An Overview of EMDR, Updated 4/25/19
Howard Lipke, PhD
Eye Movement Desensitization and Reprocessing (EMDR) is a method of psychotherapy developed by psychologist Francine Shapiro as a treatment for psychological distress associated with trauma. It began when she chanced to notice a connection between a decrease in her own emotional distress from a troubling concern after having spontaneously moved her eyes back and forth. Shapiro then developed and informally tested a therapeutic structure around the eye movements integrating aspects of, at least, imaginal exposure, cognitive therapy, psychodynamic therapy, and mindfulness teachings, and adding an early positive psychology idea, Shapiro developed a treatment, which she informally tested. Shapiro (1989a) first systematically tested her work in a wait list control study of 21 subjects recruited from local mental health centers, including a DVA veteran readjustment center. Remarkably, all of her first 21 subjects showed profound single session desensitization effects. In addition, Shapiro (1989b) published a case study in a journal edited by Joseph Wolpe, an originator of behavior therapy, in which Wolpe, in an editorial footnote, endorsed Shapiro’s rapid effects from his own informal replication.
In response to Shapiro’s unique findings of effectiveness, her attempts to ensure that the method would be taught competently, and the odd nature of the eye movement component, considerable controversy erupted in which academic psychologists, in particular, publicly criticized many aspects of EMDR. Despite this controversial beginning, EMDR has been validated by numerous well-designed outcome studies, which have appeared in scientific peer-reviewed journals. As a result of these EMDR has been endorsed as an effective treatment for PTSD by many major US and International scientific and professional mental health organizations, including the International Society for Traumatic Stress Studies (ISTSS; Foa et al. 2009), the US Veterans Administration/Department of Defense (2004), the American Psychiatric Association (2004), SAMHSA’s National Registry of Evidence-based Programs and Practices (October, 2010) and rating bodies in England (Bisson & Andrew,2007), Northern Ireland (CREST 2003), the Netherlands (Dutch National Steering Committee Guidelines Mental Health Care, 2003), France (INSERM, 2004), and Israel (Bleich et al., 2002).. Other references for the specifics of the research and ratings are available at EMDR.com or EMDRIA.org.
Analogue studies, and now an animal study, have unequivocally supported the value of the most controversial aspect, the eye movement activity. These studies have demonstrated the role of the eye movement in reducing emotional responsivity and vividness of imagery for personal emotionally evocative memories (Andrade, Kavanaugh, & Baddeley 1997; Gunter & Bodner, 2008; Kavanagh, Freese, Andrade, & May, 2001; Maxfield, Melnyk, & Hayman, 2008; Sharpley, Montgomery, & Scalzo,1996; Van den Houts, Muris, Salemink, & Kindt, 2001).
More recently in a 2019 study published in Nature, Baek (et al. 2019) reported that fear conditioning in rats was more fully extinguished when they engaged in EMDR type eye movements than with other extinction learning interventions. The Baek et al results also found a psychophysiological path involving the Colliculus, Thalamus and Amygdala.which appeared to account for the effects of the bilateral eye movement.
In clinical dismantling studies the role of eye movement now is supported, to the extent that a least one long term critic (McNally, 2013) of the role of em now acknowledges their active effect. A leading candidate to explain the role of eye movement has been the idea that if it is elicited while the traumatic memory is brought to “working memory” (see Maxfield et al. 2008) it affects the way that memory is subsequently stored, or reconsolidated. However, the recent Baek et al. study lends support to another early hypothesis (see Lipke, 1999) that the eye movement creates an “orienting response” that interferes with the conditional response created by the trauma experience and allows for natural memory processing of the event, from not-declarative (reliving memory) to declarative (historical/intellectual) memory.
Aspects of EMDR which, added to the positive outcome research, make it a candidate for treatment of choice for the psychological effects of trauma are, the high frequency of rapid therapeutic effects, the absence of requirement for disclosing the details of traumatic event or dwell on the painful memories, and the absence of a requirement for extensive client homework.
The Basics of EMDR Treatment
Shapiro has been careful to distinguish EMDR as a technique, from EMDR as a method of treatment, and then an overall approach to psychotherapy. As a technique for reducing distress related to traumatic incidents, as well as increasing adaptive consideration of these events, clients are asked bring to awareness a most painful image, a related belief about themselves (called the present or negative cognition, e.g. “ I am powerless”), and the emotions and body sensations currently associated with this target traumatic event. Asked to be aware of the preceding, clients are instructed to be mindful of what occurs to them as they follow the therapist’s hand with their eyes as it is moved back and forth about a foot and a half in front of the face, across the full range of vision for about 25 repetitions. The clients then, if willing, report the content of awareness at the time the eye movement stopped. (This lack of a requirement to report content is one of the attributes that makes EMDR particularly attractive to trauma survivors.) In the most straightforward cases eye movements are applied to the new content of awareness, and repeated until desensitization or processing is complete. For example, in the middle of a session one might find this interaction:
Client: Stupid, that was stupid, I don’t see how I ever could have done that.
Therapist: See what happens next (leads set of em) Let it go, Take a deep breath…What comes to you now?
Client: Now I am thinking about how I didn’t really have a good choice about what to do.
Therapist: Notice that. (set of em) Take a deep breath… What comes up now?
