Psychotherapy Networker: enigma of emdr

The Enigma of EMDR
1993 Nov/Dec
By Katy Butler

Richard Webster walked awkwardly on his prosthetic shoes into psychiatrist David McCann’s office in Salt Lake City on a hot summer day in 1991. His face was badly scarred from burns he’d suffered in a terrible mining accident. He had artificial arms, and he was deaf—a side- effect of the heavy doses of antibiotics that had kept him alive during a long hospital stay. The physical damage was serious enough. But it was his psychological suffering that had truly cast him into hell. For eight years, he had experienced the accident that had nearly taken his life not as past, but as eternally present.

Early in May 1983, Webster, then 33, was working in a silver mine on the Utah-Nevada border. He had been lowered into a narrow mineshaft to do some welding when gases below him ignited, and he was blown to the surface in a ball of flames. He spent the next two years in the hospital; since then, he had required nursing care 24 hours a day.

Each night, he fell asleep feeling as though his scalp were on fire; every day, he saw himself burning and felt as though he were again gasping for air. He had nightmares; he couldn’t sleep; he had trouble concentrating; he avoided television because he became so upset when he saw fires and explosions. He had refused Prozac and Thorazine because he believed they would suppress rather than cure what was inside him. He felt as though he was heading “for the rubber room at the lollypop farm.” Like millions of other survivors of war, accident, incest and crime, he suffered from the intrusive thoughts, nightmares and flashbacks of PTSD—post-traumatic stress disorder.

McCann spent Webster’s first two visits taking a careful history, communicating with the help of notes and Webster’s skillful lip-reading. Then McCann suggested they try a new technique he’d read about called Eye Movement Desensitization and Reprocessing (EMDR). It might not help, McCann said, but it probably wouldn’t hurt; why not give it a whirl? Webster agreed, and McCann, using an approximate version of a method he had never seen demonstrated, pulled his chair up close to Webster’s. He told Webster to hold three things in his mind: a single image from the accident (being consumed in the ball of fire); the associated emotion and body sensation (fear and an overwhelming adrenalin rush); and the related thought (“My God, I’m on fire”). Then, McCann moved his hand back and forth 20 times, while Webster tracked the movement with his eyes. Afterward, McCann told him to relax and report what came to mind.

A second vivid memory had flashed through Webster’s mind: the sound of his wrench careening off the rocks on its way to the bottom of the mineshaft, and the thought, “I’m a dead man.” Focusing on that memory, again Webster tracked McCann’s moving hand. Another image arose: Webster’s hard hat falling into the shaft, and the thought, “1 have to get out of here.” Once again, he held feeling, image and thought and flicked his eyes from side to side. Another Image came: from a vantage point somewhere high above the scene, he saw himself lying on the ground in flames while his foreman cursed and his fellow workers cried out in horror. “My God,” was the thought, “Do something to help me.” Then tangentially related image arose: an earlier, nearly fatal, work accident, when his tattered jacket had become entangled in a spinning drilling rig. After each memory arose, McCann repeated the deceptively simple procedure.

Then the terrifying and traumatic images left. Webster saw a calm and peaceful scene, as though he were floating on clouds. “I’m alive!” he thought. Although he was not a religious man, he later said that he realized “there are other dimensions in this universe—things don’t just end here.” Tears came to his eyes. He told McCann that he felt an almost overwhelming sense of peace.

A week later, Webster came back and told McCann his nightmares and flashbacks were gone. His scalp no longer burned. He could read, work on his computer, concentrate and watch television. “I just want to be as independent as I can now,” he said. For the first time in eight years, he could do without a nurse for eight hours a day. He began to water his lawn in the evenings and to help prepare his own meals.

The next month, Webster passed a driving test, bought a car and drove around town feeling like a prisoner on parole. He told McCann, “A boulder was lifted off me.” The next year, he drove across Utah to see his family, visited Canyonlands National Park, made friends with other amputees, and joined the board of directors of Child Reach Funding Program, an organization that helps provide prosthetic limbs to needy children.

