EMDR and Neuroscience Research: Some Questions and Implications for Psychotherapy Integration
Kenneth L. Welch, PsyD
August, 2007
Dr. Kenneth Welch is a psychologist in the Louisville, Kentucky area who trained in EMDR in 1993. He is currently in private practice as a general practitioner, also specializing in forensic evaluations and trauma treatments.
Contact: 1501 State Street, New Albany, IN 47150 USA
Email: Kwelch1996@yahoo.com
Since its introduction, Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro, 1989) has received the attention of many mental health professionals. There has been much critical debate on the subject of EMDR. Most of the clinical discussion has centered on the role of EMDR in the treatment of Posttraumatic Stress Disorder (PTSD).
While the EMDR procedure has been compared to Mesmerism (McNally, 1999), declared as pseudoscience (Herbert, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, and Tolin, 2000), or regarded as a highly marketed placebo (Lilienfield, 1996), most studies support the efficacy of EMDR in treating PTSD (Ironson, Freund, Strauss, and Williams, 2002; Lee, Gavriel, Drummond, Richards, and Greenwald, 2002; Marcus, Marquis, and Sakai, 1997; Rothbaum, 1997; Van Etten and Taylor, 1998; Wilson, Becker, and Tinker, 1997). There has been some evidence for accompanying physiological changes in PTSD subjects treated with EMDR with patterns of cortex functioning, (Levin, Lazrove, and van der Kolk, 1999; Nicosia, 1994) event-related potential changes (Lamprecht, Kohnke, Sack, Matzke and Munte, 2004), as well as positive effects on the level of the stress hormone cortisol (Haber, Kellner and Yehuda, 2002).
EMDR has been recognized as an efficacious treatment of PTSD by an American Psychological Association clinical review committee on psychotherapy treatments, the American Psychiatric Association, as well as by the International Society for Traumatic Stress Studies as an effective treatment for posttraumatic stress disorder (American Psychiatric Association, 2004: Chambless, Baker, Baucom, Beutler, Calhoun, Crits-Christoph, Daiuto, DeRubeis, Detweiler, Haaga, Johnson, McCurry, Mueser, Pope, Sanderson, Shoham, Stickle, Williams and Woody, 1998; Foa, Keane, and Friedman, 2000). However, controversy continues; there are some researchers that believe that EMDR “is a threat to the science of psychology and psychiatry” (Devilly, 2005). One of Devilly’s major concerns is the lack of scientific theory involved in the creation of EMDR as well as training/dissemination issues.
Theoretical discussions of EMDR’s mechanism of action for treating PTSD have included an accelerated information process model (Shapiro, 1995), a reorientation model
(Kuiken, Bears, Miall, and Smith, 2002), neurobiological models (Shapiro, 1889; Stickgold, 2002), an investigatory reflex/de-arousal model (Macculloch and Feldman, 1996), a dosed exposure/non-specific effects model (Hyer and Brandsma, 1997), a non-specific effects model (Lohr, Lilienfeld, Tolin, and Herbert, 1999) a working memory model (Andrade, Kavanagh, and Baddeley, 1997), a distraction model (Dyck, 1993), and a hemispheric communication model (Welch and Beere, 2002). Most of the models have face validity and it may be that multiple models are useful in explaining the phenomena.
In the meanwhile, despite the numerous criticisms, EMDR has been acclaimed as having some degree of preliminary utility on a range of disorders in addition to PTSD. Much research is yet to be done to determine efficacy and utility with various applications. However, the spread of EMDR and EMDR’s application to many conditions and disorders has been rapid. This rapidity of adoption, before efficacy has been established, has troubled many researchers (Herbert, Lilienfeld, Lohr, Montgomery, O’Donohue, Rosen, and Tolin, 2000; Lohr, Tolin, and Lilienfeld, 1998; Muris and Merckelbach, 1999) as well as the lack of EMDR’s integration with existing models of psychotherapy (Keane, 1998; Van Etten and Taylor, 1998). In any case, the proliferation of EMDR has been wide spread.