Client: I’m feeling a little calmer
Therapist: Okay, see what happens next. (leads set of em)
Also occurring prior to adding the eye movement, but not explicitly attended to when it begins, clients rate their level of distress when contemplating the worst moment of the traumatic event on a 0 – 10 version of Joseph Wolpe’s Subjective Units of Disturbance Scale. Clients are also asked to offer a thought they would prefer to have when remembering the traumatic event (called the preferred or positive cognition, e.g. “I dohave choices in life.”). The preferred cognition is rated on a “gut” level of believability from 1 to 7, as the person contemplates the target trauma. These ratings taken, before the eye movement activity begins, are later used to help evaluate progress toward what Shapiro first thought of as desensitization, but later considered reprocessing of the trauma, (Hence the change of name from the original EMD) but might best be considered the continuation of processing.
Shapiro (2001) considers EMDR more than the technique described above. As a method of psychotherapy it is described as including 8 phases. These include all of what one would expect in psychotherapy for trauma related psychological problems, i.e. problem identification, history taking, evaluation of coping ability, rapport building, explanation of treatment and stress management. Phases 3 and 4, described in the “technique” section above, are the core of treatment. Phases 5 and 6 involve activities aimed at making sure reprocessing is complete, that is that the memory of the target event is no longer maladaptively distressing, and if possible, whatever good that can come out of the event becomes dominant when the event is contemplated. Phase 7 involves closing a session, especially if the processing is not complete, and Phase 8 involves re-evaluation of the therapeutic work in the next session, and finally, termination considerations. Also guiding treatment is what Shapiro refers to as the “three prong protocol”. This denotes the need to reprocess memories of past events, present situations in which the past event leads to maladaptive responses, and imagined possible future related problematical situations.
As an approach to therapy Shapiro considers EMDR to contain a philosophy of experience based psychopathology, embodied by what she currently refers to as the Adaptive Information Processing Model (AIP). According to the AIP, experience based psychopathology is caused by the memory of events being held in dysfunctional “neuro-networks”; natural adaptive information processing “accommodation and assimilation” has been blocked because of the overwhelming emotion associated with these events.
It should be noted that the reprocessed events need not be what is conventionally called trauma; seemingly innocuous events ( e.g. an off hand insult, at the wrong time) may, be taken as traumatic. This recognition of the emotional power of events considered outside of the conventional definition of trauma appears to be consistent with current thinking in the mental health field. (see Mol et al. 2005)
As life proceeds, ongoing eventsmay trigger these memories, which she describes as being held in “state specific” form, and produce dysfunctional thoughts, emotions and behavioral responses. This aspect of the AIP has much in common with some earlier theories including the psychodynamic work on traumatic stress by Mardi Horowitz (1976). The AIP specifies that EMDR treatment is not considered complete until all dysfunctionally held memories are processed, and potentially difficult future situations are attended to.
EMDR clinicians have observed that while clients are processing the target memory other memories with similar themes, not necessarily found in the reported history, may arise. They have reported this to be a feature significantly separating EMDR process from other methods they have used. (Lipke, 1995) The notation of connection of these memories is another key feature of the AIP. In the AIP traumatic memories are most fundamentally, though not exclusively, organized around and connected by affect.
The feature of the AIP least related to other theories and practice is the expectation that the reprocessing of memories can take place very quickly, as seen in Shapiro’s single session initial studies, as well as in later research. There is the expectation of a significant 1 – 3 session psychotherapeutic response in most clients with a single traumatic experience. In contrast expectations for other methods is a longer course of treatment, such as the 8 -12 sessions for prolonged exposure, with frequent homework added. This rapid response is attributed to what has been referred to so far as the eye movement component. In fact, early in the development of EMDR such activities as alternating bilateral auditory or tactile stimulation have been used with clinical success.
The variety of activities which can substitute for eye movement led that aspect of EMDR to be conceptualized and referred to as either Bi-lateral Stimulation (BLS) or Dual Awareness. While each of these attempts to abstractly define this part of therapy capture some aspect of it, each has some theoretical problems. However, other compelling descriptive names have not yet been suggested. If the above mentioned working memory hypothesis holds up to scrutiny, perhaps the activity will be called the “Working Memory Overload”, or the “Orienting Response Creating” component. Though these ideas might not explain the research results which show eye movement can lead to improved episodic memory, or the above mentioned tendency of EMDR to bring unexpected new associations, both troubling and redemptive, to awareness. It has been suggested, first by Shapiro, that the mechanism of effect may be the same as found in dreaming sleep, and later in a proposed discussion of possible psychophysiological mechanisms of effect by neurophysiologist Robert Stickgold (2002, 2008). REM sleep has been found to produce remote associations. If this is the process then in EMDR, the unexpected troubling associations and “curative” material which comes to awareness would be like the “remote” associations not normally accessed during traumatic nightmares and intrusive thoughts and images.
As we can see, while there is plenty of evidence of the psychological effects of eye movement, there are many open questions about the theoretical basis of EMDR. The answers as to underlying mechanisms may turn out to be quite complex.
