Eye movement desensitization and reprocessing (EMDR) is a recently developed psychotherapy method for working through traumatic memories and related psychological problems. Recent literature reviews find strong support for EMDR's superiority to traditional approaches to trauma therapy. The first studies using EMDR with children and adolescents yield similar findings. EMDR appears to be a promising new resource for helping children and adolescents recover from trauma and loss.

Eye movement desensitization and reprocessing (EMDR) is a recently developed psychotherapy method which is best known as a treatment for traumatic memories and their psychological sequelae. In 1987, a psychology graduate student named Francine Shapiro noticed that her own upsetting thoughts faded when her eyes spontaneously moved rapidly from side to side. Over the next several years, she and her colleagues developed and refined this discovery into a systematic therapeutic approach.

EMDR is a complex method which combines elements of behavioral and client-centered approaches, in a manner which is hypothesized to stimulate and facilitate the innate psychological healing processes (Greenwald, 1995b; Shapiro, 1995). To oversimplify, the client is asked to concentrate intensely on the most distressing segment of a traumatic memory while moving the eyes rapidly from side to side (by following the therapist's fingers moving across the visual field). Following the initial focus on the memory segment, after each set of eye movements (of about 30 seconds), the client is asked to report anything that "came up," whether an image, thought, emotion, or physical sensation (all are common). The focus of the next set is determined by the client's changing status. For example, if the client reports, "Now I'm feeling more anger," the therapist may suggest concentrating on the anger in the next set. The procedure is repeated until the client reports no further distress and can fully embrace a positive perspective. Shapiro (1995) has presented this method in detail.

EMDR's brief history has been marked by considerable excitement as well as confusion and controversy. Shapiro's (1989a, 1989b) initial reports, which included step-by-step instructions, presented eye movement desensitization (EMD) as a single-session cure for post-traumatic stress disorder (PTSD). Since PTSD had previously been viewed as intractable, with treatments being slow, arduous, and of limited efficacy (Solomon, Gerrity, & Muff, 1992), many replications of the new EMD were attempted. Meanwhile, as Shapiro observed that practitioners of her new technique were often not doing as she was, she came to appreciate the complexity of the method, including the "reprocessing" element, which was added to the name (Shapiro, 1991b). She expanded her training program to include more detailed instruction as well as small-group supervised practicums, and suggested this supervised training as a minimum requirement for responsible practice (Shapiro, 1991a) - a position which has been supported by subsequent data (Greenwald, 1995a, 1996). Meanwhile, outcomes in published reports of EMD and EMDR varied considerably, probably due to variations in the quality of the intervention (Greenwald, 1994b, 1996). This led to a division between appropriately trained clinicians, who believed from personal experience that EMDR worked, and appropriately skeptical scientists, who had not been convinced by the empirical findings.

Later studies, reflecting a higher fidelity to the revised EMDR protocol, have been quite positive, and essentially consistent with Shapiro's initial findings. EMDR's efficacy (and superiority) is already supported by more controlled studies than any other psychotherapy treatment for trauma (Shapiro, 1996). Greenwald (1994b, 1996, 1997) and Shapiro (1995, 1996) have discussed EMDR's history and status in some detail. At this writing, EMDR is becoming widely recognized as highly efficacious and is considered by many to be the treatment of choice for traumatic memories and related applications. A few representative studies will be summarized here.

Silver, Brooks, and Obenchain (1995) reported a post-hoc study which compared EMDR with two other treatment conditions, biofeedback and relaxation training, in an inpatient veterans' PTSD program (N=100). Using a self-report measure, EMDR was found much superior to the other treatments on almost all symptom scales.

Carlson, Chemtob, Rusnak, Hedlund, and Muraoka (in press) compared EMDR with wait-list/psychoeducation and relaxation/biofeedback control groups for combat veterans with chronic PTSD (N=35). This study featured random assignment, standardized, comprehensive assessment pre-treatment, post-treatment, and at 3 month follow-up, and 12 treatment sessions using clinicians who were trained and experienced in the respective modalities. The EMDR group showed much greater treatment effect than the other conditions, indicating clinical as well as statistical significance.

