EMDR is a very popular treatment option for pretty much everything.

At this point though, it began as a treatment for trauma.

You're probably seeing it everywhere and have been, and

there's a good chance you've worked with a therapist who uses EMDR.

When most people think of EMDR, they picture a therapist waving a finger in

front of someone's face, and that's it.

That image has become shorthand.

This shorthand image causes a lot of confusion when it

comes to accurately assessing.

What's actually helpful about EMDR.

So in this episode, I'm gonna look at what EMDR is beyond the eye movements.

Also, I'll look into whether or not EMDR is helpful based on research, and

even more interestingly, what research says about what's helpful about EMDR.

If you're new to the podcast.

Hi, I am Justin Sunseri.

I'm a therapist licensed in California, and I've been, I've been practicing

for about 17 years with a wide range of demographics, uh, populations.

I primarily use a blend of very present, moment focused, body-based

and solution-oriented techniques.

I also run the Unstucking Academy.

It's a small, private community for those who love what I do here on the

podcast and are ready to take their self-regulation efforts to the next level.

I'll have links to the Unstacking Academy and everything that I discuss

here in this episode in the description.

Okay, so the first thing is we need to understand what EMDR actually is.

This is gonna change how you hear everything that comes

after this first uh, piece.

Uh, and to do that, we will look briefly at the eight phase structure of EMDR.

Phase one includes history taking and treatment planning.

The therapist gathers context, identifies target memories and judges whether

the person is ready to begin trauma processing, pro trauma processing.

Phase two is preparation and stabilization.

The therapist explains.

The EMDR process builds rapport and teaches the client grounding

skills and uh, ways to manage when things get intense, which.

I, they very likely will just due to the nature of talking about traumas,

phase three or traumatic incidents.

Phase three is assessment.

Here the therapist and the client activate a specific memory and identify

the components, the image, the negative belief attached to it, the positive

belief the client wants instead, the emotions, the bodily sensations.

They measure the distress and the believability of the new belief using

baselines before processing starts.

Phase four is desensitization.

This is the one almost everyone thinks of when they hear EMDR.

In this phase, the client holds the target memory in mind while following a

bilateral stimulation of some sort, and the therapist continues the bilateral

stimulation until the distress reduces.

Phase five is installation where the therapist again uses bilateral stimulation

to strengthen a new adaptive belief.

Phase six is the body scan.

The client holds the memory and the new adaptive belief.

And then scans the body for any resi- residual tension.

If tension shows up, additional processing can follow.

Phase seven is closure sessions end with containment strategies and the

return to baseline, so the client leaves feeling stable whether or not,

uh, the processing was completed.

And finally, phase eight is reevaluation.

At the next session, you check whether or the therapist checks whether

the the gains are held, whether the target is still processed, and

whether new targets need attention.

So notice where bilateral stimulation shows up.

It's mainly in phases four, five, and if needed six.

That means the eye movements or taps, or sounds or whatever

are a part of the process, but they're not the whole therapy.

When viewed as a cohesive whole, the vast majority of EMDR is not very special.

Once you remove the bilateral stimulation component, it involves

assessing and treatment planning, the rapport building, managing distress,

questioning beliefs, and thinking, thought replacement, bodily awareness,

discussing past traumatic incidents, reevaluating and making new goals.

All of these pieces are fairly typical therapy components.

If you ask any therapist if they do any of these pieces, they'll probably say, yeah,

and they'll probably say that they, uh, do many of these pieces in some combination.

Likely all of them.

So does EMDR work?

The short evidence-based answer is yes.

Multiple organizations have, uh, recognized EMDR as an effective

treatment for PTSD, the American Psychological Association, the APA

includes it among evidence-based options.

Well, uh.

Sort of, there's a caveat there.

They list it as a second tier option.

The APA says it's more helpful than being on a wait list and more

helpful than treatment as usual, and that the pros of EMDR outweigh the

cons or the cons of, I guess, not undergoing anything at all, basically.

Well, it's better than standing around and doing nothing and probably better

than very basic talk therapy, so.

That's kind of something.

The World Health Organization lists, EMDR as a standard, and the

United States Department of Veterans Affairs and Department of Defense

give EMDR a strong recommendation.