(Rather than present a lengthy list of references readers are directed to the lists in the guidelines and web sites mentioned in the first section of this paper)
Following Shapiro’s initial controlled study, numerous case studies and then experimental studies were conducted. In treatment of PTSD and Acute Stress Disorder these compared EMDR with wait list controls and with other methods of treatment. Subject populations have included children and adults, veterans and civilians, survivors of natural disasters, sexual abuse, rape, auto accidents, and the innumerable other causes of traumatic response. Results have been sustained on follow-up studies of one, three and 15 months. There have been several meta-analyses of EMDR effectiveness. When these have compared EMDR to other methods, EMDR has been found to produce progress similar to the most often highly rated treatment method, prolonged exposure. Some of these analyses have also supported the rapidity of effectiveness. EMDR efficacy is not likely attributable to researcher allegiance effects, as three controlled EMDR studies conducted by two different respected research teams, two under the leadership of Barbara Rothbaum (1997; et al 2006) a highly regarded exposure treatment advocate, have shown positive results for EMDR despite the fact that the principle investigator would not be considered an EMDR advocate,.
Studies have shown EMDR’s effectiveness with both acute and chronic traumatic responses. EMDR has also been reported to be used effectively for individuals with diagnoses other than PTSD including, depression, body dysmorphic disorder, chronic pain (including phantom limb pain), phobia, and performance anxiety.
EMDR and Veterans
The first published research on EMDR included the presentation of successful treatment of some combat veteran subjects (Shapiro 1989a), as have several other published controlled (Carlson et al. 1998) and systematic clinical studies (e.g Graca et al. 2014; and Botkin 1999). It is much more common for veterans than for civilian trauma survivors to have psychological trauma related to their own actions. Hence, one aspect of EMDR which makes it particularly valuable in the treatment of combat related trauma is the way guilt and shame based traumatic memories are handled. While cognitive therapy and exposure require discussion of events which the veteran may not be willing to reveal, and exposure therapy is only designed for fear based trauma, EMDR does not have these limitations. If a client has debilitating PTSD symptoms related to harming or killing, which he fears if revealed might leave him or her condemned by the therapist, or even in legal jeopardy, work on the most troubling issues, or even therapy itself, may often be avoided. With EMDR the therapist does not need to know the details. So, in establishing the image, negative cognition, feelings, and an alternative cognition, before eye movement begins, there can be a general discussion of how one finds redemption from acts, common in war, which are sometimes called unforgivable. The result of such treatment is that oftentimes while the eye movement is taking place, the veteran comes to understand the situational causes of the action and/or the underlying fear or grief. The loss of those who died and his own loss of innocence may be mourned, .He or she may become much less likely to have to rely on anger as a defense, and be able to lead a much more productive and less destructive life.
Early criticisms of EMDR were strong and sometimes personal, as one might expect of a treatment in which a therapist from California waved her hand in front of the client’s face, and claimed substantial one-session effects for a problem sometimes considered intractable. The earliest criticisms were based on doubt that the reported outcomes were valid, and that if they were the therapeutic effects were substantially the result of other embedded established aspects of treatment, especially cognitive therapy and exposure. Ignoring Shapiro’s insistence that EMDR be called “experimental” until replications of her research existed, and her promotion of research by offering free training to researchers, another line of criticism (Baer et al. 1992; Herbert et al., 1995) was that the marketing of EMDR included excessive claims, and that the training policies reflected excessive propriety concerns, which limited full scientific exploration.
Many of the criticisms have been answered by the research supporting EMDR effectiveness, as well as that supporting the eye movement component of EMDR decreasing intensity of visual imagery and emotional intensity of memories with a strong affective component. Other research has supported the role of eye movement in promoting intellectual information processing (Christman et al. 2003). Also problematic to the critics who have claimed that the EMDR mechanism of effect is simply exposure, or the effects of the cognitive aspects of the protocol, is the amount of time dedicated to each of these activities. The amount of imaginal exposure is far less than such therapies prescribe, especially when considering that exposure homework is not part of the EMDR protocol, and the client is not encouraged to concentrate on the trauma material, but rather free associate to it. A claim that EMDR effects were attributable to mindfulness instructions would be at least as viable as the exposure claim. Similarly, in many EMDR sessions the cognitive restructuring activity is limited to the extent that in those cases it could not account to the level of change observed clinically or in experimental studies.
While the overwhelming majority of reports by psychotherapy rating bodies, as mentioned in the introduction, have supported EMDR as a front line treatment for PTSD, two have acknowledged it may have beneficial effects, but have been less enthusiastic in their praise. These were issued by the Institute (2007) of Medicine (IOM) and the American Psychological Association (2017). In both cases the evaluators excluded important supportive EMDR research. Most notable was their exclusion of the Wilson, Tinker and Becker (1997) study, showing strong 3 month and 15 month therapeutic effects. Both claimed that the study failed to establish that subjects met criteria for PTSD. However both ignored the fact that when results were analyzed for subjects who met criteria the positive effects were statistically comparable to the sample as a whole. Both rating teams were, as requested, given feedback on Wilson et al. as well other studies after distributing their preliminary reports, and both appeared to ignore the provided information.
The question of Shapiro’s proprietary control has been addressed by the establishment of an independent professional association, the EMDR International Association (EMDRIA), which oversees training, Sometimes, however, critiques of control are from advocates of EMDR who object to what they consider EMDRIA’s excessive restrictions on content, the form of training requirements, as well as requirements to establish and maintain the various levels of “expertise” mandated by the organization.