“It was an amazing experience that defies imagination,” Webster said recently two years after his single, one- hour treatment with EMDR. “I concentrated on the most terrible things that had ever happened to me, and it all went away.

“The treatment made me look deep — very deep—into my own existence. Now, I see very clearly the fragility of human life and what it means to me. I’m more attentive to my feelings. I treasure each and every moment of my life.

“Is the treatment wearing off? No, absolutely not. I will not allow it to get away front me. It’s in me forever.”

McCann wrote up the case for the Journal of Behavior Therapy and Experimental Psychology last year, another in a growing collection of favorable testimonials that have stimulated the rapid spread of EMDIL “This is something entirely new that operates according to principles we don’t understand,” says McCann, who usually specializes in drug therapy and short-term psychotherapy. “It’s like the early days of antidepressants. EMDR seems to work, but we don’t know how.”

CASES LIKE RICHARD WEBSTER’S ARE the undeniable miracles of EMDR. Nobody understands them. The procedure seems ludicrous at first. It defies common sense to think that flicking the eyes back and forth can catapult someone into vividly reliving—and rapidly resolving—traumas that have ruled their lives for 20 years. No psychological or self- transformative tradition in history h-as made use of anything like it, aside from a few yoga exercises and one paper in a psychology journal in the 1950s by Baltimore psychiatrist Harry Teitelbaum, who noted that his patients flicked their eyes while concentrating.

In its combined rapidity and emotional intensity, EMDR challenges most existing therapeutic paradigms: behaviorists say that repeated exposure is necessary to extinguish traumatic response; family therapists warn against focusing too much on the past and the identified patient; and psychodynamic clinicians believe that insight, time and a close therapeutic relationship are crucial for profound psychological change. And yet, if the stories told over the past five years are true, EMDR works.

A hundred survivors of Hurricane Andrew In 1992, treated once with EMDR by volunteer therapists in crisis clinics and shelters, reported dramatic decreases in anxiety. A man in Bellingham, Washington, shot by a robber and left for dead, got relief after five years of recurrent nightmares. A Vietnam veteran who, for 20 years, had been obsessed with memories of unloading body bags off helicopters, watched his memory fade. In its place he saw the Vietnam he’d first seen as a young soldier flying in on the plane—a garden paradise. “The war is over,’ he said, after one session of EMDR, ‘and I can tell everyone to go home.”

A frightened 23-year-old woman in Mount Pleasant, New York who stammered in the presence of men, had a single EMDR session focusing on three childhood incidents of sexual abuse involving strangers; afterward, she established her first long-term sexual relationship with a man. Another woman, suffering from an intrusive, horrifying image of her sister curled in fetal position and dying of lung cancer, felt the pain of her memory fade as the image changed from color to black and white, and she suddenly felt she could move on with her life.

Since 1987, when an unknown clinical psychology graduate student named Francine Shapiro discovered the technique while walking in a California park, more than 4,000 therapists in America, Israel and Australia have been trained in EMDR, and it has captured the attention of respected therapists from widely divergent psychological traditions. Pioneering behaviorist Joseph Wolpe says, ‘There are certain cases in which this is the only known potent method.” Says Braulio Montalvo, one of the founders of structural family therapy “There’s something to this that’s independent of the magic practitioner.” And George Hartlaub, a psychoanalyst and professor at the University of Colorado Health Sciences Center, calls it “the greatest single advance in psychotherapy since I’ve been doing it, which is 30 years.”

Are these testimonials and case studies simply evidence of the Hawthorne effect—the tendency of new techniques to get better results at first, as therapists and clients are carried along on a wave of enthusiasm and mutually reinforced hope? Is the eye movement just a gimmick? Or has Shapiro unlocked a way to help people quickly overcome lifelong traumas by affecting the brain on a neurochemical level? And if horrifying experiences can rearrange the brain’s synaptic pathways in microseconds, why should we assume they cannot be healed just a Instantly?