Wilson, Becker, and Tinker (1995) reported on a study featuring random assignment, a delayed treatment control group, several EMDR-trained therapists, independent, blind assessment, multiple standardized measures, follow-up at 30 days, 90 days, and a year, and an N of 80 traumatized participants (about half meeting PTSD criteria). Following 3 treatment sessions, their results were positive and substantial, consistent with Shapiro's (1989a) original findings. Their analysis of treatment effect size (and duration) makes clear that the findings could not be plausibly accounted for by placebo or demand effects, and were in fact more than double the magnitude normally found even with effective treatment.

Scheck, Schaeffer, and Gillette (in press) compared 2 sessions of EMDR with 2 sessions of Active Listening (AL), treating 60 females between the ages of 16 and 24, who were actively pursuing high-risk behaviors (substance abuse, unsafe sex, criminal acts, suicide attempts, etc.) and who had histories of trauma. This study included random assignment, 24 well-trained therapists, independent blind assessment, and multiple standardized measures. Although both groups improved post-treatment, EMDR outperformed AL on all five measures, with significant differences on four of the five. The EMDR group's post-treatment gains were also clinically significant, with mean scores falling within one standard deviation of the non-clinical norms on all measures, whereas for the AL group, only one of the measures was in the normal range. Two measures readministered at 90 day follow-up showed maintenance of gains.

Marcus, Marquis, and Sakai (1996) randomly assigned 67 PTSD patients within a managed care system to standard care or to treatment featuring EMDR. This study also featured multiple objective measures, and a blind independent evaluator who also conducted PTSD-oriented clinical interviews. Although both groups improved, the EMDR group showed much greater symptom reduction (also statistically significant differences on all measures) while using only 55% of the total visits (including individual, group, and medication) used by the control group.

Edmond and Rubin (1996) studied 59 adult female survivors of childhood sexual abuse, comparing EMDR with eclectic treatment (a variety of techniques organized to treat the focal issues) and to a delay-treatment control group. Several objective and subjective measures were used. Although the same four therapists conducted the treatment for both treatment groups, three of the therapists had not heard of EMDR before being trained for the study; and indicated varying degrees of skepticism - which controlled somewhat for bias, and turned out to be unrelated to their effectiveness. The EMDR sessions were subject to independent fidelity ratings, and found acceptable. After the 6 sessions, both treatment groups showed improvement, with the EMDR group's gains being more than double the eclectic group's (comparing effect sizes), whereas the delay group showed no change at all. At three month follow-up, the EMDR group continued to improve, whereas the eclectic group's gains deteriorated somewhat.

Although these studies have focused on trauma and/or PTSD, EMDR has been applied to numerous conditions, including dissociative disorders, grief, somatic problems, anxiety, depression, and addictions (Shapiro, 1995). Generally the approach is to locate and reprocess the disturbing memory(ies) at the root of the disturbance. However, some applications also rely on the apparent enhancement effect of EMDR on other techniques, including hypnosis, visualization, affirmation, and learning. This range of application is consistent with Shapiro's (1995) proposition that EMDR induces accelerated information processing. While awaiting further reports on EMDR's possible range of applications, its stature as a trauma treatment can no longer be denied.

EMDR for Children & Adolescents

EMDR's applicability to the treatment of traumatized children and adolescents appears to be quite promising. Anecdotal reports on hundreds of child and adolescent cases (Greenwald, 1993) support EMDR's effectiveness with this population, as well as the need for additional training to master age-appropriate technical variations of EMDR. Case reports have been positive and consistent with findings on similar treatment of adults, except that child treatment may be even more rapid (e.g., Cocco & Sharpe, 1993; Greenwald, 1993, 1994a; Pellicer, 1993; Shapiro, 1991a). For example, Greenwald (1994a) reported on the 1-2 session treatment of 5 children traumatized by a hurricane, and found that all returned to pre-trauma functioning, with gains maintaining or increasing at 1m follow-up. Several larger studies have recently been reported, and will be summarized here.