In addition, Shapiro’s AIP model appears to have been elevated to being the foundational model of EMDR, and inextricable from it. Aspects of the AIP and its description of how psychological problems occur, how they can be can be ameliorated, and how personal growth can be promoted through EMDR may be valuable. However, there are aspects of the AIP which leave it less successful in its stated role than EMDR is in its clinical effectiveness. One of these problems is that while, as mentioned above, in many cases cognitive restructuring is very limited and could not account for level of therapeutic change, in a minority of cases there is reliance on the kind of cognitive or interpretive interventions found in other traditions of psychotherapy. The AIP does not account for the cognitive restructuring which is part of the method as it is taught and practiced. Current representations of the AIP (e.g. Solomon and Shapiro, 2008) fail to conceptualize this integration of mechanisms of effect. Another limitation of the AIP is the claim it is a psychophysiological model without offering a psychophysiological mechanism. (Lipke, 2009)
EMDR is widely accepted as an evidenced based treatment for PTSD and is used extensively Based on reports from various EMDR training organizations it is reasonable to suppose over 100,000 therapists have been trained worldwide. While it has considerable academic support outside the USA, it has not found a comfortable home in the academic world in the USA itself. Two of the reasons for this may be that many are still tied to their early strong criticism of EMDR, finding it difficult to accept the research results, and that Shapiro, and later, EMDRIA did not establish training policies which were seen as promoting the academic freedom expected in a university setting. Nonetheless, research activity on EMDR is extensive and continues to grow, with studies often coming from research groups outside the United States, and covering mechanisms of effect and exploring its potential with problems and concerns beyond PTSD. Since 2007 there has been a peer reviewed journal, the Journal of EMDR Practice and Research, dedicated to research and clinical reports on EMDR. At least as much with any other subject, in order to be up to date with the current status of EMDR, one must follow the journals or proceedings of professional conferences. Finally, it should be mentioned that EMDRIA now officially refers to EMDR as, “EMDR Therapy”
American Psychological Association (2017) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults
American Psychiatric Association (2004). Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines.
Baek, Jinhee; Lee, Sukchan; Cho, Taesup; Kim, Seong-Wook, Kim, Minsoo; Yoon, Yongwoo; Kim, Ko Keun; Byun, Junweon; Kim, Sang Jeong; Jeong, Jaeseng, Jeong; Shin, Hee-Sup (2019) Neural circuits underlying a psycho therapeutic regimen for fear disorders. Nature, 566, pp 339 – 445. https://doi.org/10.1038/s41586-019-0931-y
Baer, L., Hurley, J.D., Minichiello, W.E., Ott, B.D., Penzel, F.,&Ricciardi, J. (1992). EMDR workshop: Disturbing issues?the Behavior Therapist, 15, 110 – 111.
Bisson, J., & Andrew, M.(2007).Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub3.
Bleich, A., Kotler, M., Kutz, I., & Shalev, A. (2002).A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel
Carlson, J.G., Chemtob, C., Rusnak, K., Hedlund, N., & Muraoka, M. (1998) Eye Movement Desensitizaton and Reprocesing (EMDR) treatment for combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3 – 24.
Christman, S. D., Garvey, K. J., Propper, R. E. & Phaneuf, K. A. (2003) Bilateral eye movements enhance the retrieval of episodic memories. Neuropsychology, 17, 221 – 229
CREST (2003).The management of post traumatic stress disorder in adults.A publication of the Clinical Resource Efficiency Support Team of the Northern Ireland Department of Health, Social Services and Public Safety, Belfast.
Committee on Treatment of Post Traumatic Stress Disorder, Institiute of Medicine(Iom): The National Academies (2007) Treatment of posttraumatic stress disorder: An assessment of the evidence. http://www.nap.edu/catalog/11955.htmlDepartment of Veterans Affairs & Department of Defense (2004).VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense. Office of Quality and Performance publication 10Q-CPG/PTSD-04.
Dutch National Steering Committee Guidelines Mental Health Care (2003).Multidisciplinary Guideline Anxiety Disorders. Quality Institute Heath Care CBO/Trimbos Intitute. Utrecht, Netherlands.
Graca, J.J., Palmer, G.A. & Occhietti, K. E. (2014) Psychotherapeutic interventions for symptom reduction in veterans With PTSD: An observational study in a residential clinical setting. Journal of Loss and Trauma: International Perspectives on Stress & Coping, 19:6, 558-567, DOI: 10.1080/15325024.2013.810441
Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies(2nded.) New York: Guilford Press.
Herbert, J.D., Lilienfeld, S., Lohr, J., Montgomery, R. W., O’Donohue, W., Rosen, G.M. & Tolin, D. (2000) Science and pseudoscience in the development of Eye Movement Desensitization and Reprocessing: Implications for clinical psychology. Clinical Psychology Review, 20, 945 – 971.
Horowitz, Mardi (1976) Stress Response Syndromes. New York: Jason Aronson/
INSERM (2004).Psychotherapy: An evaluation of three approaches.French National Institute of Health and Medical Research, Paris, France.