In randomized trials, EMDR, consistently outperforms wait list

controls and non-specific treatments.

Which is important, but again, it doesn't really tell us very much beyond the fact

that the protocol does more than the passage of time or simple attention.

People get better and evidence shows that EMDR helps them get better.

So that's important.

But that's only half the question really.

When researchers compare eMDR to other trauma-focused therapies like,

um, cognitive processing therapy, or trauma-focused CBT or prolonged

exposure the outcomes are, broadly speaking, similar direct comparisons

amongst these tend to show equivalent reductions in PTSD symptoms.

That pattern shows up across multiple trials and meta-analyses.

So what does that tell us?

It suggests EMDR is an effective, uh, and effective to make sure that was

clear and effective path to healing, but not necessarily a unique one.

Different roads can lead to the same place basically.

So let's talk about what those shared roads look like.

In psychotherapy research, common factors emerge- elements that

appear across different therapies and explain much of why they work.

For trauma therapies, these common factors are maybe especially relevant.

So the first one, I'm gonna give you four.

The first one is the therapeutic alliance, the relationship between

therapist and client is a major predictor of positive outcomes

across almost every form of therapy.

I would say every form of therapy actually.

That bond the therapist's empathy, the attunement, the ability to repair

ruptures- these create predictability and a safe other to heal with.

This co-regulation process from therapist to client, creates a platform for safety.

It'll even activate the body's ventral vagal pathways, which are

responsible for many cognitive, social, and health benefits when active.

When active, the then the therapy techniques are useful.

So when in safety, then techniques become useful, whether that's challenging false

beliefs or telling the trauma narrative.

So that's, that's the first one.

Number two is exposure.

Processing a traumatic memory by holding it in mind while

staying present is exposure.

In EMDR, the client activates the memory and stays with it during desensitization.

In prolonged exposure, the person repeatedly recounts the narrative.

Trauma-focused CBT has the client tell the narrative repeatedly as well.

The formats differ, but all of these involve confronting the

memory rather than avoiding it.

Exposure allows the brain and the body to relearn that the memory is

a memory and not a current threat.

The recovery process of exposure is also extremely important- i- is important,

but I would say extremely important.

The system learns that it can access discomfort, whether through

a memory or something else.

It can access discomfort and then recover from it.

Repeatedly doing so builds the body's distress tolerance.

Third is expectancy and hope.

Belief that the therapy will work matters.

Positive expectations is mobilizing.

Somebody with hope is more likely to take action and maximize their therapy time no

matter what style the therapist is using.

Simply having hope is big and having hope with a safe other is even bigger.

And number four, the last one is cognitive reprocessing.

Most therapies involve some level of questioning thoughts,

whether through reframing them or reality testing or something else.

Many clients of mine actually, they will explicitly tell me or ask me to,

to call them out on their thinking.

Like if they're avoiding things through making excuses or rationalizing

their pain or minimizing it.

People want to have clearer thinking.

They wanna be called out on it.

These elements and more show up across various therapies.

They are not unique to EMDR.

They account for a large share of positive outcomes regardless

of the modality a therapist uses.

So we have addressed whether or not EMDR is effective, but there's a much more

interesting question we need to ask.

Do the eye movements or other forms of bilateral stimulation matter?

Is that the active ingredient that makes EMDR special, or is it just an accessory

on top of the things that actually work?

People have tried to answer this question with dismantling studies.

These are clinical trials that compare full EMDR with versions that

remove the bilateral stimulation or put other controls in place

of the bilateral stimulation.

And research trials have found that EMDR, with and without eye movements found no

significant difference in PTSD symptoms.

A meta analysis of several dismantling studies found no

significant- significantly, uh, statistically significant advantage

for bilateral stimulation.

But there was another meta-analysis that found a moderate benefit to eye movements

in lab-based studies, but this benefit was inconsistent in clinical PTSD trials.

So a benefit in the lab, but not so much outside the lab.

You're wondering, "But Justin, why would lab results be different than clinical

trials?" Well, many potential reasons.

Uh, in lab studies, everyone is on their best behavior.

