Why Doesn’t Every Therapist Offer EMDR?

When I learned EMDR (eye movement desensitization & reprocessing) in 1992, I recognized it as a game-changer. I was already an effective trauma therapist, but EMDR enabled me to do the job far more thoroughly and efficiently. As my experience – and the research – grew, I came to believe that EMDR would become part of the standard repertoire of the next generation of therapists.

That was thirty years ago, is that next generation here yet? It feels like it should be; we know enough by now. We know that:

  • Trauma – broadly defined to include loss, family dysfunction, and other adverse experiences – causes or contributes to a wide range of emotional, behavioral, and even health problems (Figley, 2012; Middlebrooks & Audage, 2007).
  • Whereas the so-called common factors (empathy, warmth, positive regard, therapeutic alliance, etc.) are necessary for treatment success (Duncan, Miller, Wampold, & Hubble, 2010), they may not be sufficient. The specific factor of facing and processing previously avoided emotional experience accounts for the greatest portion of change in psychotherapy (Ecker, Ticic, & Hulley, 2012; Weinberger, 1995). This factor is so important because it can faciliate memory reconsolidation, typically by processing traumatic (including loss etc.) memories.
  • EMDR is the most cost-effective (efficient) of the well-established trauma treatments (Mavranezouli et al, 2020), and it’s also well tolerated.

 

Therapists are generally intelligent, educated, and serious about helping their clients. So why doesn’t every therapist have EMDR in their repertoire? I’m not sure, but here are some possible reasons.

The nature of psychotherapy practice inhibits integration of treatment advances.

In the practice of medicine, most advances can be adopted as a matter of course. For example, if a new medicine is found to be better than an older one, doctors will learn about it from a professional journal or continuing education program, and start prescribing the new medicine. This works as well as it does (and I know, it could work better!) because doctors do not have to fundamentally change the way they work, to integrate the advance. Rather, they can incorporate the advance into the way they already work.

In psychotherapy, on the other hand, there is not one standard way of practicing. The various treatment orientations – psychodynamic, cognitive-behavioral, family systems, humanistic, etc. – each have their own theoretical framework and methodology. And even therapists who are “eclectic” – that is, who are not strictly aligned with a single orientation – generally work with some hybrid of those theories and methodologies.

Advances in psychotherapy do not tend to get widely adopted, at least, not very quickly. Because (for example) a psychodynamic therapist may not know how to incorporate a behavioral intervention into their existing treatment approach; or vice versa. Furthermore, whereas a medical advance might just involve prescribing a different medication or referring for a different procedure, for a psychotherapist to use an advance might require many days of training. And the field is so broad that therapists can’t possibly keep up with every advance – especially those outside their own areas of interest and expertise.

Essentially, in psychotherapy we have a bunch of semi-specialists, many of whom operate as general practitioners. And if our personal way of working is helpful for a given client – but not as helpful as some other treatment (such as EMDR) would be – well, bad luck for the client. We do it the way we do it. When a client’s presenting problem is clearly outside our area of expertise, we do refer. But when we feel we can be helpful, we may not refer, even when we are not offering the treatment of choice.

People don’t know what they don’t know.

In our EMDR trainings, after the first practice session, I ask the group, “If you are surprised that EMDR actually works, raise your hand.” And most of the hands go up! Even therapists who have already made the investment in EMDR training do not expect it to be so powerful. It’s like sex, drugs, and rock & roll: a person might feel that they understand the concept of EMDR, but they don’t really “get it” until they experience it.

Many therapists are treating trauma with symptom management strategies such as DBT, yoga, mindfulness, medication, etc. Or perhaps they are doing trauma healing work, but using slower methods. Therapist and client often experience this work as helpful, and it may be. But managing the symptoms, and slowly chipping away at the trauma, just isn’t the same as going in there and getting the healing done, in the efficient and profound manner that EMDR affords.

Therapists who are already working with trauma – and who have not personally experienced EMDR – may say something like this: “Yeah, I hear that EMDR is good. But I’m doing pretty well already, I don’t think I need to learn EMDR too.” Sadly, because these caring and well-intentioned therapists don’t know what they don’t know, they are not serving their clients as well as they could be.

When people finally do get EMDR – even after months or years of therapy they may have perceived as helpful – they routinely say, “Wow! I wish I had done this a long time ago!”

Learning EMDR is resource-intensive.

EMDR is not only a trauma resolution procedure, it’s also an entire treatment orientation (or an exemplar of the trauma treatment orientation; Greenwald, 2010), with its own theoretical framework and methodology. It takes a lot to learn and get good at EMDR. Even therapists who have been wanting to learn EMDR may not have been able to come up with the time and money to invest in the training.

However, trauma healing will often be an important component of treatment, whether a therapist specializes in treating clients with anxiety, depression, anger, addictions, relationship issues, or just about any problem. So learning EMDR is worth the investment.

Alternatively, therapists can learn some other trauma healing method that may more or less do what EMDR does, but requires less of an investment to learn. For example, progressive counting (PC) has now matched EMDR on effectiveness and efficiency in several comparisons (e.g., Greenwald & Camden, 2022), and PC only takes 3/4 of the training time as EMDR. As other methods such as the Flash technique accumulate more research support, there may be additional lower-cost options, as well.

The bottom line is that since trauma plays a role in so many problems, a trauma healing method like EMDR should be a standard element of most therapists’ repertoires. Before another thirty years go by.

References

Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what works in therapy (2nd Edition). Washington, DC: APA.

Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. NY: Routledge.

Figley, C.F. (Ed.) (2012). Encyclopedia of Trauma: An Interdisciplinary Guide. Thousand Oaks, CA: Sage.

Greenwald, R. (2010). What is EMDR? A data-informed re-conceptualization. Journal of EMDR Practice and Research, 4, 170-174.

Greenwald, R., & Camden, A. A. (2022). A pragmatic randomized comparison of intensive trauma-focused EMDR and PC with victims of crime. Psychological Trauma: Theory, Research, Practice, and Policy.

Mavranezouli, I., Megnin-Viggars, O., Grey, N., Bhutani, G., Leach, J., Daly, C., Dias, S., Welton, N. J., Katona, C., El-Leithy, S., Greenberg, N., Stockton, S., & Pilling, S. (2020). Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults. PLOS One, 15(4), Article e0232245. https://doi.org/10.1371/journal.pone.0232245

Middlebrooks, J.S., & Audage, N.C. (2007). The effects of childhood stress on health across the lifespan. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Weinberger, J. (1995). Common factors aren’t so common: The common factors dilemma. Clinical Psychology: Science and Practice, 2, 45–69.

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3 Responses

  1. I would not discount the extremely dishonest but widely circulated critiques of Scott Lillienfield and Richard McNally in the failure of EMDR to gain traction. Both are rooted in academic jealousy, egocentricity, fear of “unscientific” beliefs and so on.

    Despite Shapiro’s efforts, EMDR got tagged in the public and professional zeitgeist as woo-woo and “unscientific”. Academics in the business of developing and assessing psychotherapy systems just hate to admit how utterly unscientific that field is, and EMDR became the poster child for that fear.

    Also, Shapiro’s clumsy “neural nets” and other supposedly explanatory theory and terminology, which are indeed utterly without scientific content, activated deep academic fear of the extremely weak, if not non-existent scientific basis of the field.

    It also did not help that Shapiro (a) kept EMDR extremely proprietary and tightly controlled in an attempt to prevent what happened to NLP from happening to EMDR; (b) told a patently concocted origin story (the walk in the park) instead of the likely truth that she got the idea for the use of eye movements from Grinder. But eye movements or even BLS in general, are not what EMDR is truly about.

    In particular, the emphasis on bilateral stimulation as the “active ingredient” of EMDR rather than a supportive technique has left EMDR vulnerable to the accusations of woo-woo-ness. In fact (IMHO) the active ingredient of EMDR is a brilliantly conceived process of (a) systematic, titrated and pendulated (Peter Levine’s term) trauma exposure — not prolonged exposure; (b) assessment and “bookkeeping” of the client’s progress (your “efficient and profound manner that EMDR affords”) (c) catalyzed by BLS and (d) powered by personalized interventions at stuck points (interweaves, etc).

    How Shapiro came up with this process is a story that has not been honestly told. I suspect a big factor was her LACK of formal training in psychotherapy theory and practice.

    BTW, the key to understanding why EMDR works so well is, IMHO, understanding that PTSD is not something you “get” from a traumatic experience. It’s where you get stuck when the natural healing process after such an experience fails and leaves you in a the grip of cyclic retraumatization, much of which occurs in sleep. The only people who bother to walk into a therapist’s office are those who are stuck in that way — that’s why PTSD seems so intractable — you only see the thoroughly stuck cases — the others resolve on their own and you never hear about them.

    And those stuck points are specific to each individual, which is why the highly personalized interweaves, safe places, etc are so important, and group trauma therapy is generally so ineffective.

    The two-phase structure (as opposed to the incoherent 8-phase model foisted by Shapiro in an attempt to make EMDR sound scientific and manualized) is also crucial. But in fact, it’s less a two-phase structure than a continuous gradation of applying the methodology to increasingly distressing content, up to and into serious traumatization.

    Enough for now. But I agree — what a tragedy for humankind that the best method is so dissed!

  2. Well, Shapiro was a powerful advocate and promoter of EMDR, but also shot herself in the foot here and there. I discussed some of these issues in: Greenwald, R. (1996). The information gap in the EMDR controversy. Professional Psychology: Research and Practice, 27, 67-72. And I agree that the dishonest smear campaign has had lasting impact.

    I’m not sure what you’re intending to say about the eye movement/bilateral stimulation component, but it has definitively been found to contribute to treatment effect: Lee, C. W., & Cuijpers, P. (2012). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44, 231-239. Furthermore, in an unpublished meta-analysis, I found that the only competitors for EMDR’s efficiency also had a dual focus component. Finally, I suspect that the dual focus component also supports the client’s ability to tolerate the trauma work. However, I think what you’re saying is that it’s a facilitator rather than the mechanism of effect; and I agree with that.

  3. A couple of interesting points came up in a facebook discussion of this post:

    – Some therapists specialize in areas in which trauma healing may be helpful but is not generally considered the main event. And it takes a lot of time and effort to get good at EMDR, which may not be that therapist’s wisest investment.

    – Not every therapist is cut out to do trauma work. And there’s nothing wrong with that; there are plenty of other valuable personalities and skill sets that therapists can have.

    In each of these instances, trauma healing can/should still be included in the course of treatment. However, those therapists can refer out for the trauma healing work. For a single-incident trauma, this can easily be done by referring to an hour-per-week therapist for one to a few sessions. For a bigger trauma healing project, a referral for intensive trauma-focused therapy would make more sense. Then the primary therapist can work as they prefer, while ensuring that the trauma healing element of treatment is included.

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