EMDR

EMDR stands for eye movement desensitization and reprocessing, which is a mouthful and also kind of misleading because the eye movements may not actually be the active ingredient. The therapist sits across from you, has you bring up a traumatic memory, then has you track their finger back and forth with your eyes (or taps your knees alternately, or hands you small buzzers that vibrate alternately) while you focus on the memory. After a couple minutes you check in, then go again, and you keep going until the memory loses its emotional charge. It sounds like nonsense.

It’s not nonsense. Here’s the honest version of my stance on it, because the conversation about EMDR in this field is usually one of two equally annoying extremes. Personally I think it’s hokey. I couldn’t take it seriously enough to find out whether it would do anything for me. That’s a personal aesthetic complaint. The research doesn’t care what I think. For single-incident adult PTSD, the data is solid, often better than I would have predicted given how the protocol looks from the outside. When it works, it works as well as anything else in the field, and sometimes faster than the alternatives. So I refer for it. Refusing to refer because the protocol feels weird to me would be putting my preference above the patient’s outcome, and that’s not how this is supposed to work.

What the evidence actually says

For single-incident adult PTSD (a car accident, a specific violent event, a single bad call on the job), EMDR has roughly the same effect size as trauma-focused CBT (cognitive behavioral therapy, the structured worksheet-and-homework version of psychotherapy), which is the other gold-standard PTSD treatment. Both work. EMDR is often faster… five to ten sessions versus twelve to twenty for CBT, depending on the case. That’s the main selling point and it’s a real one.

For complex trauma (childhood abuse, repeated traumatization, the kind where your whole nervous system got built around defending itself), EMDR can still help, but it’s a longer haul and it usually needs to be combined with other work. EMDR for the patient who watched a fatal accident on the job two years ago is one project. EMDR for the patient whose childhood was a continuous parade of bad situations is a different project, with a longer setup, more stabilization work first, and a slower rollout.

For depression without trauma underneath, anxiety without trauma underneath, OCD, or general life dissatisfaction, EMDR isn’t really indicated. Some therapists try to use it for everything because it’s what they trained in, and that’s a sign you should find a different therapist. A tool that’s good for one specific use case used for everything is the field’s most common quiet failure mode.

What a session actually looks like

First couple sessions are setup. The therapist takes a history, builds a target list of memories to work on, teaches you some grounding skills in case things get too intense during processing. Then the processing sessions start, which are the weird-looking part if you’re describing them to a friend at a bar later.

You bring up the memory, you rate how disturbing it is on a 0-to-10 scale, you identify a negative belief you have about yourself related to it (“I should have done something,” “I’m not safe,” “I’m weak,” the usual greatest hits), and a positive belief you wish you had instead. Then the bilateral stimulation starts. The therapist guides you through sets of eye movements or taps. Between sets they check in: what came up, what are you noticing, where do you want to go next. You don’t have to talk much during the actual sets, which a lot of guys actually appreciate. It’s not the talking-cure version of trauma work.

The memory often shifts on you. Sometimes new details surface. Sometimes you find yourself remembering something else that’s related but you hadn’t connected before. Sometimes you cry, sometimes you don’t, and the not-crying version isn’t a sign the work isn’t happening. By the end of a good session, the original memory has lost some of its punch. You can still recall it, but it doesn’t grab you by the throat the same way.

Who it’s good for

People with a clear, identifiable traumatic memory or set of memories driving current symptoms. Veterans with combat trauma. First responders with a particular bad call that won’t leave them alone. Survivors of car accidents, assaults, medical traumas, single bad events that landed and stayed. The clearer the target, the better EMDR tends to work, and the more it ends up looking like the success-rate numbers in the literature.

Patients with diffuse, chronic, started-in-childhood trauma where there’s no single “the thing” to point at can still benefit from EMDR, but it’s not the place to start. Stabilization work first, distress tolerance, often DBT skills (dialectical behavior therapy, the skills-and-group approach for handling big feelings), sometimes medication first, then EMDR layered in once you’ve built enough capacity to handle the processing without falling apart for a week after every session.

What’s nice to hear when it works

The thing about EMDR that doesn’t get said enough is how relatively fast it can be when it’s the right tool for the right person. Five to ten sessions for a single-incident case isn’t a lot of therapy. Say you’ve got a line worker who responded to a major storm and watched a coworker get electrocuted ten feet away, starts having nightmares a year later, starts avoiding storm calls, starts drinking before bed. Clear target, recent event, classic PTSD. Six sessions of EMDR and he reports back that he can think about the day without his hands shaking, which had been a weekly thing for months. The memory’s still there, he’s not going to forget it, but it doesn’t run his life anymore.