Ironson, G.I., Freund, B., Strauss, J.L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure.Journal of Clinical Psychology, 58, 113-128.
Lipke, H. J. (1999) EMDR and Psychotherapy Integration.Boca Raton: CRC Press
Lipke, H. J. (2009) Letter to the editor: On science, orthodoxy, EMDR and the AIP. Journal of EMDR Practice and Research, 109 – 110.
Lipke, H.J. (1995) Eye Movement Desensitization and Reprocessing (EMDR): A quantitative study of clinician impressions of effects and training requirements. EMDR clinicians survey. In: Shapiro, F. Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedure: First Editions.New York: Guilford. Available at HowardLipke.com
Lipke, H.J. and Botkin A. (1993). Case studies of Eye Movement Desensitization and Reprocessing (EMDR) with chronic post-traumatic stress disorder. Psychotherapy, 29:4, 591-595.
Maxfield, Louise, Melnyk, W. T., & Hayman, C.A. G.( 2008) A working memory explanation for the effects of eye movement in EMDR. Journal of EMDR Practice and Research, 247 – 268.
McNally, R. J. (Fall, 2013) The evolving conceptualization and treatment of PTSD: A very brief history. Trauma Psychology, pp.7-11.
Mol, S.S.L., Arntz, a., Metsemakers, J.F.M., Dinant, G., Montfort, P.A.V. & Knottnerus, J.A. (2005) Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study. British Journal of Psychiatry, 186, 494 – 499.
Rothbaum, Barbara ( 1997) A controlled study of Eye Movement Desensitizationand Reprocesing in the treatment of posttraumatic stress disordered victims. Bulletin of the Menninger Clinic., 61,317 – 334.
Rothbaum, B., Astin, M. & Marsteller, F. (2006) Prolonged exposure versus Eye Movement Desensitization and Reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607 – 616.
Shapiro, Francine (1989a) Efficacy of the Eye Movement Desensitization Procedure in the treatment of traumatic memories. Journal of Traumatic Stress. 2(2),199-223.
Shapiro, Francine (1989b). Eye Movement Desensitization: A new treatment of post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry. 20(3). 211-217.
Solomon, R. M. & Shapiro, Francine (2008) EMDR and the Adaptive Information Processing model. 315 – 325.
SAMHSA’s National Registry of Evidence=based Programs and Pratices (October, 2010) Eye Movement Desensitization and Reprocessing. http://nrepp.samhsa.gov/ViewIntervention.aspx?id=199
Shapiro, Francine (1995) Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures. New York: Guilford.
Shapiro, F. (2001) Eye Movement Desensitization and Reprocessing: Basic Principles, Protocals and Procedures (2nd ed.). New York: Guilford.
Shapiro, Francine (2018) Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures. (3rd ed.) New York: Guilford.
Spates, C.R., Koch, E., Cusak, K., Pagato, S. & Waller, S. (2009) Eye Movement Desensitization and Reprocessing. In Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies(2nded.) New York: Guilford Press.
Stickgold, Robert ( 2002) EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58,61 – 76.
Stickgold, Robert (2008) Sleep-dependent memory processing and EMDR action. Journal of EMDR Practice and Research ,2, 289 – 299
Van Etten, M. & Taylor, Steven (1998) Comparative efficacy of treatments for post-traumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5, 126 – 144.
Wilson, S., Becker, L.A., & Tinker, R.H. (1997). Fifteen-month follow-up ofeye movement desensitization and reprocessing (EMDR) treatment of post-traumatic stress disorder and psychological trauma. Journal of Consulting and Clinical Psychology, 65, 1047-1056.
In their influential discussion of the psychological effects of war, Litz et al. (2009) offer the term “moral injury” to describe the destructive effects of the moral and ethical challenges (that is, horrors) of war. That they are raising the subject to academics, many of whom consider the emotional problems related to trauma essentially fear based, is a valuable service. They also usefully summarize research on the effects of moral conflict and violation of life principles on warriors. So, perhaps it will be considered quibbling if I raise a few concerns about their presentation, nonetheless:
1. Litz et al. assert that since DSMIII “there has been very little attention paid to the lasting impact of moral conflict-colored psychological trauma among war veterans in the clinical science community.” If by “the clinical science community” they mean non-practicing clinicians, they might be right, however,
2. when they go on, in their Introduction, to say that:
“A possible reason for the scant attention is that clinicians and researchers who work with service members and veterans focus most of their attention on the impact of life-threat trauma, failing to pay sufficient attention to the impact of events with moral and ethical implications; events that provoke shame and guilt may not be assessed or targeted sufficiently. This explanation seems plausible given the emphasis on fear memories in evidence-based models of treatment…”
it looks to me as if they are demonstrating their lack of knowledge about the work practicing clinicians actually do with combat veteran clients. The clinicians I have known, over my 35+ year career working with combat veterans in a VA treatment center and in providing consultation to therapist in many VA treatment centers, have continually tried mightily to help veterans with profound destructive non-fear related emotions.