A partial list of the diverse disorders/conditions that have been attempted to be treated with EMDR, other than PTSD include fear of public speaking (Carrigan and Levis, 1999), choking phobia (De Jongh and Ten Broeke, 1990, chronic pain (Grant and Threlfo, 2002), Major Depression (Manfield, 1998; Parnell, 1998), Body Dysmorphic Disorder (Brown, McGoldrick, and Buchanan, 1997), pathological gambling (Henry, 1996), dental phobias (De Jongh, Van Den Oord, and Ten Broeke, 2002), children’s nightmares (Pellicer, 1993), negative body image (Hassard, 1993; Lazrove and Fine, 1996), loss of a romantic partner (Marquis, 1991) morbid jealousy (Blore, 1997), blood and injection phobias (Kleinknecht, 1993), work inhibition (Marquis, 1991), test anxiety (Maxfield and Melnyk, 2000), spider phobia (Muris and Merckelbach, 1997), sexual dysfunctions (Wernick, 1993), “narcissistic vulnerability” (Knipe, 1998), eating disorders (Hudson, Chase, and Pope, 1998), psychogenic seizures (Chemali and Meadows, 2004), Claustrophobia (Lohr, Tolin, and Kleinknecht, 1996), increasing work performance (Foster and Lendi, 1996), “masochistic personality disorder” (Grand, 1998), enhancing athletic performance (Foster and Lendi, 1995), Panic Disorder with Agoraphobia (Goldstein, de Beurs, Chambless, and Wilson, 2000; Goldstein and Feske, 1994), substance abuse treatment (Shapiro, Vogelmann-Sine, and Sine, 1994) complicated mourning (Sprang, 2001) and Dissociative Identity Disorder (Fine and Berkowitz, 2001; Paulsen, 1995).
Besides traditional mental health applications, healthcare professionals have also utilized EMDR to enhance coping in cancer patients (Henderson, 1997; Peters, Wissing, and du Pluess, 2002), with dermatological disorders (Gupta and Gupta, 2002), with gastro-intestinal problems (Kneff, 2004), and with expectant mothers to lower anxiety about giving birth (Taylor, 2003).
In brief, there seems to be almost no shortage of attempted applications for this kind of treatment. Certainly, EMDR is not likely the “magic cure” for every non-psychotic psychological disorder, but some measure of success is frequently reported in case reports for various conditions. It also seems reasonable that the widespread applications of EMDR without extensive research would concern many in the field. Some studies, (Feske and Goldstein, 1997; Muris, Merckelbach, and Holdrinet, 1998) have suggested that EMDR is not as effective as standard treatments for panic disorder or phobia.
In addition, other similar eye movement techniques have been used with differing types of headaches, interpreting dreams, marital conflict, anger, parenting issues, problems falling asleep, and stress in general (Beaulieu, 2003; Freidberg, 2001). While these techniques are not EMDR, they are similar in their use of eye movements for therapeutic change. Another possibly related treatment concerns the use of alternating optical goggles (Schiffer, 1998) to effect reported positive therapeutic changes. What mechanism(s) can account for these differing uses of eye movements/manipulations to produce allegedly positive results?
Another trend has been the adoption of EMDR as a technique for use in different psychotherapy systems in an unprecedented rapid manner. EMDR has been combined within the framework of Multimodal therapy (Lazarus and Lazarus, 2002) hypnosis (Beere, Simon, and Welch, 2001; Gilligan, 2002), gestalt therapy (Tobin, 2004), feminist therapy (Brown, 2002), psychodynamic approaches (McCullough, 2002; Wachtel, 2002), relationship therapy (Flenke and Protinsky, 2003), family system theory (Kaslow, Nurse, and Thompson, 2002), humanistic approaches (DiGiorgio, Arnkoff, Glass, Lyhus, and Walter, 2004), individual psychology (Barker, and Hawes, 1999), experiential approaches (Bohart and Greenberg, 2002), cognitive-behavioral approaches (Smyth and Poole, 2002; Young and Zangwill, 2002), and transpersonal approaches (Krystal, Prendergast, Krystal, Fenner, Shapiro, and Shapiro, 2002). This poses another question: how is it that EMDR is apparently easily integrated into other differing theoretical systems?