They're following protocols.

They know they're being monitored, maybe evaluated, and therefore

that provide, they provide the best possible treatment that they can.

In controlled trials therapists are also more likely to be trained

for the study and supervised, unlike the real clinical world.

On top of- where therapists act more in silos.

On top of that, the client may also be experiencing the like next level

of placebo, where they subconsciously buy into the process even more due to

the nature of the lab experiment and professionals and data and whatnot.

Another reason is that lab participants often have less intense

PTSD symptoms, or they're asked to focus on distressing memories, but

not necessarily traumatic ones.

And these are often voluntary students who are a part of these trials.

There are also critiques about how the EMDR field has

responded to these findings.

When early dismantling studies fail to find a difference, train EMDR

training materials and manuals were updated to emphasize different dosages

and variants of bilateral stimulation

when different modes of bilateral stimulation like tapping showed similar

outcomes, tapping became framed as a legitimate variant of EMDR rather than a

distinct control that proves otherwise.

Obviously if the unique feature of EMDR can be expanded to include

other things, then it's not unique.

I actually, I once talked to a, uh, fellow therapist who had just returned

from an EMDR conference, and they were genuinely convinced that walking was

now an EMDR intervention, walking.

Why?

Well, because it involves alternating bilateral movement, right?

And you're, you're, you're right: that sounds odd.

At some point, if everything counts like tapping or sounds or walking,

then really nothing is being tested.

Critics rightfully argue that this looks like moving the

goalpost, and I would say it's.

That's a very serious critique.

The field of psychology advances by testing hypotheses with a willingness

to accept inconvenient answers.

If the specific mechanism you name as central to your modality, if it fails

repeated tests, the honest response is to revise the theory rather than to

redefine the terms so your treatment still fits the original claim.

That is fairly questionable, if not shady, in my opinion.

If you do a deeper dive into, uh, EMDR and its founder Shapiro, there's uh,

actually more questionable ness to it.

Um, I highly recommend the YouTube video from Neural Transmissions.

Uh, the video is titled "A Hard Look at EMDR and Its Unscrupulous Founder."

Of course I'll have a link in the description along with all the

sources that I'm pulling from, but not naming in the episode.

As I said before, EMDR is supported by evidence, but the evidence has

weaknesses and there's actually more weaknesses- all, all this for you.

Um,

One major concern is allegiance bias.

Many EMDR studies are conducted by clinicians who train in and promote EMDR.

Studies run by invested parties tend to produce larger effect sizes

or more ben- benefit basically across psychotherapy research.

And, you know, that doesn't automatically invalidate things, but

it does mean we need to spend more time on independent replications.

Uh, also, sample sizes in many trials have been small, which has weakened statistical

power and increases uncertainty.

Publication bias is always a concern.

Negative or null trials are less likely to be, to be published, which, um,

inflates what we think is true about EMDR.

So these shortcomings, by the way, they're, they're not just an EMDR issue.

Psychotherapy studies in large part have major problems such as these.

Uh, let's do a little thought experiment to, to illustrate the, the overall point.

Imagine you were coming to me for therapy because I have a revolutionary

new method that has shown great results.

I help my clients to process their trauma through telling the trauma,

narrative the story, but while they do, so, they flex and curl their

toes and then they release it.

It's called Toe Curling Desensitization and Reprocessing, or TCDR.

At first you think, Justin, you want me to tell you my traumas the most horrific

things in my life while curling my toes?

It seems weird to you.

I assure you that tow curling creates a rhythmic motor pattern that occupies

a portion of working memory and thereby reduces the vividness of the traumatic

image while you hold it in mind.

TCDR still sounds silly to you, but the reasoning I give you sounds fancy

enough and you can't argue with the studies that say there's benefit.

And everyone's talking about it and Bessel VanDerKolk raves about it and

The Body Keeps the Score, which you, a book you love, so you cautiously agree

to meet with me, desperate for change.

When we meet, I don't just ask you to clench and release your toes, obviously.

I also greet you at the door and I invite you in.

The office is calming with natural greens and blues.

It's, it's silent, and there's a nice view out the window, which overlooks the water.