Puffer, Greenwald, and Elrod (1996) reported on a study of 20 children & adolescents who were non-randomly assigned (according to convenience of scheduling) to EMDR treatment or 1m delayed treatment groups. Treatment was a single session; the focus was a single trauma or loss. The first author conducted all treatment and assessment, using several measures, at pre, post, and 1-2 m follow-up. There was no change during the no-treatment delay, and significant improvement between the first and last scores on all measures. On the best measure of trauma symptoms (Impact of Events Scale), of the 17 participants starting in the clinical range, 11 moved to normal levels, and 3 others dropped 12 or more points, while the other 3 stayed the same. Problematic design features include lack of independent assessment (although no subjective scoring was involved) and use of a therapist with only partial EMDR training. Also, 3 participants had ongoing sources of distress, making recovery unlikely. Still, the results were quite positive, although somewhat more variable than in other studies.

A study of 10 institutionalized sex-offender adolescents found that 3 EMDR sessions (focusing on their own trauma) led to decreased disturbance, increased sense of cognitive control, and increased empathy for their victims (Datta & Wallace, 1996). Generally improved behavior in the school and the community was also reported, up to a year after treatment. Although control groups were used, the psychometric properties of the primary measure were not well developed, so the results must be viewed with caution.

The Scheck, Schaeffer, and Gillette (1996) study of high risk females, described above, included both adolescent (ages 16-19, N=18) and young adult females (ages 20-25, N=42). This study found no differences in the responses of the young adults compared to the older adolescents (J. Schaeffer, personal communication, 11/96), in that EMDR was equally effective.

Chemtob and Nakashima (1996) reported very positive results in using EMDR with 32 children and adolescents traumatized by Hurricane Iniki in Kauai, who did not respond to a generally effective previous treatment program. The design featured a delay control group, independent assessment with several standardized measures, and five therapists with varying levels of EMDR training and experience. The treatment protocol was clearly specified, and a number of efforts were made to ensure treatment fidelity. The participants averaged a 58% reduction on the primary trauma measure following 3 sessions, with results holding several months later.

Discussion

In a very few years, EMDR has grown from a bizarre-sounding new technique to the most effective and extensively researched psychotherapy treatment for adults with PTSD. It is unclear to what extent downward age extension of a method's effectiveness can be presumed following preliminary supportive research to that effect. As the recent studies including children and adolescents are entirely consistent with earlier case studies, and with comparable adult studies, it is likely that that EMDR will prove to be about as effective with children and adolescents as with adults. However, EMDR with children and adolescents will not be widely accepted until more high quality studies targeting this population are completed, assuming results consistent with current data.

Clinicians appropriately trained in this method may now legitimately try EMDR as a first-line treatment for children and adolescents suffering from the effects of trauma. It should be clearly understood that EMDR is not a stand-alone technique, but a tool judiciously used by a qualified clinician in the context of an overall treatment plan. Therefore, if EMDR should prove ineffective in a particular case, this will quickly become apparent, and other methods can be tried. Furthermore, as long as therapists are appropriately trained to use EMDR, it may actually have fewer side effects than other therapy methods (Greenwald, 1993, 1996), with the potential for intensely distressing sessions more than balanced by speedy resolution of the upsetting materaial. On the other hand, the traditional therapy approaches for traumatized children entail extended treatment and variable effectiveness (Finkelhor & Berliner, 1995; Saigh, Yule, & Inamdar, 1996). Whereas the empiricial data on EMDR and children can only be considered supportive at this point - not definitive - the benefits of this potentially rapid and effective treatment may already outweigh the risks.

Although this discussion has focussed on trauma, children often react to major loss in a very similar manner (Newcorn & Strain, 1992), except that the hyperarousal effect may be absent. Child trauma and loss is so widespread as to be normative (e.g., Ford et al, 1996), yet potentially severely detrimental to psychosocial development and quality of life (Terr, 1991). As we increasingly recognize the prevalence and consequences of child trauma and loss, much more effort is being devoted to helping children cope. Because EMDR appears to offer both effectiveness and efficiency, it may afford new hope for children and adolescents suffering from trauma or loss. Further controlled research on EMDR for children and adolescents is urgent.

References

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Chemtob, C. & Nakashima, J. (1996, November). Eye movement desensitization and rereprocessing (EMDR) treatment for children with treatment resistant disaster related distress. Presented at the annual meeting of the International Society for Traumatic Stress Studies, San Francisco.

Cocco, N. & Sharpe, L. (1993). An auditory variant of eye movement desensitization in a case of childhood post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 24, 373-377.

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