Because of the range of disorders/conditions, it would be make sense that a theoretical model explaining EMDR’s mechanism of action might be able to account for how EMDR may treat these other disorders and/or operate readily within other psychological approaches. It would seem that theoretical explanations that focus on psychological or physiological factors exclusive to PTSD would have difficulty accounting for how EMDR may have utility in dissimilar disorders such as chronic pain conditions, dissociative disorders or panic disorder. It would also seem that “pure” exposure models would have similar liabilities in that exposure treatments have not been indicated as possible treatment of depression or body dysmorphic disorder, for example. Importantly, however, to declare that EMDR might have some utility in treating these disorders is not the same as stating EMDR is a preferred or a first line treatment for these above disorders/ conditions.
In explaining how EMDR is possibly useful across many types of disorders and within various theoretical systems, it may useful to briefly look at common factors between theoretical approaches.
EMDR and Other Psychotherapy Approaches
A number of methods have been developed to compare and contrast different types of psychotherapy. One way to compare psychotherapies is to search for common factors between approaches. Of course this is a challenging task considering the vast array of theoretical approaches. While much has been written about how approaches differ, there are recognized common mechanisms operating in many approaches. Certainly, non-specific mechanisms such as genuineness, accurate empathy, expectations for improvement, demand characteristics, and placebo effects are well known.
Some authors (Hyer and Brandsma, 1997) have suggested that EMDR is a combination of psychotherapeutic and non-specific mechanisms. A number of common psychotherapy factors in combination such as dosed exposure, non-threatening language, free association, a nondirective format, accessing associative memory networks, and attention to affect are suggested to account for therapeutic effects of EMDR.
This author would like to suggest, in addition, that another common therapeutic mechanism involves taking an irrational thought and somehow changing that thought to a more rational thought or more adaptive thought. That is, replacing a “dysfunctional” thought with a “corrective” thought. This general idea arises in various similar forms within different therapeutic systems.
Sigmund Freud’s purported dictum that “Where the Id was, there shall ego be” seems to reflect this general idea. By Ego, it seems he is referring to the rational part of a person and to the Id as an irrational, impulsive part of a person. In object relations approaches, at the core are beliefs about others and the self that are a focus and research suggests that effective psychodynamic therapy targets those maladaptive emotional beliefs to bring about adaptive flexibility (Luborsky, and Crits-Christoph, 1990).
In client-centered therapy, Carl Rogers (1951; 1957) stressed that one of the major tasks of counseling is to turn emotional experience into symbols; that the experience is made into a verbal or conceptual understanding.
In narrative therapy, one of the goals of treatment is to change the patient’s story from a negative emotional narrative, deconstruct it, and form alternative explanations of a patient’s story which provides new structure and meaning (White, 1995). Similar ideas are evident in Rational Emotive Behavior Therapy, or Reality Therapy as well as general cognitive-behavioral interventions. In these psychotherapeutic systems, a common thread seems to be transformation of emotional responses to more logical, adaptive, flexible, as well as to more rational understanding(s).
From this point of view, EMDR probably uses largely the same process in treating disorders that other psychotherapies do. Responses that are largely based in emotional reasoning are then augmented or processed by more rational facilities in many types of psychotherapeutic approaches. A point of difference between EMDR and other psychotherapies is how this is done. Most of the above approaches utilize verbal processes to understand, interpret, and reframe difficulties. The multiple attention feature of EMDR (the client’s focus on the therapist’s moving finger, on a mental image(s), as well as on physical sensations of emotions) seems to evoke improvement in both verbal and emotional processing. This suggests a question: Does multiple focus or eye movements by an individual increase activation/connectivity in the brain? Some researchers (Christman, Propper, and Brown, 2006) have suggested there is a growing amount of evidence that horizontal eye movements increase interhemisphereic communication, which then increases episodic memory retrieval.
PTSD brain imaging studies have found distinct PTSD brain activation patterns in positron emission tomography (PET) scans. When an individual is in a re-experiencing flashback, much of the brain activity is on the right side of the brain, especially in the right prefrontal area (Rauch, van der Kolk, Fisler, Alpert, Orr, Savage, Fischman, Jenike, and Pitman, 1996). This parallels with behavioral observations of the person; he or she is very emotional and not processing much logical information. Other studies indicate a functional disconnection between the brain hemispheres in both PTSD and alexithymia (Zeitlin, Lane, O’Leary, and Schrift, (1989; Zeitlin, McNally, and Cassiday, 1993).