These are the questions I3MDR has posed since the summer day in 1987 when Shapiro took a walk in Los Gatos park while preoccupied with old memories and disturbing thoughts. A former high school English teacher, she had developed cancer in 1979, moved to California, divorced and studied meditation, guided imagery, Ericksonian hypnosis, Neurolinguistic Programming (NLP) and anything else that seemed to hold promise. In 1987, her cancer was long past; she was 38 years old and close to getting her Ph.D.

Shapiro says she no longer remembers the details of the disturbing memories that were preoccupying her that day. But they seemed to dissolve as she spontaneously moved her eyes rapidly back and forth. Amazed by her serendipitous discovery, she experimented with 70 volunteers and obtained similar results, and the next year organized a formal research study in Mendocino County, California. Her 22 subjects were survivors of rape, childhood sexual abuse and war. Their flashbacks and sleep disturbances had persisted for an average of 23 years; they had been in therapy for an average of six years; and they suffered from low self-esteem and relationship problems. Shapiro gave each of them one 60-minute EMDR session, focused on a single traumatic memory that was currently bothering them. She then asked them to tell her how distressed they felt when recalling it, and how believable they found statements expressing self-confidence and hope.

All of these subjects, Shapiro wrote in what became her doctoral thesis, said that their memories had lost most of their devastating charge, and they found positive self statements much more believable. Their gains, she said, dropped only slightly at a three-month follow-up; many sexual abuse survivors spontaneously told her that they had become more assertive and more open in their relationships. A control group that simply called up a memory without using the eye movement showed no relief at all.

It seemed almost too good to be true. (In fact, nobody has reported quite such uniformly positive results since—a testament either to Shapiro’s intuitive clinical skills, or to the possibility that her clients felt subtly pressured to give her good news.) Nevertheless, armed with a published paper based on her doctoral study and some videotapes of her work, Shapiro introduced herself to the Mental Research Institute of Palo Alto (MRI) and became a research fellow there. Still accumulating hours toward her license, she tried EMDR with more rape victims and Vietnam War vets, with an agoraphobic woman who was terrified in the presence of her husband and children, and with a child suffering from nightmares after the 1989 San Francisco earthquake. She volunteered at the local veteran’s center, where one of her clients, Erie Smith, who had been haunted since the war hy the remembered screams of Vietnamese women and children, had four sessions and was able to sleep through the night for the first time in 20 years.

If Shapiro had been a less driven and more retiring woman, she might have quietly continued her work this way, exciting only mild curiosity about her intriguing and peculiar technique. But she was hill of ambition, and distressed by the pain that she saw on the faces of trauma victims who appeared on television and in newspapers every day. Spreading EMDR became her mission. She wanted to see it researched and taught in universities, but also wanted it used right away. In 1989, she vigorously began to promote it among licensed therapists, targeting behaviorists because of their familiarity with brief therapy, as well as specialists in rape, incest and PTSI). She took her tapes to conferences and VA. centers and brown-hag lunches, wrote articles for professional newsletters, and spoke to anyone who would listen. “1 thought she was either a genius,” say therapist Jennifer Lendl, who heard her speak at a brown-hag lunch for therapists at the Giarretto Institute in San Jose that year, “or cisc she was out of her mind.”

At a conference in 1988, Shapiro introduced herself to Joseph Wolpe, the venerable originator of systematic desensitization, considered one of the most effective methods for post-traumatic anxiety. “She caine up to me after a panel and said she had a new kind of treatment and an article she would like published,” remembers Wolpe. “1 was rather skeptical, but I said we would consider it. Then I tried out this method with two or three patients and it worked.”

Wolpe published her article in the journal he edits, The Journal of Behavior Therapy and Experimental Psychology, and he and other behaviorists began to experiment with EMDR The next year, Wolpe published his own case study, involving a woman so terrified of being raped again that she spent most of her time at home, curled protectively in a fetal position. After 15 unproductive sessions of psychodynamic therapy, she had been given 10 sessions of EMDR; she stopped her heavy drinking, began flirting with men and enjoyed walks alone on the beach. “Post-traumatic stress disorder is an exceptionally stressful syndrome that his been extremely difficult to treat,” wrote Wolpe. “The prognosis was recently dramatically improved by the introduction of eye movement desensitization... [now being] used by a substantial number of behavior therapists, with highly gratifying results. There is often marked decrease in anxiety after one session, and practically no tendency to relapse.”

