EMDR, or Eye Movement Desensitization and Reprocessing therapy, is a type of psychotherapy that was originally developed to address individuals who had experienced some form of trauma or seriously disturbing emotional event. The basics of the technique were developed in the late 1980s by psychotherapist Francine Shapiro. Shapiro was working with clients who had experienced some form of subjective trauma, and noticed that when they made lateral eye movements while discussing their experiences and feelings, they reported relief from their stress.
Lateral eye movements are side-to-side movements of the eyes. Shapiro developed a technique where clients followed her fingers back and forth across their visual field, and then discussed their feelings, memories of trauma, etc. As she developed the technique, she borrowed major principles from Cognitive Behavioral Therapy. The only element of EMDR therapy that is unique is the use of eye movements or of other types of attention-grabbing techniques, such as the use of sounds or finger tapping to get the client to focus their attention while discussing their feelings about emotionally laden experiences.
EMDR was originally designed to treat individuals who had experienced stress as a result of traumatic experiences, such as for people diagnosed with PTSD (post-traumatic stress disorder) or similar issues. As the technique developed, it was applied to other issues, including substance abuse that was related to trauma and stress.
Over time, Shapiro and her followers developed an organization devoted to the practice of EMDR. The technique is now applied over many different issues that are not related to the stress associated with the experience of a traumatic event. EMDR can be used to treat numerous problems, including substance abuse.
How Does EMDR Work?
EMDR therapists have their clients focus on some type of external stimulus, such as their finger, and follow the stimulus back and forth as the therapist moves it side the side. This is the rapid-eye-movement component of the EMDR technique, although in some cases, eye movements are not used, and clients are instructed to concentrate on finger tapping or some other external stimulus. As the client’s focus is on this external stimulus, the therapist and client discuss the client’s memories and beliefs, and attempt to use a cognitive-behavioral approach to restructuring the client’s beliefs around troubling memories or other issues.
EMDR therapists believe that this process retrains the brain, and allows the client to become desensitized to memories of stressful or traumatic events, or to beliefs that lead to behaviors that are dysfunctional, such as substance abuse. Shapiro and her colleagues contend that this process is based on the findings of behavioral neuroscience; however, many of the explanations for the use of the eye-movement component of the technique are questionable. EMDR does use established therapeutic principles from different psychological paradigms and incorporates these into the overall process; however, these principles were established before the development the EMDR, and most of them are based on the principles of cognitive therapy, behavioral therapy, or other established principles from psychotherapy in general.
- The use of the therapeutic alliance as the main mechanism of change is a very important component of EMDR. The therapeutic alliance refers to the commitment of the therapist and the client to work together to help the client resolve their issues, and it has a long history of research evidence to identify it as one of the most important aspects of successful therapeutic outcomes. The use of the therapeutic alliance as an important factor in treatment outcomes was recognized long before the development of EMDR.
- The use of exposure techniques, which involve physically or mentally confronting stressful issues or disturbing beliefs (using imagery), was established by behavioral psychotherapists as a main approach to treating issues with anxiety long before EMDR was developed. Having clients visualize and verbally discuss their experiences and feelings is simply a method of exposure therapy using imagery. This approach was in use long before the development of EMDR.
- The use of systematic desensitization is an application of exposure therapy that is used in EMDR. Clients develop a hierarchy of stressful or anxiety-provoking situations, and then learn relaxation techniques. The therapist and the client work together to have the client imagine the least stressful situation on the list while engaging in relaxation techniques. This allows the client control over their feelings of stress or anxiety, and eventually they are able to tolerate the stressful situation. Once the client can handle the least stressful situation, they move down the list to the next anxiety-provoking event and repeat the process. This process continues until the client can tolerate the most anxiety-provoking or stressful situation on the list. Systematic desensitization was used long before the development of EMDR.
- The use of cognitive restructuring, changing one’s dysfunctional attitudes or beliefs into beliefs that are realistic is the main component of Cognitive Behavioral Therapy. EMDR therapists use this technique in conjunction with the eye-movement component. Cognitive restructuring techniques are one of the main components of Cognitive Behavioral Therapy and were in use long before EMDR was developed.
Other components used in psychotherapy that had been established prior to the development of EMDR include thoroughly assessing the client’s situation before applying therapeutic techniques, developing concrete goals for the therapy, using relaxation techniques such as diaphragmatic breathing and progressive muscle relaxation, assigning homework projects, and reevaluating therapeutic progress. Many proponents of EMDR, including the national organization that is devoted to the practice of EMDR, speak of these components in their program as if they are unique to EMDR.