Since verbal and coping abilities are largely influenced by left prefrontal cortex functions (Davidson and Fox, 1989), the individual with PTSD struggles to cope and think in a rational manner while the PTSD is largely a one-sided prefrontal activation (right) pattern. EMDR appears to use a multiple attention focus to disrupt this functional disconnection. Exactly how this happens is open to conjuncture at this point; but this does appear to happen and several studies suggest that brain activation patterns are “normalized” after successful EMDR treatment by electroencephalograph (EEG) or single photon emission computed tomography (SPECT) (Levin, Lazrove, and van der Kolk, 1999; Nicosia, 1994). Perhaps improved hemispheric communication and/or increased availability of episodic memory is involved (Christman, Propper, and Brown, 2006).
Neuroscience Research
Recent advances in neuroscience research through neuroimaging have vastly increased knowledge of the inner workings of the human brain. PTSD research has indicated asymmetrical hemisphere prefrontal activation patterns during provocation trials. While it is a large jump to generalize to other disorders from PTSD, there have been an increasing number of studies, which indicate involvement of specific areas of the brain in various psychopathologies. A number of these psychopathologies involve irrational, negative emotional thoughts such as depression or phobias. Recent studies also seem to point toward functional disconnections between areas of the brain as well as functional brain activity asymmetries operating in common psychological disorders.
Neuroscience researchers (Irwin, Anderle, Abercrombie, Schaefer, Kalin, and Davidson, 2004) utilizing PET and functional magnetic resonance imaging (fMRI) have noted functional, not structural, amygdala disconnections in the brains of depressed individuals; this was not evident in non-depressed individuals. Could this disconnection be involved in the etiology/maintenance of depression (or some subtypes of depression), as it appears to be in PTSD? An interesting question is posed concerning the successful treatment of depression; do these functional disconnections reconnect during successful treatment by EMDR or any approach? Many research studies (for a review see Henriques and Davidson, 1991) have also noted left prefrontal hypoactiviation in depression.
Other researchers (Rauch, Savage, Alpert, Fischman and Jenike, 1997; Davidson, Marshall, Tomarken and Henriques, 2000) have found relatively higher levels of right prefrontal hemisphere activation patterns (and relatively lower left) with the anxiety disorders of social phobia, PTSD, obsessive-compulsive disorder, and simple phobia as compared to control subjects. Other anxiety disorders have an apparently similar neurosubstrate as PTSD in terms of a high level of right hemisphere activation and accompanying lower rates of activation in the prefrontal left hemisphere. Research has indicated that larger levels of right prefrontal cortex asymmetry correlate with higher levels of anxiety (Davidson, 2002; Davidson, Abercrombie, Nitschke, and Putnam, 1999). These anxiety disorders were also marked with high levels of amygdala activation. Research on the effects of psychotropic (benzodiazepine) drugs for anxiety has indicated that, with treatment, there is an increase in left sided blood flow in the prefrontal cortex and a decrease in right sided cortex blood flow (Buchsbaum, Hazlett, Sicotte, Stein, Wu and Zetin, 1985; Mathew, Wilson, and Daniel, 1985).
Still other studies have implicated baseline functional brain asymmetries in some types of personality disorders in the prefrontal cortex (Goethal, Audenaert, Jacob, Van den Eynde, Beragie, Kolindou, Vervaet, Dierckx, and Van Heeringen, 2004). Mallet and colleagues examined by PET three patient groups and found differences in functional brain connectivity between Schizophrenia, Obsessive-compulsive Disorder, and Major Depression (Mallet, Mazoyer, and Martinot, 1998). This study also found less connectivity between the right and left hemispheres compared to control subjects. Moreover, a lack of left prefrontal perfusion seems to be involved in Dissocative Identity Disorder (Sar, Scher, Emre, Turgut, and Endinc, 2001) It appears that functional brain disconnections and brain activity asymmetries are common in many kinds of psychological disorders and are not present in control subjects.
