Dual Focus: An Important Element of Trauma Treatment

What makes trauma treatment work? And what can make it work better? This is another in an irregular series of posts focusing on key elements of trauma treatment.

One of the early debates about eye movement desensitization and reprocessing (EMDR; Shapiro, 2001) was whether or not the eye movement component actually contributed to the treatment effect, or was just a gimmick. Despite the EMDR originator’s insistence on the importance of eye movements (Shapiro, 2001), a meta-analysis published in a top-tier journal concluded that eye movements make no contribution to EMDR’s treatment effect (Davidson & Parker, 2001). EMDR’s detractors characterized the eye movements as being like a “purple hat” that made the method appear distinctive but had no impact (Lilienfeld, Fowler, Lohr, & Lynn, 2005). They asserted that “What is new in EMDR is not effective, and what is effective is not new” (McNally, 1999).

Those days are gone. EMDR is widely recognized as one of the leading trauma treatments (e.g., Bisson & Andrew, 2007), and recent meta-analyses have found it to be more effective (on some outcomes; Ho & Lee, 2012) and more efficient than the other well-established trauma treatments (Greenwald, McClintock, Hall et al, 2014). It is clear that EMDR is not simply another variant of exposure, in that its methodology violates some of the core principles of exposure, e.g., using only short bursts of exposure, and encouraging free-association (Rogers & Silver, 2002). And dual focus – eye movements or other distraction while concentrating on the trauma memory – has been definitively determined to contribute to EMDR’s treatment effect (Lee & Cuijpers, 2013; van den Hout & Engelhard, 2012).

Dual focus is also a prominent feature of progressive counting (PC; Greenwald, 2013), which was found to be even more efficient than EMDR in the most recent comparison (Greenwald, McClintock, Jarecki, & Monaco, 2014). Thus dual focus has not only been found to contribute to EMDR’s treatment effect, it is present in these two highly efficient trauma therapies and absent in most others.

Why should dual focus contribute to trauma treatment’s effectiveness and/or efficiency? The prevailing theory (van den Hout & Engelhard, 2012) is that the distraction, plus concentrating on the trauma memory, provides a certain optimal total cognitive load that taxes working memory. Working memory is like the brain’s RAM chip: it determines how much we can concentrate on, retain in awareness, in a given moment. According to the working memory account, when a trauma memory is accessed and activated, and then working memory is overloaded via distractors, the quality and emotional intensity of the trauma memory deteriorates, resulting in a less distressing memory.

I’m not convinced. Even though the results of numerous studies are consistent with the working memory account, that account is inconsistent with clinical observation of actual EMDR or PC sessions, as well as with what clients say about their experiences (Greenwald, 2012). The working memory account would presumably predict a gradual desensitization of the trauma memory, but many clients do not progress through the memory work in that particular way. Instead, we often see precipitous changes, typically following some emotional working-through or the achievement of a key insight.

I propose what I call the mindfulness account. Even if a therapy client working through a trauma memory does not become overwhelmed, it may take a lot of effort to avoid that, and that effort can slow the work down. However, by concentrating on something else (e.g., the therapist’s moving fingers in EMDR, or the therapist’s counting aloud in PC) at the same time as the trauma memory, the client is no longer only inside the memory, but also outside it concentrating on the distractor. This enables the client to be an observer of the self and of the memory while also engaging with the memory. This mindfulness effect frees the client from getting overwhelmed or bogged down, facilitating the mind’s ability to proceed with the desensitization, emotional working through, insight-making, or whatever is needed to heal from the memory.

Whereas both the working memory account and the mindfulness account are similarly supported by the same body of research documenting the therapeutic benefit of dual focus, there are key differences between them. First of all, the working memory account would predict a gradual reduction of memory-related distress over the course of the trauma resolution session, as if the memory were being desensitized, and this is inconsistent with much (though not all) clinical observation and client self-report. The mindfulness account, on the other hand, does not specify a particular pathway to healing, and thus is consistent with whatever mental means a given client may use to achieve resolution of the memory. The second difference is that in the working memory account, the over-taxing of working memory is itself the mechanism of effect, or the healing element, whereas in the mindfulness account, the mindfulness effect is facilitative of other mechanisms or healing elements.

The mechanism by which dual focus yields therapeutic effect remains to be determined. Regardless, dual focus does contribute to treatment effect, and probably adds efficiency to trauma resolution work.


Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub3.

Davidson, P. R., & Parker, K. C. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305-16.

Greenwald, R. (2012). Progressive Counting: Asking recipients what makes it work. Traumatology, 18, 59-63.

Greenwald, R. (2013). Progressive Counting within a phase model of trauma-informed treatment. NY: Routledge.