Around the same time, an article of Shapiro’s was published by The Journal of Traumatic Stress Studies. It was accepted with a mixture of skepticism and curiosity. “I thought we’d been snookered,” says psychologist Steve Silver, director of the inpatient unit of the VA. Center in Coatesville, Pennsylvania, and a member of the journal’s editorial board. “1 had worked in trauma for 20 years, and I had never seen people becoming desensitized to traumatic memories with the rapidity she was describing.”

At the time, PTSD, especially among Vietnam veterans, was widely considered so intractable that some neurophysiologists speculated that intense trauma produced permanent changes in brain chemistry. The suicide rate among combat vets was high—more had committed suicide than had died in the war— and psychologists feared the numbers would climb even higher in the I 990s as the vets hit mid-life. Their intrusive thoughts and images from the war had not gone away, no matter what treatment therapists tried. Some had been dreaming the same nightmares and reliving the same battles for 20 years. Others found limited relief through behavioral techniques like implosion, flooding and systematic desensitization, all of which required them to repeatedly imagine old, painful scenes. But the procedures were so unpleasant that many vets refused treatment. The more years that passed and the longer the discouraged vets lived with their nightmares, flashbacks, substance abuse, work problems and family unhappiness, the more therapy success rates declined.

“By the late 1 980s, things were at a snail’s crawl,” says Silver. “I had become a complete thief, using anything I could— gestalt, systems, implosion, flooding— anything that would show any promise, and I felt we were condemned to relative inefficiency. I was very discouraged.”

At other VA. centers across the country, Silver’s colleagues felt the same. “We weren’t getting very good results with intrusive thoughts, nightmares and flashbacks,” says Howard Lipke, director of the inpatient PTSD unit at the North Chicago VA. Medical Center. “The best we could do was to have clients talk about them and try to understand them.”

Today, EMDR is a standard treatment at more than a dozen VA. medical centers. “It is the single most effective thing we do,” says Lipke. “Some people get complete resolution of their difficulty with a particular memory in one session.”

SHAPIRO THOUGHT AT FIRST THAT she had discovered nothing more than a behavioral technique that would desensitize clients to flashbacks and nightmares. She called it “eye movement desensitization” and thought that other clinicians could pick it up, as McCann had, simply by reading her article. But as she saw more clients, she realized that more was involved than simple desensitization. Her clients often spontaneously looped back to childhood memories in a way that a psychodynamic therapist, but not a behaviorist, would expect. And as she analyzed her own work, she saw that eye movement was woven into a tight fabric of intuitive clinical skills and embedded in her own ideas about trauma’s destructive impact on the brain.

Sonia Frye, for example, is a San Francisco social worker who was violently raped in 1985. Four years later, as a brief and ill-considered marriage was breaking up, she went to see Shapiro at MRI. First, Shapiro began by carefully framing Frye’s traumatic memory in a way that encouraged her to notice and discriminate among her visual memories, body sensations, emotions and thoughts. Trauma survivors, Shapiro believes, are left not only with unbearable images and body sensations of horror—a pain in the throat, for example—but with chronic, self- denigrating thoughts and feelings about themselves and the world. She postulated that all of these imprints of trauma are stored together on their own neurochemical islet, so calling them all up at once increases the likelihood of finding a pathway to the traumatic material.

Shapiro asked Frye to remember the most distressing picture associated with the rape, to identify the feeling in her body (a clutching in her belly) and to identify what she called its associated “negative cognitions” —the overgeneralized thoughts that are apparently implanted along with the emotional memory of a horrifying event, statements like “I’m helpless,” or “It’s my fault.”