If EMDR does facilitate the reconnection of a functional disconnection in PTSD, EMDR may do likewise for other disorders, which could account for the different types of disorders reported to be successful treated by EMDR.
Hemisphere functional reconnection/increases in left prefrontal activation could account for positive effects in several ways. First, the left prefrontal cortex appears to have an inhibitory effect on the amygdala (Davidson, 2002; LeDoux, 1996). This is important because this inhibitory effect on the amygdala shortens the time course of negative affect and increases positive affect (Davidson, 2002). High rates of right-sided amygdala activation have been observed in both depression and different types of anxiety disorders (Davidson, 2002; Davidson, Abercombie, Nitschke, and Putnam, 1999; Drevets, Videen, Price, Preskorn, Carmichael, and Raichle, 1992; Shin, Kosslyn, McNally, Alpert, Thompson, Rauch, Macklin, and Pitman, 1997).
A functional reconnection of the circuit between the amygdala and the left prefrontal cortex could be important for the inhibition effects on the amygdala. Shapiro (1995) was the first to suggest that EMDR may reconnect areas of the brain. Unfortunately, at this point in time there are few EMDR brain imaging studies to draw from. One study, a SPECT study of a successful EMDR treatment case of PTSD, found increased activation of the left prefrontal cortex, which correlated with improvement in psychological tests scores (Levin, Lazrove, and van der Kolk, 1999). Other studies (Donghoon, and Jooho, 2004; Lansing, Amen, Hanks, and Rudy, 2005) have also observed increased activation of the left prefrontal cortex in PTSD cases treated successfully with EMDR as revealed by SPECT. However, a weakness of these studies linking EMDR to increased left prefrontal activity is the small number of subjects (9). As brain imagery becomes more commonplace, perhaps more definitive evidence will be found.
The second way that reconnection/left prefrontal cortex activation could account for symptom improvement is that coping and verbal areas are lateralized on the left hemisphere (Davidson and Fox, 1989). An increase in left hemisphere activation could likely increase these important functions, which could manifest themselves in an increase in logical verbal processing and utilization of more effective coping skills. Studies attempting to have subjects consciously repress negative affect, demonstrated an increase in left prefrontal activation (Jackson, Burghy, Hanna, Larson, and Davidson, 2000). In addition, maintaining and enhancing positive affect as well as resilience to negative affect is linked to increased left prefrontal cortex activation (Jackson, Mueller, Dolski, Dalton, Nitschke, Urry, Rosenkranz, Ryff, Singer, and Davison, 2003).
The third way that reconnection/left prefrontal activation could be useful in treatment is that the working memory is contained largely in the left prefrontal cortex (Davidson, 1994; Davidson, 2001). With high right amygdala activation and hypo functioning left prefrontal cortex, this memory could be functionally disrupted which could lead to a reduction of goal directed positive affect and reduction of goal directed behavior (Davidson, 1994). Researchers (Andrade, Kavanagh, and Baddeley, 1997) have suggested that the working memory is activated during successful EMDR treatment.
Research has also indicated that the rate of metabolic activity in the right amygdala predicts the level of negative affect in depressed individuals (Abercrombie, Schaefer, Larson, Oakes, Lindgren, Holden, Perlman, Turski, Krahn, Benca, and Davidson, 1998). Related also, is that in recovery from depression, there is less activity in the amygdala (Bench, Frackowiak, and Dolan, 1995). Of course, while the amygdala is apparently a pivotal component of many types of emotional responses/behaviors, there are many other neuro-structures that contribute to affective and anxiety disorders (for a discussion of brain structures involved in mood disorders see Davidson, Lewis, Alloy, Amaral, Bush, Cohen, Drevets, Farah, Kagen, McClelland, Noen-Hoeksema and Peterson, 2002).
A high level of right amygdala activation is also linked to reward system problems, which are common in depressive disorders (Depue and Iacono, 1989; Henriqes, Glowacki, and Davidson, 1994; Tomarken and Keener, 1998). There is also support for amygdala involvement in both depression and anxiety and may account for the common co-variance of these disorders (Davidson, 1998).