Clients who have alcohol use disorders and are treated with EMDR are exposed to all of these principles within the organized approach that EMDR uses to treat clients with all types of problems.
The Use of an 8-Step Approach
EMDR classically uses an eight-step approach to guide the therapist in addressing the needs of the client. EMDR would be classified as an action-oriented psychotherapy where clients actively engage in treatment and do not passively listen to recommendations, interpretations, or instructions of the therapist. Briefly, the eight-step approach (often referred to as an eight-phase approach) for treating an individual with an alcohol use disorder is outlined below.
- The therapist gathers information by fully assessing the client’s needs and the issues that brought the client to therapy. The therapist will continue to assess the client throughout treatment; however, in the early phases of treatment, the idea is to identify specific issues or targets that will need to be formally addressed. For treatment of an alcohol use disorder, targets include conditions that induce cravings and understanding how alcohol fulfills the individual’s needs.
- The therapeutic alliance is strengthened by having the therapist explain the goals of the therapy, further developing goals with the client, and giving the client tools to immediately use, such as teaching the client progressive relaxation and the use of mental imagery to deal with stress, anxiety, or even cravings for alcohol.
- The specific targets of the treatment are identified, targets are rated in terms of their subjective stress to the client, and the overall goals of the treatment are developed.
- The fourth stage begins to use the actual EMDR technique by having the client focus on stressful memories, dysfunctional behaviors, or irrational attitudes, and follow the therapist’s finger with their eyes as the therapist moves it back and forth. During this process, cognitive restructuring techniques are also used to change the client’s beliefs.
- Cognitive restructuring continues, and functional coping mechanisms (e.g., not using alcohol to deal with stress or to relax) are developed.
- The client and therapist evaluate the effectiveness of the treatment and continue to work on issues that need to be resolved.
- Reassessment of progress continues, and the client begins to rate their satisfaction with their progress. Areas may be readdressed, and the therapist and client begin to work on terminating the therapy.
- The overall progress is reevaluated. If the client is satisfied with the therapy, treatment is terminated, but the client can return any time if needed.
During the reassessment phases of the treatment, the therapist and client can go back to any previous step and start over if it is determined that more intensive work needs to be done. EMDR uses a very methodical and structured approach to addressing the needs of the client. Individuals with substance use disorders identify the reasons for their substance use, how their alcohol or other substance use makes them feel, evaluate the dysfunctional aspects of their alcohol use, and learn to replace their dysfunctional beliefs that promote the use of alcohol to more realistic beliefs that promote sobriety.
Most EMDR applications designed to address issues with alcohol abuse or other substance abuse are used in conjunction with treatment for past trauma and stressful events. For instance, individuals diagnosed with PTSD often have significant issues with alcohol abuse or other substance abuse, or an individual who has suffered physical, emotional, or sexual abuse may turn to alcohol or drugs. An EMDR therapist would concentrate on helping the client restructure their beliefs and actions associated with the experience of trauma, and also work on treating the individual’s substance abuse issue.
Pros and Cons of EMDR
Many EMDR therapists will make the assumption that addictive behaviors are related to prior experiences of trauma, and they will attempt to discover what types of trauma or stress the individual has experienced prior to the development of their alcohol use disorder. Even though the major organizations that define and identify treatment methods for addictive behavior, such as the American Psychiatric Association, recognize that individuals who experience trauma or stress are at an increased risk to develop any type of substance use disorder, they also recognize that:
- Any individual who is diagnosed with any type of mental health disorder is at an increased risk to develop a substance use disorder, such as an alcohol use disorder.
- Any individual who is diagnosed with any type of substance use disorder is at an increased risk to also be diagnosed with nearly any other mental health disorder.
- A risk factor to develop PTSD or any other trauma- and stressor-related disorder is having a pre-existing substance abuse issue.
Thus, despite the contentions of many that substance abuse is often used to self-medicate existing issues, a full understanding of the relationship between substance abuse and other mental health issues indicates that these relationships are very complicated, and there is no single explanation as to why they co-occur together. It has long been recognized that treatment for individuals who have co-occurring disorders (a substance use disorder and some other psychological disorder) can only be successful if both conditions are treated at the same time. Therefore, if a therapist is using EMDR techniques to treat co-occurring conditions, such as a trauma- and stressor-related disorder and an alcohol use disorder, they are simply following the long-observed standard treatment protocol to address the situation. EMDR therapists have not discovered anything new when they treat substance abuse and PTSD concurrently.
There are some pros to the use of EMDR.
- There appear to be no side effects associated with the treatment.
- There is evidence that EMDR is at least as effective as Cognitive Behavioral Therapy in treating trauma and stress (see below).
