levels on the Impact of Events Scale, and all but 3 showed at least partial symptom relief on several of the measures at 1-3 months following the single EMDR session. Limitations include the small sample size and lack of no-treatment control group.
Length of post-intervention follow-up: 1-3 months.

Scheck, M., Schaeffer, J. A., & Gillette, C. (1998). Brief psychological intervention with traumatized young women: The efficacy of Eye Movement Desensitization and Reprocessing. Journal of Traumatic Stress, 11, 25-44.

Type of Study: Randomized controlled trial
Number of participants: 60 females
Population:

Age Range: 16-25
Race/Ethnicity: 62% Caucasian, 15% African American, 15% Hispanic, and 8% Native American
Status (e.g., foster care, CW): Recruited through municipal agencies.

Location/Institution: Colorado
Summary: (To include comparison groups, outcomes, measures, notable limitations)To study the efficacy, of Eye Movement Desensitization and Reprocessing (EMDR) with traumatized young women, 60 women between the ages of 16 and 25 were randomly assigned to two sessions of either EMDR or an active listening (AL) control. Factorial ANOVA (analysis of variance) interaction effects and simple main effects for outcome measures (Beck Depression Inventory, State-Trait Anxiety Inventory, Penn Inventory for Posttraumatic Stress Disorder, Impact of Event Scale, Tennessee Self-Concept Scale) indicated significant improvement for both groups and significantly greater pre-post change for EMDR-treated participants. Pre-post effect sizes for the EMDR group averaged 1.56 compared to 0.65 for the AL group. Despite treatment brevity, the post treatment outcome variable means of EMDR-treated participants compared favorably with non-patient or successfully treated norm groups on all measures.
Length of post-intervention follow-up: 90 days.

Chemtob, C. M., Nakashima, J., & Carlson, J. G. (2002). Brief-treatment for elementary school children with disaster-related PTSD: A field study. Journal of Clinical Psychology, 58, 99-112.

Type of Study: Randomized controlled trial with wait-list comparison group
Number of participants: 32
Population:

Age Range: 6 to 12 years
Race/Ethnicity: 28.1% Filipino, 31.3% Hawaiian, 12.5% Japanese, 18.8% Caucasian, and 9.4% Mixed.
Status (e.g., foster care, CW): Children who had experienced trauma due to a hurricane.

Location/Institution: Hawaii
Summary: (To include comparison groups, outcomes, measures, notable limitations)This study was conducted using two groups in an ABA design plus a 6-month follow-up. EMDR was found to be an effective treatment for children with disaster-related PTSD who had not responded to another intervention. Measures included the Revised Children's Manifest Anxiety Scale and the Child Depression Inventory (CDI). This is the first controlled study for disaster-related PTSD, and the first controlled study examining the treatment of children with PTSD.
Length of post-intervention follow-up: 6 months.

Soberman, G. B., Greenwald, R., & Rule, D. L. (2002). A controlled study of Eye Movement Desensitization and Reprocessing (EMDR) for boys with conduct problems. Journal of Aggression, Maltreatment, & Trauma, 6(1), 217-236.

Type of Study: Randomized controlled trial
Number of participants: 29
Population:

Age Range: 10-16 years
Gender: 100% males
Race/Ethnicity: Doesn’t specify
Status (e.g., foster care, CW): Participants were in residential or day treatment at the same facility and all had acting out behaviors. Primary diagnoses included Conduct Disorder (59%) as well as Post-Traumatic Stress Disorder, Attention Deficit Hyperactive Disorder, Learning Disability, Substance Abuse, and Oppositional/Defiant Disorder.

Location/Institution: New York
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were randomly assigned to either a control group or to an experimental group. All participants were given the same standard treatment, including weekly individual psychotherapy, group psychotherapy, special education services, a behavioral point modification system, and medication and/or psychoeducational parent family counseling as needed, but those in the experimental group additionally received three sessions of Eye Movement Desensitization and Reprocessing (EMDR) treatment. Measures to assess post-trauma symptoms included the Subjective Units of Distress Scale (SUDS), which measures intensity of subjective distress in response to a particular stimulus, such as a traumatic memory; the Impact of Events Scale – 8 Items (IES-8), which assesses avoidance and intrusion symptoms; and the Child and Parent Reports of Post-traumatic Symptoms (CROPS and PROPS, respectively). Additionally, the Problem Rating Scale (PRS) was used by the caretaker/parent to assess his or her primary concerns regarding the child; also used was the Behavioral Reward Scale (BRS), which rates numerous desired and undesired behaviors daily. From pre- to post-treatment, the EMDR group’s mean SUDS scores dropped 6.1 points, compared to the control group’s drop of only 0.38 points. At two-month follow-up, the EMDR group’s mean PRS score dropped 8.7 points, compared to the control group’s drop of only 2.6 points. (Both the SUDS and PRS scores are from 1-10 points) Thus, EMDR did help to reduce reactivity to traumatic memories in these boys with conduct problems (CP), and treating traumatic memories with EMDR, in turn, helped to reduce CP symptoms. Limitations of the study include the small sample size and use of only male participants with conduct disorders.
Length of post-intervention follow-up: 2 months.