Moreover, individuals with a right prefrontal baseline asymmetry may have an important bias in perception different from individuals with a left prefrontal asymmetry. One study has found that individuals with a baseline right prefrontal pattern selected negative word pairs more often while individuals with pronounced left asymmetry selected positive word pairs more often (Sutton and Davidson, 2000); also individuals with right asymmetry remembered negative movie scenes more in detail or had more negative affect as compared to the opposite pattern in left asymmetry individuals (Cahill, Haier, Fallon, Alkire, Tang, Keator, Wu, and McGaugh, 1996; Tomarken, Davidson, and Henriques, 1990). This difference in cognitive bias coupled with diminished response to positive rewards and decreases in extinction rate (Davidson, 1994) may strongly contribute to maintaining depression once it is established
In contrast, individuals with prefrontal baselines favoring the left appear to recover from negative affect more quickly than individuals with a more right prefrontal asymmetry pattern (Larson, Sutton, and Davidson, 1998). Other studies of formerly depressed individuals with PET reveal a right prefrontal hemisphere activation pattern, as do their first-degree biological relatives who have not been clinically depressed (Henriques and Davidson, 1991). Studies with infants suggest that baseline prefrontal asymmetry patterns are, in part, genetic and active early in life (Davidson and Fox, 1989).
Learning to change prefrontal baseline asymmetry, however, is suggested by a study which used a brief training course in mindfulness meditation to increase baseline left prefrontal activation; the training also increased immune system (antibody titers from flu vaccinations) function (Davidson, Kabat-Zinn, Schmacher, Rosenkranz, Muller, Santorelli, Urbanowski, Harrington, Bonus, and Sheridan, 2003). Left prefrontal asymmetry at resting baseline has also been linked to the positive emotions including a sense of well-being, self-acceptance, a feeling of mastery, and a feeling of purpose in life (Urry, Nitschke, Dolski, Jackson, Dalton, Mueller, Rosenkranz, Ryff, Singer, and Davidson, 2004). Left prefrontal activation increases also correlates with improvement in depression (Bench, Frackowiak, Dolan, 1995).
While there are many cortical and sub-cortical structures that are involved in the production of emotional responses/behavior, the prefrontal cortex function appears to be modifiable by psychological interventions. Another study (Schaefer, Jackson, Davidson, Aguirre, Kimberg, and Thompson-Schill, 2002) suggested that amygdala activity could be consciously modified. Interventions targeting both changing prefrontal cortex asymmetry and targeting amygdala activity changes promise to be major areas of future applied research.
Immune system function is also positively related to left prefrontal baseline asymmetry (Davidson, Kabat-Zinn, Schmacher, Rosenkranz, Muller, Santorelli, Urbanowski, Harrington, Bonus, and Sheridan, 2003; Kang, Davidson, Coe, Wheeler, Tomorken, and Ershler, 1991; Rosenkranz, Jackson, Dalton, Dolski, Ryff, Singer, Muller, Kalin, and Davidson, 2003). These research studies indicate that individuals with a resting baseline left asymmetry have been shown to have higher levels of natural killer cells, lower levels of the stress hormone cortisol, lower levels of corticotropic releasing factor, higher levels of antibodies, and other positive immunity markers.
How do apparent extreme differences in emotional behavior/physical health linked to prefrontal baseline cortex function make sense? The prefrontal cortex appears to be specialized for several functions. Many researchers have concluded there are two cortical systems that underlie emotion and motivation (see for reviews Davidson and Irwin, 1999; Gray, 1987; Tomarken and Keener, 1998). One system is described as having a positive valance and having a goal directing influence on behavior and is known as the behavioral approach system (BAS). The other system is described as having a negative valance and having an inhibiting influence on behavior; this is referred to as the behavioral inhibition system (BIS). Importantly, by itself, right prefrontal cortex baseline asymmetry is not pathological; right prefrontal baseline asymmetry is probably related to a vulnerability to develop types of psychopathology (Wheeler, Davidson, and Tomarken, 1993).