Litz et al. offer no support for their claim about how clinicians act in this matter, but, as the above quote indicated they do offer speculative reasons why this imaginary phenomena might have “occurred”. Their assertion in the above quote that clinicians have been attending primarily to fear based emotions because they are influenced by evidence based methods appears to dismiss years of evidence cited by Karlin and Cross ( 2014), VA colleagues of Litz et al., who conclude that evidence based methods have been practiced in research settings and “…have not crossed the bridge into community practice settings in public and private mental health care systems.” (p19)
3. In their review of the clinical practices available for treating “moral injury” Litz et al. erroneously find no evidence based methods that explicitly address this issue. This failure appears to be inexplicable ignorance of EMDR, one of the few widely accepted evidence based treatments for PTSD ( e.g. VA/DoD, ISTSS guidelines), and one that explicitly acknowledges the non-fear based psychologically destructive effects of war and other traumatic experience. It is inexplicable, because this group of authors have certainly been aware of EMDR and its scientific standing.
Very early in Shapiro’s development of EMDR she conceptualized one source of distress as related to how clients held themselves responsible for events, whether or not they were reasonably to blame. So, in the cognitive therapy like (actually, it seems most specifically similar to, but not the same as, Ellis’ REBT) portion of EMDR treatment, she had clients develop what might become an understanding of the events and their regretted behavior that would conceivably not be associated with debilitating level of emotions, such as guilt, shame or despair they feel ( e.g. A client might remember a traumatic event and think “I am worthless”, or” I am evil”. The therapist then works with the client to develop a plausible potential belief, such as “ I can learn from this.” or “ I did the best I could under the circumstances”, or “I can find forgiveness.”) These or many other possible ways of understanding the events are discussed with the client as goals to find emotional resonance that is worked toward with EMDR. It must be noted that these understandings could include spiritual and/or philosophical beliefs, and evocation of the internalized beliefs of figures the client respects. Litz et al propose similar activity in the later stages of their 8 step “moral injury” intervention. There are some other overlaps, which we cannot call borrowing by Litz et al. because there is not indication in their work that they are aware of EMDR, but it is at least the failure to fully consider the precedent literature.
It should also be mentioned that in Shapiro’s (& Forest, 1997) book, describing a variety of cases, that there is an extensive report of her successful treatment of a combat veteran for the debilitating guilt related to the death of a prisoner being held by his unit.
For the authors to miss EMDR in surveying the field before offering their own treatment approach seems to reflect a lack of a required openness to precedent, which makes it difficult to consider their work a result of true scientific inquiry.
In a future post I hope to present some ideas on the question of the use of the term “injury” in this context. Litz et al. do say they do not want to medicalize these issues, however, I don’t know if you can use their terminology and not do so. It is a complex and difficult issue, on which which I hope to be able to share useful thoughts.
Karlin, B.E. & Cross, G. (2014) From the laboratory to the therapy room. American Psychologist, 60 (1), 19 – 33
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P, Silva, C.& Maguen, Shira (2009) Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695 – 706
Shapiro, F. & Forest, M. (1997) EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books.
Hamlet (to Polonius) Good my lord, will you see the players well bestowed?…
Polonius: My lord, I will use them according to their desert.
Hamlet: Use every man after his desert, and who should ’scape whipping?
Hamlet II 2
What is wrong with the phrase “moral injury”?
If we are to have a label for the category of problems related to the destructive psychological effects following harming or believing you have harmed others, it should not be “moral injury”. As Shakespeare’s quote suggests the injury would apply to us all, thus not of much use. If we consider “moral injury” as only applying to some, then, perhaps the difference is between those who know it and those who don’t. We could then divide the world between Poloniuses (who don’t know it) and Hamlets (who know it). And, then subdivide the Hamlets between pre/not-symptomatic and symptomatic. In Hamlet’s case the symptoms would have to be considered to have started after the father-murdered/mother-remarried trauma.
Furthermore, in that the designation “moral injury” is being applied in psychotherapeutic practice, specifically to people looking for help because of depression or symptoms usually considered part of PTSD, then the “moral injury” label is likely to be counter-productive. As a therapist, I have often tried to help people whose feelings of guilt over destructive actions (or inaction) have interfered with their being able to lead productive lives, and even potentiated the negative effects of their regretted behavior. But, I think categorizing them as having been morally injured would make many think I was treating them as the primary victim of their behavior, which they would find grossly insensitive.
What is the alternative?
If you are going to attack a term that has a use, as how “moral injury“ helps make the portion of mental health professionals stuck exclusively in the fear based understanding of the destructive psychological effects of trauma, then you are responsible for offering an improvement.
I have not been able to come up with anything that has the aesthetic fluidity of ”moral injury”, so far the best I can do is “trauma potentiating guilt”. I think it does not judge whether or not regretted acts should be considered an injury to the actor, but rather makes the focus helping people do what is worthwhile, given their experience. Psychotherapy relating to these issues is complex and I will not try to describe in detail here. It alluded to in the previous post in the discussion of EMDR and in some detail in EMDR and Psychotherapy Integration. I plan on updating and elaborating on those ideas in a later post.
North Chicago Conflict Resolution Institute
(a work in progress)
The nccri is a semi-fictional organization created to help people peacefully resolve internal conflicts and conflicts with others. Sometimes it teaches skills they need to accomplish this, but often times it just reminds them to use what they already know. Of course, the principles can be just simply stated for people to use if they choose, but when ideas are attached to a structure or organization, and practice is encouraged we often find it easier to use them when we need them.