We smile together, we chitchat a bit.

Talk about the weather.

I learn more about you and assess your needs.

We make a treatment plan together.

You know, basic, basic therapy stuff.

Right now, as you're ready, you tell me your traumatic life context.

Yes, while curling and releasing your toes.

And it's not pleasant to talk about this stuff, but you're okay.

You recover.

We process what happened.

You get homework and we meet again the following week.

I suspect that TCDR would be just as effective as EMDR.

Not because the toe curling, which is obviously not necessary, right?

But even though it might sound plausible, but because of the

common factors of therapy.

The the toe curling is, is dressing it's cosmetic and ultimately unnecessary.

So what's the practical takeaway?

First, EMDR is an evidence-based option.

If you have found a clinician who uses EMDR and you feel safe

and supported and you're making progress, that is meaningful.

And that's positive.

And I'm happy for you.

Second, many of the helpful components of EMDR are not unique to EMDR.

Actually, the majority of it.

Safety building, co-regulation, gradual exposure, cognitive change,

and more show up in effective therapies across the board.

You do not need to have EMDR to get those ingredients.

Third, the central signature of EMDR- bilateral stimulation, especially

with eyes- is probably not essential for the bulk of its clinical effects.

The research suggests it may add a small effect in tightly

controlled lab conditions, but in the messy reality of therapy it is

not the engine driving recovery.

That conclusion should be liberating more than upsetting

or maybe for clients, more so.

Potential clients.

Healing trauma is not locked behind a single ritual or a single technique.

If you're worried that you missed something because you didn't have EMDR,

or you're choosing between therapists and the only option is someone who

practices prolonged exposure or cognitive reprocessing therapy, that's That's okay.

Or something else.

That's okay.

Focus instead on the practical markers of good care: a therapist who

prioritizes safety, who can help you regulate, who builds a steady alliance,

who introduces the work slowly and who helps you make meaning of change.

Those pieces are essential and, and more.

As a therapist and coach, I also use gradual exposure to discomfort.

But instead of asking clients to tell me trauma narratives, uh, we focus on

emotions that are typically difficult to acknowledge, uh, difficult to pay

attention to, to feel, but they're there anyway, so we gotta pay attention to 'em.

We pay attention within or slightly past the edge of what the client

can tolerate, and then we recover.

Once back at a baseline, we can try again if they would like and if

they're ready to over time, typically within a single session, these

emotions become much more tolerable.

Not cured, I'm not saying that, but much more tolerable.

And we can then target more difficult ones as they are

already, as their capacity allows.

But I don't think, personally, I don't think that there's a need to

add anything else to the mix, like eye movements and tapping and sounds

and no, not even clenched toesies.

You can if you want.

In fact, I believe I can even step back from the equation for many

potential clients who don't have a severe level of dysregulation.

I'm not saying that.

And that these potential clients with mild to moderate activation,

that they can learn and practice their own self-regulation skills

through the Unstuckinging Academy.

Well, for the most part, I'll step back in the academy.

You'll still learn from me.

You'll meet with me during live q and As and Nervous System Capacity

Builder live events and more.

You'll listen to prerecorded meditations from me to help you

build up your skills, but the practices are ultimately up to you.

It's still up to you to show up.

Still up to you, up to you to learn and to apply.

The small community is incredible and has lots of wisdom within it.

And all Unstucking Academy co-regulation to your students can join the many live

cohorts and live events throughout their subscription, like safety, simplified

and Self-Regulation simplified.

You can learn more about The Unstucking Academy, by the way, at

Stucknotbroken.com/UnstuckingAcademy.

Again, stucknotbroken.com/UnstuckingAcademy.

So to wrap up, EMDR gives clinicians and clients a structured

path to change toward change.

Bilateral stimulation is part of that path, but probably not the sole

reason the path exists and probably not even a necessary piece of it.

That puts power back into your hands as a potential therapy client.

You have lots of choices.

Healing is not a trick.

It's not a gimmick.

It's not a hack.

It's a reliable set of practices built on top of safety and all those

wonderful co-reg pieces of therapy that all styles should have in common.

Thank you so much for spending time with me here on Stuck Not Broken.