Fernandez, I., Gallinari, E., & Lorenzetti, A. (2004). A school-based EMDR intervention for children who witnessed the Pirelli building airplane crash in Milan, Italy. Journal of Brief Therapy, 2, 129-136.

Type of Study: Pretest/Posttest
Number of participants: 236 schoolchildren
Population:

Age Range: 6-11 years
Race/Ethnicity: 60% European, 40% Other
Status (e.g., foster care, CW): Schoolchildren who witnessed the Pirelli Tower crash.

Location/Institution: Milan, Italy
Summary: (To include comparison groups, outcomes, measures, notable limitations)A non-randomized trial of a group intervention of EMDR was provided to 236 schoolchildren exhibiting PTSD symptoms 30 days post-incident (witnessing Pirelli building airplane crash in Milan Italy). At four-month follow up, teachers reported that all but two children showed a return to normal functioning after treatment. Distress was also assessed with the Subjective Units of Distress Scale, modified for use with children; and through content of children’s directed drawings.
Length of post-intervention follow-up: 4 months.

Jaberghaderi, N., Greenwald, R., Rubin, A., Dolatabadim S., & Zand, S. O. (2004). A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy, 11(5), 358 – 368.

Type of Study: Random Assignment (see summary)
Number of participants: Fourteen females
Population:

Age Range: 12-13
Race/Ethnicity: Iranian
Status (e.g., foster care, CW): Volunteers recruited from schools.

Location/Institution: Iran
Summary: (To include comparison groups, outcomes, measures, notable limitations) Fourteen Iranian girls ages 12-13 who had been sexually abused were randomly assigned (with some adjustments to promote equivalence between groups) to receive up to 12 sessions of Cognitive Behavioral therapy (CBT) or EMDR treatment. Assessment of post-traumatic stress symptoms and problem behaviors was completed at pre-treatment and 2 weeks post-treatment. Both treatments showed large effect sizes on the post-traumatic symptom outcomes, and a medium effect size on the behavior outcome, all statistically significant. A non-significant trend on self-reported post-traumatic stress symptoms favored EMDR over CBT. Treatment efficiency was calculated by dividing change scores by number of sessions; EMDR was significantly more efficient, with large effect sizes on each outcome. Limitations include a small sample, single therapist for each treatment condition, no independent verification of treatment fidelity, and no long-term follow-up.
Length of post-intervention follow-up: 2 weeks.

Ahmad, A., Larsson, B., & Sundelin-Wahlstein, V. (2007). EMDR treatment for children with PTSD: Results of a randomized controlled trial. Nordic Journal of Psychiatry, 61(5), 349-354.

Type of Study: Randomized controlled trial
Number of participants: 33
Population:

Age Range: 6 to 16 years
Race/Ethnicity: EMDR: 70.6% Swedish, 29.4% Other; Control: 43.7% Swedish, 56.3% Other
Status (e.g., foster care, CW): Children at an outpatient clinic who received a diagnosis of PTSD due to familial abuse or neglect.

Location/Institution: Sweden
Summary: (To include comparison groups, outcomes, measures, notable limitations)Children diagnosed with PTSD were randomly assigned to receive EMDR or to a wait-list control group (WLC). Exposure to traumatic events was assessed using the Harvard-Uppsala Trauma Questionnaire for Children (HUTQ-C). Diagnosis was also established using the Diagnostic Interview for Children (DICA) and the Posttraumatic Stress Symptom Scale (PTSS-C). The experimental group of children received developmentally appropriate versions of EMDR. Post-treatment PTSS scores were significantly lower for children in the EMDR group.
Length of post-intervention follow-up: None.

Adúriz, M. E., Bluthgen, C., & Knopfler, C. (2009). Helping child flood victims using group EMDR intervention in Argentina: Treatment outcome and gender differences. International Journal of Stress Management 16(2), 138.

Type of Study: Pre-test/Post-test design
Number of participants: 124
Population:

Age Range: 4-17 years
Gender: 61 boys, 63 girls
Race/Ethnicity: Not given
Status (e.g., foster care, CW): Participants had experienced disaster-related trauma during a massive flood in Santa Fe, Argentina, in 2003, and all were recruited from the Instituto de la Sagrada Familia.