So, the nacre was created as an entity to provide that structure, and is called an institute instead of a club, because of the educational component. The value of this general approach can be demonstrated with an example involving my friend William. He came across a kitten stuck in a tree. He was in a hurry to get where he was going, and was tempted to walk on, however, he remembered he was a member of the Help-A-Treed-Kitten Club (HATKC) and stopped to help poor tabby down.
The nccri was formed out of a concern as serious as the HATKC’s (I hope I don’t get in trouble for saying this) is frivolous. It was developed to help veterans meet the goal of preventing combat solutions to non-combat problems. The military teaches skills for violent resolution of conflict, and the American military does it particularly well. The lessons learned in the military, before and during combat, helped veterans survive there, and may even help veterans survive violent situations in civilian settings. However, when people are so well trained for and experienced in combat, that kind of solution can come out automatically, before other solutions are considered, especially when there is stress involved. It should be said that it is not just the military that teaches aggression, and employs anger to block hurt, many parents and others involved in child raising teach or foster a similar martial approach, which gets absorbed and can dominate reactions to stress.
The internal combat response does not only involve emotions, it also involves thinking patterns. The thinking pattern that becomes most likely to turn non-combat situations violent is rapidly thinking of others as enemies. This may save lives in war, but can be self defeating, increasing rather than limiting risk outside the combat zone.
This institute was originally established, about 25 or 30 years ago , in conjunction with the Stress Disorder Treatment Unit (SDTU) at what is now called the Lovell Federal Health Care Facility. nccri activities partially overlap with SDTU programs for both resident and non-resident participants. It is a principle of the Institute that successful study of peaceful conflict resolution, when appropriate, will go hand in hand with decreases in symptoms of PTSD for those who have these symptoms. However, the distress and disruption of meaningful and pleasurable functioning that may come with having been in war cannot be fully described in terms of psychiatric symptoms. They must also be considered from other points of view, spiritual, philosophical, educational, vocational, and social. These are more the purview of exploration and education than treatment.
To be a member of the nccri one only has to agree that making peaceful conflict resolution, when possible, is a goal. Membership in the Institute is completely voluntary. There is no list of members. However, the founder Howard Lipke, is the only one authorized to decide what is, or is not, an official activity of the nccri. A membership card is offered below, it can be downloaded and printed.
Howard Lipke, PhD
As taught by 500 veterans who have been tormented by their war.
Part 1 How to know you are a war hero
(pick some from the list below)
Believe you didn’t do enough
Believe the real heroes are dead
Have pride in what you did
Despise what you did
Not give a shit about what you did
Believe you should have died
Think you must figure out the secret reason you didn’t die
Be angry at the people who weren’t there
Think of everything you can to keep your kids from going
Love anyone else for going
Think you only did what you had to do
Think you didn’t have to do everything you did
Think this is not how heroes think and feel
Part II How to get over being a war hero
Grieve everything and everyone you lost
Grieve all the yous you think you could have been
Go through the grief until you recognize the impossibility of the other selves
Learn we have an obligation to find serenity
Learn that nobody in their right mind needs you to suffer anymore
Learn that living your life well is the only way to honor the dead
Learn that trying to carry other people’s pain would be an insult, if insults could exist
Stop pretending you are not going to die
Learn that knowing something once is not enough, we must keep coming back to it
We don’t pray once
Part III Where you learned the definition of the word hero
Maybe when you were a kid you learned to look up to someone as a hero
You thought that person had all the answers, all the power, all the skill, and none of your kind of fear
Then you grew up, but still never noticed
that the hero didn’t feel what you thought he felt
Now we know that the courageous are scared,
and the skillful aren’t always courageous
Part IV Summary
There was a new recruit from Maine
who thought he would earn him some fame.
He got in the fight,
and Lord it got tight,
but you better not call him a hero because now he knows
it is much more complex than that, and besides all the heroes are dead
Podcast from the University of Buffalo School of Social Work
Listen to a 35 minute interview with Howard Lipke conducted by Dr. Nancy Smyth, dean of the School of Social Work. The basics and history of the development of the HEArt program are discussed, as are research, general ideas about anger prevention work and clinical practice with combat veterans.
Episode 180 – Dr. Howard Lipke: HEArt for Veterans: Identifying the Hidden Emotion. (2015, November 23). inSocialWork® Podcast Series. [Audio Podcast] Retrieved from http://www.insocialwork.org/episode.asp?ep=180
Below are two paragraphs from a paper on stigma, especially as it applies to veterans. (Actually there are two papers, one addressed to veterans and one more academically written for MH professionals) In the second paragraph it is suggested that if vets, or anyone with trauma related “symptoms,” is going to get down on themselves they should at least “Get it right.” which is the name of the academically oriented paper these quotes come from.
That stigma (being marked or believing one is marked as disgraced) is a primary barrier to veterans seeking help to overcome the destructive psychological effects of trauma is one of those cultural phenomena which is easy to see, widely acknowledged, and also supported by research (Hoge et al 2004) . As is often pointed out, the stigma has two manifestations, (e.g., Corrigan, 2004) the belief by others that the need for psychological help is a sign of essential inferiority, and the same belief held by the self. Both are important with the self-stigma clearly most damaging.