- The process is very structured and organized.
- The process is time-limited and does not require a person to be in therapy for years like psychoanalysis often may.
- Insurance companies may cover it.
- Clients in treatment are actively involved in the recovery process.
- EMDR therapist require specialized training before they can be certified in use of the technique
Other perceived pros to using EMDR treatment could be that there is some scattered research evidence that it is effective in treating issues with substance abuse. For instance, two research studies reported in the Journal of EMDR Practice and Research report positive outcomes for the treatment of substance abuse in individuals with trauma and stress-related issues and those without a formal diagnosis of this type of disorder. However, the Journal of EMDR Practice and Research is the official publication of the EMDR International Association, an organization that is solely devoted to the practice and continued propagation of EMDR. Thus, the studies do not qualify as independent research studies, but could be interpreted as selective publications. Instead, independent research and independent evaluations of EMDR offer a slightly different viewpoint.
A previous pilot study using a very small number of participants reported in the Journal of Psychoactive Drugs found EMDR treatment for trauma was effective, but it was not effective for treatment of substance abuse in these individuals. The results of the study cannot be generalized due to the small sample size, but do suggest that more independent research that investigates how treatment with EMDR affects use of alcohol or other drugs is needed. The above studies do not qualify as independent research.
Questions about the Eye-Movement Component
There is no question that the overall approach used by EMDR therapists is useful in treating trauma and stress, but there are significant concerns and questions about whether the technique offers anything different or advantageous. One of the major issues with EMDR is that independent research and even EMDR practitioners often recognize that the eye-movement component of the therapy is not necessary for the treatment to be effective. For instance, other types of attention-focusing techniques are sometimes substituted for the eye-movement component, such as the use of sounds or even the therapist tapping their finger. Replacing the eye movement component with these techniques does not appear to affect the outcome of the treatment. This means that the theoretical foundation of EMDR, the eye-movement component’s value, should be seriously questioned.
In addition, the scholarly book Science and Pseudoscience in Clinical Psychology, which attempts to differentiate empirically validated types of treatment from those that lack sufficient empirical validation, investigated the research on this technique and concluded that the eye-movement component does not add anything to already established treatment principles used by EMDR therapists. An article published in Scientific American came to the same conclusion. These results suggest that EMDR therapists are simply using behavioral and cognitive-behavioral techniques to achieve their therapeutic success. The eye-movement component adds nothing to these already established techniques.
Meta-analytic research is considered to provide a far more reliable evaluation of a therapeutic technique than any single research study. Meta-analytic research combines the results of numerous research studies to determine if the research demonstrates an overall effect for the therapy technique. Meta-analytic studies have come to the same conclusion that the eye-movement component of EMDR does not offer any incremental validity; it does not add anything to the already established techniques and principles that EMDR uses in its treatment approach.
Finally, a review in the very prestigious source The Cochrane Review came to the conclusion that the use of EMDR is superior to no treatment at all for addressing issues with trauma and stressor-related disorders. However, EMDR did not offer an advantage to other established forms of treatment, such as Cognitive Behavioral Therapy used to address these issues. This means that EMDR is superior to no treatment at all (a positive finding), but despite the claims of its supporters, it does not offer anything in addition to already established treatments. The use of EMDR results in overall outcomes that are generally equivalent to those produced by Cognitive Behavioral Therapy or other established techniques; however, this should not be a surprise because EMDR liberally borrows from cognitive and behavioral principles.
The reason why these findings are important is that they have established that the special component of EMDR, the eye-movement component, appears to offer no additional value or effectiveness for most individuals who become involved in treatment. This would most likely apply to treatment for substance use disorders alone as well as treatment for other types of disorders.
The bottom line is that EMDR is not dangerous, will not hurt anyone, and is equally efficient when compared to other established forms of therapy in treating issues with stress and trauma. The downside to EMDR is that the eye-movement component of the therapy, so valued and cherished by its practitioners, does not seem to add anything to already established treatment principles. In addition, more research needs to be done to determine the effectiveness of EMDR in the treatment of substance abuse, such as for alcohol use disorders.
When it comes to individual subjective experiences of therapy, it is certainly possible that some individuals with alcohol use disorders may find the organized approach used by EMDR therapists, the special attention they get, and the engagement in the process of treatment that occurs with EMDR to be especially satisfying for them. If a person is faced with the prospect of paying out of pocket for therapy, and treatment with EMDR is more expensive than treatment with more traditional providers of cognitive-behavioral principles for alcohol use disorders, it may be prudent to opt for traditional therapy. If cost is not an issue, anyone who wishes to be part of EMDR treatment should be able to benefit from the experience.