Location/Institution: Argentina
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study illustrates a comprehensive group intervention of a one-session group Eye Movement Desensitization and Reprocessing (EMDR) protocol for children who experienced disaster-related trauma during a massive flood in Santa Fe, Argentina, in 2003. Measures included the Child’s Reaction to Traumatic Events Scale (CRTES), which assesses psychological responses to stressful life events, as well as the Subjective Units of Disturbance Scale (SUDS), which assesses subjective distress and the effectiveness of EMDR treatment. The EMDR-Integrative Group Treatment Protocol showed statistically significant reduction of posttraumatic symptoms immediately after the intervention. These statistically significant differences were sustained at post-treatment evaluation 3 months later. Limitations include the lack of a control group, as well as the questionable generalizability of the sample, which is comprised of children in the same school, who experienced the same event.
Length of post-intervention follow-up: 3 months.

Hensel, T. (2009). EMDR with children and adolescents after single-incident trauma: an intervention study. Journal of EMDR Practice and Research, 3, 2-9.

Type of Study: Non-randomized pre-/post-test design
Number of participants: 36
Population:

Age Range: 1 year & 9 months – 18 years & 1 month
Gender: 22 boys, 14 girls
Race/Ethnicity: Not given
Status (e.g., foster care, CW): Participants joined the study consecutively through the years from 2002-2007 as they came to the author’s outpatient private practice for treatment of symptoms related to a single-incident trauma.

Location/Institution: Kinder Trauma Institut, Offenburg, Germany
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study examined the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) on children and adolescents who presented with posttraumatic symptoms after having been exposed to a single-incident trauma. In order to have standard measurement across all age-groups, the Parent Reports of Post-traumatic Symptoms (PROPS) assessment was used, measuring the parent’s report across a full spectrum of posttraumatic symptoms in the child (higher total scores reflect more posttraumatic symptoms). From its initial, pre-treatment point of 28.33, the mean PROPS score for the sample dropped to 9.69 by the end of treatment. Thus, the majority of children had showed significant reduction of symptoms, with maintenance of treatment effects at 6 months post-treatment. Limitations include the small sample size and lack of a randomized control group.
Length of post-intervention follow-up: 6 months.

Kemp, M., Drummond, P., & McDermott, B. (2010). A wait-list controlled pilot study of Eye Movement Desensitization and Reprocessing (EMDR) for children with post-traumatic stress disorder (PTSD) symptoms from motor vehicle accidents. Clinical Child Psychology & Psychiatry, 15(1), 5-25.

Type of Study: Randomized controlled trial
Number of participants: 27
Population:

Age Range: 6-12 years
Gender: 15 boys, 12 girls
Race/Ethnicity: Not specified
Status (e.g., foster care, CW): Participants were recruited from 404 motor vehicle accident victims who were first contacted by phone. Over a four-year period, 27 pre-adolescents were entered into the study following their admission to a hospital emergency department after a motor vehicle accident. All participants scored at least a 12 on the Child Post-Traumatic Stress-Reaction Index (Child PTS-RI) or met at least two Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria (including exposure) for PTSD.

Location/Institution: Australia
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study examined the efficacy of four one-hour Eye Movement Desensitization and Reprocessing (EMDR) sessions in comparison to a six-week wait-list control condition in the treatment of children suffering from persistent PTSD symptoms after a motor vehicle accident. Participants were randomly assigned to either the wait-list control (n = 14) or EMDR-group (n = 13). Outcome measures were taken at pre- and post-treatment, and three and 12-month follow-up. Measures to assess trauma symptoms, depression, and behavior problems included the Child PTS-RI, PTSD Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, the State Trait Anxiety Inventory for Children (STAIC), Children’s Depression Scale (CDS), and the Child Behavior Checklist (CBCL). All participants initially met two or more PTSD criteria. After EMDR treatment, this decreased to 25% in the EMDR group, but remained at 100% in the wait-list group. For children in the EMDR condition, both the number of DSM-IV PTSD criteria and child PTS-RI scores improved from post-treatment to 12-month follow-up. From post-treatment to three month follow-up, the number of participants meeting two or more PTSD criteria improved from eight (34.8%) to five (22.7%), and at 12 month follow-up only two participants (13.3%) met two or more criteria. Limitations of the study include small sample size, homogeneity in the cause of PTSD symptoms (all were in motor vehicle accidents), and the fact that a single therapist completed the treatment and outcome assessments.
Length of post-intervention follow-up: 3 months and 12 months.

Adler-Tapia, R., & Settle, C. (2009). Evidence of the efficacy of EMDR with children and adolescents in individual psychotherapy: A review of the research published in peer-reviewed journals. Journal of EMDR Practice and Research, 3(4), 232-247.

Adler-Tapia, R.L. & Settle, C.S. (2009) EMDR psychotherapy with children. In, A. Rubin & Springer (Eds.) Treatment of traumatized adults and children: Part of the clinician’s guide to evidence based practice series. New York: Wiley.

Chemtob, C. M., Nakashima, J., Hamada, R. S., & Carlson, J. G. (2002). Brief-treatment for elementary school children with disaster-related posttraumatic stress disorder: A field study. Journal of Clinical Psychology, 58, 99-112.