Related to left prefrontal cortex function is the neurotransmitter serotonin. The prefrontal lobe has significant serotonergic projections and receptor sites (Davidson, Putnam, and Larson, 2000). Deregulation of the serotonin system (and possibly the “downstream” left prefrontal cortex) has been linked to depression, criminality, conduct disorder in adolescents, violence, and suicide (Corraro, and Kavoussi, 1997; Davidson, Putnam, and Larson, 2000; Unis, Cook, Vincent, Gjerde, Perry, Mason, and Mitchell, 1997). Anti-depressant medication such as Selective Serotonin Reuptake Inhibiters (SSRI) may treat depression, in part, by restoring serotonin balance so that the left prefrontal cortex can exert its inhibitory effect(s) on the amygdala. This suggests via a biologic substrate of how SSRI medication and psychotherapy could work together to relieve depression (and possibly other disorders, also).
The combination of the inhibition of negative affect and the access to verbal as well as other coping abilities such as working memory may account for the surprisingly rapid gains, reported in some EMDR treatment cases for varying types of disorders such as PTSD, claustrophobia, blood/injection phobia, sexual dysfunction, and nightmares (Kleinknecht, 1993; Lohr, Tolin, and Kleinknecht, 1996; McCann, 1992; Pellicer, 1993; Shapiro, 1989; Wernik, 1993) in effect, a “specific non-specific effect” that can occur during a single EMDR session. However, it is likely that other forms of successful treatment would have similar physiological effects and use similar brain pathways; the difference would be the amount of time in which this happens. This rapidity of treatment has been noted in several recent studies comparing EMDR with other treatments such as cognitive-behavioral therapy or prolonged exposure (Ironson, Freund, Strauss, and Williams, 2002; Jaberghaderi, Greenwald, Rubin, Zand, and Dolatabadim, 2004; Lee, Gavriel, Drummond, Richards, and Greenwald, 2002). Another “horse race type study” (Rothbaum, Astin, and Marsteller, 2005) compared prolonged exposure to EMDR for PTSD. Both techniques were equally effective, but EMDR had less exposure time and no homework compared to the prolonged exposure, which employed daily homework. Likewise, another PTSD study comparing EMDR to exposure plus cognitive restructuring suggested that both methods were effective with a slight advantage for EMDR; EMDR also utilized a mean number of 4.2 sessions compared to 6.4 for the exposure/cognitive restructuring (Power, McGoldrick, Brown, Buchanan, Sharp, Swanson, and Karatzias, 2002).
The Significance of Brain Research for the Field of Psychotherapy
Increasingly there has been a convergence of research on the neurobiological effects of psychotherapy. One interesting finding for the field of psychotherapy has suggested in successful treatment, the same brain regions are affected by either psychotherapy or by psychotropic medication treatments.
A growing convergence of brain scan studies comparing psychotherapy to medication treatments for Major Depression, Obsessive-Compulsive Disorder, Panic Disorder, and Social Anxiety have found largely the same brain activation effects in successful treatment by either medication or psychotherapy (Baxter, Schwartz, Bergman, Szuba, Guze, Mazziotta, Alazraki, Selin, Ferng, Munford, and Phelps, 1992; Brody, Saxena, Stoesel, Gilles, Fairbanks, Alborizan, Phelps, Huang, Wu, Ho, Au, Maidment, and Baxter, 2001; (Fredrikson & Furmark, 2003; Furmark, Tillfors, Marteinsdottir, Fisher, Pissiton, Langstrom, and Fredrikson, 2002; Prasko, Horacek, Zalesky, Kopecek, Novak, Paskova, Skrdlantova, Belohlavek, and Hoschl, 2004);. Generally, successful treatments in these disorders involve an increase in left hemisphere activation, especially the left prefrontal cortex, and a relative decrease in right hemisphere activation.
If psychotherapy (and psychotropic medication) affects largely the same areas of the brain in successful treatment, there are sizable implications for psychotherapy research. Despite possible risks for over simplification, brain imaging could be used to better understand how does psychotherapy change brain functioning.