Greenwald, R., McClintock, S. D., Hall, S., Siebel, S., Doss, J., Halvorsen, L., Lamphear, M. L., Priest, E. G., & Gray, A. K. (2014). A meta-analytic comparison of EMDR to other trauma treatments: Effectiveness, efficiency, and acceptability to clients. Manuscript in preparation.

Greenwald, R. & McClintock, S. D., Jarecki, K., & Monaco, A. (2014). A comparison of eye movement desensitization & reprocessing and progressive counting among therapists in training. Manuscript under review.

Ho, M. S. K., & Lee, C. W. (2012). Cognitive behaviour therapy versus eye movement desensitization and reprocessing for post-traumatic disorder: Is it all in the homework then? Revue Européenne De Psychologie Appliquée/European Review of Applied Psychology, 62, 253-260.

Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44, 231-9.

Lilienfeld, S. O., Fowler, K. A., Lohr, J. M., & Lynn, S. J. (2005). Pseudoscience, nonscience, and nonsense in clinical psychology: Dangers and remedies. In N. Cummings and R. Wright (Eds.), Destructive trends in mental health. New York: Taylor & Francis.

McNally, R. J. (1999). On eye movements and animal magnetism: A reply to Greenwald’s defense of EMDR. Journal of Anxiety Disorders, 13, 617–620.

Rogers, S., & Silver, S. M. (2002). Is EMDR an exposure therapy? A review of trauma protocols. Journal of Clinical Psychology, 58, 43-59.

Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, Second Edition. New York: Guilford Press.

van den Hout, M. A., & Engelhard, I. M. (2012). How does EMDR work? Journal of Experimental Psychopathology, 3, 724-738.


12 Responses

  1. Great article, and I especially appreciate this part:
    “the client is no longer only inside the memory, but also outside it concentrating on the distractor. This enables the client to be an observer of the self and of the memory while also engaging with the memory. This mindfulness effect frees the client from getting overwhelmed or bogged down, facilitating the mind’s ability to proceed with the desensitization, emotional working through, insight-making, or whatever is needed to heal from the memory. “

    1. Thanks. I do think this is what’s going on. Haven’t been able to come up with a research design, though, to test the two theories against one another.

  2. I never bought the working memory concept either.
    But, I’d quicker posit that the BS creates a grounding, here and now experience for the client, enabling them to tend to their memories through this dual focus. While here and now orientation is integral to mindfulness, there are other aspects of mindfulness which are not within EMDR. For example, non-judging. In EMDR the client shares any and all thoughts for processing..
    I’d describe the efficacy of BS as the “grounding effect”.

    1. That’s actually fairly similar to how I see it — that the dual focus (bilateral stimulation, BS, e.g., eye movements in EMDR) “keeps the client in the room” rather than getting lost or overwhelmed by the memory. Perhaps my term is ill-advised as I do not intend to invoke the entire mindfulness concept — just the aspect I described.

  3. Please note that any Bilateral Stimulation is not merely a distractor – to keep a client present – but mimics our body’s/brain’s NATURAL processing mechanism…remember what occurs during REM sleep…where, it is thought/believed/known that our brain ‘processes’ events of our day/life… No, BS is far more than a mere ‘distractor’-surving a specific & vital purpose in the process of EMDR…!

    1. Laura, that’s what I used to tell my clients, too. But Gunter and Bodner found that having the client copy a figure drawing from one page to another had an even greater effect than the standard eye movements did. So it’s not clear that bilateral stimulation (BS) is the essential element, so much as some type of dual focus that requires the proper amount of attention.

      Gunter, R. W., & Bodner, G. E. (2008). How eye movements affect unpleasant memories: Support for a working-memory account. Behaviour Research and Therapy, 46, 913–931.

  4. Ricky,
    I agree with you and David that the dual attention component helps us to have one foot in the past and one foot in the present while we are processing – i.e. to be partially grounded in the present at the same time we are focusing on the disturbing memory. Maybe we could use the term “dual mindfulness” to convey this.
    I believe that at least part of the reason it works is because it helps provide temporal perspective. The dual attention stimulus helps clarify that the flashback is a memory from the past, not a current event, because one’s attention is not only hyperfocused on the past time and place, but is also drawn to something going on in the current time and place.

    1. David, one option might be to interview therapy clients, immediately post-session, about their subjective experience. Their descriptions should point in one direction or the other (or perhaps elsewhere). As for an experimental design that would support either one theory or another, I can’t come up with one offhand.

  5. “the dual attention component helps us to have one foot in the past and one foot in the present while we are processing”
    Unbelievable. Anybody who is in touch with reality while remembering their traumatic event is already doing that.
    Someone is going to make a boatload of money off this before people realize it’s just another gimmick.

    1. As Daniel Patrick Moynihan once said, you’re entitled to your own opinion, but not to your own facts. While any theory as to why the dual focus contributes to treatment effect is just that — a theory — the fact that dual focus does contribute to treatment effect is well established.

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