That’s the version of trauma work that gives the patient a finish line. CBT for trauma has a finish line too, but it’s longer, and the work involves more verbal processing, which some patients find easier and some find harder. EMDR offers an alternative for people who don’t want to spend twenty weeks talking through every angle of the event. The data backs the alternative. The fact that the protocol looks slightly absurd from the outside is a problem for me, not for the patient.

What it isn’t

EMDR isn’t hypnosis, even though it looks vaguely similar to somebody peeking in through the door. You stay awake, you stay aware, you can stop any time and the protocol respects that. It isn’t a memory-recovery technique either. EMDR isn’t used to unearth memories you don’t have. If memories come up during the work, fine, but the goal is reprocessing what’s already there, not digging for buried treasure. That’s the kind of thing that got the field into the recovered-memory mess in the 80s and we are not doing that again.

It also isn’t always pleasant. Sessions can be intense. Patients can leave feeling drained or raw. Most EMDR therapists tell you not to schedule anything emotionally demanding right after a session. Give yourself a quiet evening, low-stakes plans, maybe an early night. The processing keeps happening for hours after the session ends, sometimes into sleep, and pushing through with a packed evening usually means you don’t get the full benefit of the day’s work.

Finding a good one

EMDR has a real certification process through EMDRIA (the EMDR International Association). The credential is verifiable. There’s a difference between somebody who took a weekend training and somebody who completed the full certification program with consultation hours, and the difference shows up in the work. If you’re going to do this, get the certified version. The protocol is fussy enough that running it half-trained turns it into a different therapy that happens to use bilateral stimulation.

Most insurance now covers EMDR for PTSD, which wasn’t the case ten years ago. The session count is usually low enough that the financial trade-off is favorable even if you’re paying out of pocket, especially compared to the cost of staying symptomatic for years and trying to medicate around it.

The therapy works either way. The mechanism is debated and probably won’t be sorted out in our lifetimes.

The mechanism debate, which is mostly academic

Researchers have been arguing about how EMDR works for thirty years. The leading hypothesis is that the bilateral stimulation occupies enough of your short-term mental bandwidth (the part of your brain that holds whatever you’re actively paying attention to) that the traumatic memory can be re-encoded in a less activating way. There are other hypotheses involving REM sleep mechanisms, hemispheric integration, and a few that boil down to “we don’t really know yet.” It’s possible the eye movements aren’t doing the work and the structured exposure-plus-cognition piece underneath is doing most of it, in which case EMDR would be a slightly weird variant of trauma-focused CBT. Or it could be something else entirely.

From the patient’s standpoint, the mechanism debate doesn’t really matter. The protocol either works on the case in front of it or it doesn’t, and the rate at which it works is well-documented across enough trials that not knowing exactly why is more of a science problem than a clinical one. Most of medicine works this way, by the way. Lithium has been used for mood stabilization since the 1940s and the field still doesn’t entirely know how it works. The drug works anyway. EMDR is similar.

Where I land, and where you land is up to you

If you’ve got PTSD from a clear traumatic event, EMDR is one of the two best things on the table and I refer for it regularly despite the personal aesthetic reservation. If you’d rather do CBT for trauma, that’s also a defensible choice and the outcomes are comparable. If neither sounds workable and you want to start with medication, that’s also a real option, particularly if the trauma symptoms are bad enough that you can’t yet sit through the trauma-focused work without it overwhelming you. The trauma processing usually goes better after the worst of the acute distress is medicated down to a manageable level.

Bottom line

If you’ve got a specific trauma you can point at and you’re having PTSD symptoms because of it, EMDR is one of the two best treatments available. It’s often faster than CBT, and a lot of patients find it easier because there’s less talking and more just doing the work. Find a therapist who’s actually certified in it. Five to ten sessions for the average single-incident case. Then you go back to your life with the memory still there but no longer running it.

Sources

1. Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev. 2013;(12):CD003388. PMID 24338345.
2. Watts BV, Schnurr PP, Mayo L, et al. Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry. 2013;74(6):e541-550. PMID 23842024.
3. Lee CW, Cuijpers P. A meta-analysis of the contribution of eye movements in processing emotional memories. J Behav Ther Exp Psychiatry. 2013;44(2):231-239. PMID 23266601.