A Strange Cure: EMDR and the Healing of Trauma
We still don't know why EMDR is so helpful, but its effect on PTSD is clear.
Posted Jul 06, 2020
Origin stories can get pretty strange. Here’s one of the more bizarre ones I've heard: In 1987, the late psychologist and researcher Francine Shapiro was walking through a park, feeling upset by distressing memories she was having. As her eyes moved back and forth, taking in the sights of the park, she noticed that she gradually began to feel relief. By the time she had crossed the park, she felt significantly better, no longer distressed by her memories.
For whatever reason, she attributed her relief to the movement of her eyes, which she assumed had somehow made her less sensitive to the memories that had previously been so distressing to her. She wondered whether this might be the seed of something useful for persistent PTSD among the veterans she worked with, many of whom had found little or no relief from other treatments. Intrusive, distressing memories, like those she had experienced in the park, are a hallmark of PTSD.
That seems like a pretty big conceptual leap to me, from relief while walking in the park to treatment of war trauma, but it’s the leap she made. As it turned out, she was onto something.
Dr. Shapiro wondered whether this eye movement concept could be tailored into an actual treatment for PTSD. By asking trauma survivors to evoke their most distressing memories while following a therapist’s finger moving back and forth across their visual field, could the memories become less distressing (“desensitized”)? Could this procedure help people “process” traumatic experiences so that they might be stored in normal memory, readily accessible, painful perhaps but no longer too frightening to tolerate?
The answer, quite simply, is yes. And for a lot of people, it does so with remarkable speed.
At the heart of the development of PTSD is the avoidance of memories and feelings we perceive as too terrifying to experience safely. It can feel like we’ll be psychologically overwhelmed if we allow the memories and related feelings to emerge. And so we expend extraordinary energy holding the lid on the boiling pot of our own memories and emotions, terrified of what might emerge, avoiding reminders of what is simmering beneath the lid, yet seeing reminders everywhere: in recurrent nightmares, in flashbacks, in the images and sounds of our daily lives. The avoidance, the lid on the pot, comes at a terrible price—exhaustion, depression, shame, irritability, an inability to ever really be at ease in the world. But it can feel like the only thing allowing us to survive, and so we keep pressing the lid down, even as our health, our relationships, our sense of being fully alive, are all gradually worn down.
For many people, EMDR makes those seemingly overwhelming memories tolerable enough to experience safely, so that they lose their terrible power and become transformed into painful but manageable parts of our past. The traumatic experience becomes a part of our autobiography—unpleasant to recall, but not overwhelming or deeply distressing. And for some people, healing from trauma gives rise to what has come to be known as post-traumatic growth, a kind of wisdom and compassion that comes from having been through a journey of profound suffering and emerged intact, with scars perhaps, but also with insight and a deepened empathy for the suffering of others.
Dozens of studies have found that EMDR is an effective treatment for psychological trauma. At a minimum, it is as effective for treating PSTD as other evidence-based trauma treatments. It may even be better; several studies have found EMDR to be superior to other methods of treating PTSD, including cognitive-behavioral therapy (CBT) and prolonged exposure (PE), a type of therapy that entails gradual and increasingly prolonged imaginal (mental) exposure to trauma-related memories and related feelings. However, many of the studies showing the superiority of EMDR have relied on very small samples (notoriously unreliable) or had other methodological limitations, so the actual superiority of EMDR remains an open question.
How EMDR works also remains a mystery. The “how” of the method, its mechanism of action, has been studied extensively, but the findings are still inconclusive. Some researchers argue that the eye movements aren’t even necessary, that the “imaginal exposure,” taking the lid off the pot in the safety and support of the therapeutic relationship, accounts for the improvement. Other studies suggest otherwise and find that eye movements do make a difference. In a recent meta-analysis (a synthesis of existing studies), Pim Cuijpers and his colleagues in Amsterdam concluded that we simply cannot say at this point why EMDR works, or whether the eye movements actually play a critical role. However, Cuijpers et al. agree on this: EMDR is effective for treating PTSD.
I got interested in EMDR in 1988 when I was working in a clinic for Bosnian refugees in the U.S. A colleague of mine had recently been trained in the method and recommended it to me after I told her about my struggle to help a severely traumatized, elderly Bosnian man whose symptoms of PTSD, the worst I had ever encountered, simply would not diminish with conventional therapy or psychiatric medication. When she told me about how the treatment worked, I laughed dismissively. Sounds crazy, I said. The origin story alone put me off. This was before there was much evidence to support the treatment. It just sounded too strange to be true.
But I was desperate. I didn’t know what else to try. My client was in such extraordinary pain. He’d tried to kill himself twice to stop his suffering. One sibling had been shot in front of him, and the other had been slowly tortured to death in the most gruesome way. And my client had been viciously beaten and kicked into unconsciousness by Serb nationalists who had occupied his small rural village as they ethnically cleansed their way across northern Bosnia.
And so I got trained in EMDR. Working with an interpreter, both of us filled with doubt and trepidation, we offered the treatment to our client.
I describe the therapy in detail in a story called "A Strange Cure" in my book War Torn, about the impact of war on civilians. Here, I’ll simply say this: After five sessions of the most intense treatment experience I've ever been a part of, complete with the re-experiencing of trauma memories in all their terrible intensity, this previously devastated, suicidal man was relaxed, smiling, sleeping without medication for the first time in years, and becoming interested in engaging socially with other people once again. In each session, he relived with great intensity a particular trauma memory, and over the course of the session, the memory was transformed, the imagery changed, and the intensity diminished, leaving him feeling lighter and remarkably more at ease.
In my experience, EMDR has been incredibly helpful to some people and just given a headache to others. I still don’t know why it works so well for some folks and not at all for others. But like in the story of the Broad Street pump in London, which was turned off to stop a cholera outbreak long before germ theory could explain why that made sense, sometimes we do what works before we understand why it works. That's actually true with all of the major psychotherapies today: We know they are generally helpful, but the evidence for why this is so remains elusive (Cuijpers et al., 2018).
One cautionary note: While the evidence is clear that EMDR can be helpful in resolving PTSD, its most passionate advocates tend to market the method well beyond what the best evidence currently supports. It's not a panacea for all mental health problems, and despite claims about exactly what happens to the mind and brain during EMDR treatment, we really have not established that yet. If you're struggling with the effects of trauma, maybe the "why" of EMDR isn't so important. Perhaps it's enough if it offers relief and a way to leave the pain behind.
If you’re curious about EMDR, here are a few resources.
From The Atlantic, “Can Eye Movement Work Like Therapy?”
From The New York Times, a Q & A with Francine Shapiro
Here's an Introduction to EMDR video on Youtube.
From The New Yorker, an excellent article on trauma, memory, and how we are learning to heal the impact of traumatic events. How to Unmake a Memory
To learn about EMDR and its use with Syrian refugees, click here.
If you want to see the Cuijpers et al. 2020 meta-analysis on EMDR, click here.