- Current stigma term: Crazy Vet
More accurate term: Stuck Transferer
This is the stigma associated with re-experiencing symptoms. “Stuck Transferer” refers to the idea that flashbacks and reliving nightmares are a manifestation of unprocessed memory. In Horowitz’s terms (1976) memory has not moved (transferred) from short term to long term storage. In the version presented to veterans this is called moving from “reliving” to “historical” or “intellectual” memory.
Let’s start with a fairly circumscribed mild point. We need a new definition of EMDR, one that does not begin with “…evidence based …” or “…successful outcomes well documented …”, as occur in EMDRIA’s official definition. Those aren’t phrases you find in a definition, you find them in an evaluation or a press release. In addition, “evidence based” suggests that EMDR was developed from research demonstrating the effectiveness of its various aspects. It wasn’t, but more on that later.
I have a definition in which more is different from EMDRIA’s than just the absence of self praise. I don’t think my proposal is perfect, but so far it is the least bad one I know of. It should also be mentioned that a version of the one below was submitted to EMDRIA during the latest development of the EMDR definition and it was rejected. But, that doesn’t mean the discussion should be over, or that someone could not use mine if they needed one that focused on essential features.
And, here it is: Eye Movement Desensitization and Reprocessing (EMDR) is a method of psychotherapy in which aspects of a target associative network (usually a troubling memory) including visual images, thoughts, feeling, emotions, are identified, as are a preferred thought about the self when target memory is active. The believability of the preferred thought is rated, as is the level of distress felt as the troubling memory is activated before initiated eye movement.
With the painful aspects of the problem memory again brought to awareness, the client is asked to free associate while moving her or his eyes following the therapist lead, in a repeated pattern for a period of time, determined by client response, but usually about 30 seconds. After the set of eye movement, the client is asked to report on the current content of consciousness, and then eye movement is reinitiated. This pattern is repeated until distress associated with the target network is resolved, and, hopefully, adaptive associations are connected to the targeted event. In its most complete form all aspects of the target memory(ies) are addressed, including related past events and possible future situations which may elicit related psychopathological responses.
Therapist comments between sets of eye movement are limited to brief instructions, unless the client is not progressing by either becoming aware of new material or not having decreased distress. In these cases a variety of interventions, many typical of other methods of psychotherapy may be made before eye movements are resumed.
There are many variations to specific aspects of the above activities, including on what the client is supposed to try to keep in mind as em begins. These variations are determined by client response, experience and research.
As in standard psychotherapy practice negotiation of treatment contract, client evaluation, history taking, building of rapport, explanation of method, and development of stress management strategies are part of treatment.
And now a short dictionary/elevator definition:
EMDR (Eye Movement Desensitization and Reprocessing) – a method of psychotherapy which usually involves recalling a troubling experience and engaging in therapist led repetitive back and forth eye movements or other sensory/motor activity. The rest is commentary.
I was just kidding about the commentary part. This subtle reference to Rabbi Hillel’s effort to explain his religion while standing on one leg obviously doesn’t belong in a definition. However, it should also note that Rabbi Hillel is reputed to have also suggested that the commentary should be studied.
Response to a potential objection:
I can foresee objection to the phrase: “including on what the client is supposed to try to keep in mind as eye movement begins”. The allowance of the loosening of the protocol comes from clinical practice. Let’s say before the first set of eye movement, when the therapist asks the client to put in mind a picture of the worst part of the target memory, the client has an immediate strong emotional reaction, and the therapist then begins the eye movement. Since the client has already been prepared for eye movement at this point most experienced therapists I have asked would just begin it. Would this not be EMDR because most of the Assessment phase was skipped over?
There will never be a fully satisfactory definition of EMDR, and this is a problem with almost all terms in the mental health field including such basic terms as “mental health” and “psychotherapy”. So we have to pick compromises that are most useful and least problematic.
As a psychology graduate student, in the 1970’s, I came across an edited volume, The Abnormal Personality Through Literature, by Alan A. and Sue Smart Stone (1966), which presented long passages of great works of fiction to describe psychiatric syndromes and psychotherapeutics. I thought it a great idea then, and still do. The work you are reading attempts to apply their method more specifically, to just the destructive psychological effects of trauma and efforts to overcome them. The other variations from Stone and Stone include the use of shorter passages, and comments on changes in the way trauma has been recognized over the years, since it has been officially acknowledged in the Diagnostic and Statistical Manual (DSM) as the official United States standard.
A reasonably clean rough draft:
This is a paper based on work with combat veterans over many years and addresses some of the most difficult and painful concerns people can have, the difficulty of which is magnified by involvement in war. It includes discussion of forgiveness of others and the self, with the decision to forgive, not all or nothing, and not a foregone conclusion.
Recently the phrase “moral injury” has been applied to some of the issues addressed in this paper. While I’m glad the moral and emotional reactions to participating in combat are being more fully considered by psychologists who used to only talk about the fear related to traumatic experiences, I’m not sure that the injury metaphor is most useful way to consider them. The term moral injury appears to be about what is already considered when we talk about guilt. Guilt people feel related to trauma, whether it seems justified to others or not, or necessary or not, has already been subject of much psychotherapeutic work, written about for a long long time and undoubtedly considered even longer.