Component analysis studies, utilizing brain imaging, could help establish what particular segments of an intervention are involved in affecting brain functioning. In the case of EMDR, for example, there has been much debate over the contribution of eye movements for treatment effects (for example, Cahill, Carrigan, and Frueh, 1999; Perkins and Rouanzion, 2002; Spector and Read, 1999; Van Den Hout, Muris, Salemink, and Kindt, 2001); component analysis of EMDR with brain imaging would be informative. Certainly cases in which EMDR (or other psychotherapies) are not effective could yield further insights. For example, a 6 session study focused on Panic Disorder and EMDR (Feske and Goldstein, 1997) found EMDR was useful in treating Panic Disorder, but at 3 months follow-up, there was reversal of some of the positive results. What happened, in terms of brain function, after EMDR and at follow-up could be revealing.
Moreover, study in these areas could yield markers for using approaches. There may be various physiological or psychological factors, which could serve as markers for good or poor outcomes for specific approaches. EMDR, because of it apparent relatively quicker treatment effect, may be useful in research as a “model psychotherapy” for this type of research. A relatively longer psychotherapeutic approach, such as psychoanalysis, would not be as servable due to confounding variables such as time or maturation effects.
Conclusion
EMDR has established itself as being difficult to understand. Ultimately the question of how does EMDR work, leads to the question of how does psychotherapy work? The advantages of integrating what is known from neuroscience research with the models of EMDR’s mechanism of action appear to be many in understanding EMDR and psychotherapy in general.
Neuroscience research suggests that effective psychotherapies, as well as psychotropic medication, utilize similar functional pathways as well as involving similar brain structures to achieve treatment results. This article attempted to link the modification of thoughts from “negative” to more corrective or adaptive, which is active in many types of psychotherapy, with functional pathways utilized by psychotherapy that have been uncovered by imaging techniques. The difference between EMDR and other psychotherapies appears to be one of EMDR’s rapidity for some disorders with some individuals; in effect, a “specific non-specific effect”. This may account for EMDR’s frequent inclusion with other psychotherapeutic approaches as well as the number of attempted applications utilizing EMDR.
The functional reconnection of brain areas and the increased activation of the left prefrontal cortex could readily account for EMDR mechanism of action models, which include accelerated information processing (Shapiro, 1995), working memory (Andrade, Kavanagh, and Baddeley, 1997) and hemisphere communication (Welch and Beere, 2002) models. The disruption of the amygdala’s effect in sustaining negative emotion could account for observations supporting de-arousal models (Macculloch, and Feldman, 1996), distraction models (Dyck, 1993) or reorientation models (Kuiken, Bears, Miall, and Smith, 2002). One could also argue a “purist” position that there is nothing totally unique to EMDR and hold to a non-specific/common factors model (Hyer and Brandsma, 1997) since effective psychotherapy or medication appear to utilize similar neuro-pathways and involve largely the same brain structures.
Research has suggested in many studies that left prefrontal baseline asymmetry and interventions that shift baseline asymmetry to the left are related to many psychological as well as physical health factors. It seems reasonable to suggest that some of the reported positive effects of EMDR could be related to this common factor that evidently is involved in many types of successful psychological treatment.
Of course, future research looking at brain structures and emotional processing with neuro-imaging during successful and unsuccessful psychotherapy treatment of different disorders could address some of the issues raised. A critical point of interest would be if the brain activity changes associated with all types of successful treatment are causal or correlational.
While this author believes the evidence suggests that EMDR can rapidly affect brain function, much needs to be understood at more basic levels of analysis, e.g., how could EMDR and other kinds of psychotherapy work on a neurochemical level to affect brain circuit connectivity and activate the left prefrontal cortex? While there are reductionistic dangers in relying too much on neuro-imagining techniques to understand disorders, there are potentially useful benefits in studying EMDR as a “prototype psychotherapy” of investigatation by neuro-imagery. For example, since EMDR is apparently fast acting, it might have advantages over some other types of psychotherapy in that other therapies are slower and would have more confounding variables.
Finally, if changing patterns of brain functioning is what successful psychotherapy “does”, a “unified field theory” could be developed to increase understanding of psychotherapy and lead to further integration in the field and with other related fields, which could aid scientific advancement (Rand and Ilardi, 2005). At this point, there is no convincing rationale for how psychotherapy works on a physiological level, despite the evidence supporting psychotherapy’s effect on patterns of brain functioning. Besides providing insights into how psychotherapy functions, other discoveries may aid in developing interventions that are more cross-cultural in nature.
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