Frye told Shapiro she’d thought, “If only I were married, this wouldn’t be happening.” She began to see a hnk between her suffering and her chronic thoughts and feelings of powerlessness and low self- esteem. These initial steps in the EMDR procedure gave Frye some distance from her problem and introduced the possibility that her thoughts and emotions were not “reality,” but were malleable. Then Frye those a positive thought she’d rather have: “It’s past; I survived.” She rated the believability of this positive belief at one on a one-to-seven scale. Then Shapiro asked her to rate the intensity of her distress, describe where in her body her feelings la and holding the image, thought and body sensation, she followed Shapiro’s moving fingers.

“At first I thought, ‘What kind of gimmick is this?” says Frye. “Then she started moving her fingers and I was reliving it. The shakes and the sweats came back, and the tears. I could feel the shears at my throat and hear his voice saying, ‘Don’t cry,’ in my ear.”

At this point in the EMDR process, something mysterious and new occurs, something like Freudian free association at breakneck speed. Images, memories, associations, thoughts and emotions often flip rapidly through a client’s mind like shuffled playing cards. Memories of childhood or related traumas emerge. Some people cry out in rage, grief or fright, reliving events. After it is over, clients aren’t simply desensitized and less anxious—they have learned something; their thinking has changed.

in the course of the session, Frye says, the memory lost its power. The rigid, nonrational belief apparently installed at the time of the rapc—”lf only I were married, this wouldn’t be happening” - faded away. After the session, she says, she could live alone without fear and recall the rape without crying—things she’d been unable to do for four years. “Now, the memory is like a book I read or a movie I saw,” says Frye, who later was trained in FMDR and now uses it with her own clients. “Instead of feeling helpless, I am left with how resourceful and clever t was to say and do things that made him not hurt me.”

Shapiro does not ask for the details of what passes through her clients’ minds the way a psychodynamic therapist would. She obtains only enough information to choose new memories to target, rarely getting bogged down in discussing fascinating insights or in delivering interpretations of her own. She then repeats the process, targeting new images and repeatedly asking cllcnt to rate their levels of distress—she calls it, “getting a readout”—until all the memories have lost their disturbing charge. Once the images are exhausted, she again asks clients to rate the believability of their positive cognitions on a ‘scale of one to seven. If all has gone as expected, an empowered, confident self-image is now believable; helpless, rigid thinking seems absurd.

At its best, this tightly focused procedure, which Shapiro describes as a power tool, seems to act like a sort of therapeutic dentist’s drill or microsurgeon’s laser. Many people feel as though a slate has been wiped clean and a space created where new learning can take place. Bad memories no longer make their hearts lace or bring tears to their eyes. And, in an effect not often reported in psychotherapy, their visual memories actually change. A man who, at first, could only remember going down for the third time while drowning now can recall Ms rescue. A woman who pictured her intimidating father towering over her childhood self saw herself grown into an adult in seconds, In many of Shapiro’s early cases, clients’ memories lost detail, shrank or changed color, suggesting to her that something neurological was going on. As a result, Shapiro, who often speaks in the computer-influenced language of neuropsychology, renamed her technique “eye movement desensitization and reprocessing; she also calls it “accelerated information processing.”

Shapiro theorizes that the eye moven1ent, and perhaps other, yet undiscovered forms of neural stimulation, allows long-delayed learning to take place. Traumatic memories, she thinks, are like unlearned lessons locked in the brain by the surges of neurochemicals that occur in times of great stress. These undigested experiences, she suggests, remain for years, tied in their own biochemical package, impervious to the lessons of countervailing, less devastating data. Somehow, the eye movement unties the package and reconnects the previously Isolated neural networks to the rest of the brain. “All of the counter examples, all of the adult perspective is able to link in,” she says. “What’s unnecessary or degrading is discarded; what’s useful can he stored.”

Nobody understands the neural mechanism, if there is one, that generates such transformation, Shapiro believes that it may allow the rapid processing of survival- related data, which some neuroscientists believe happens during the rapid-eye- movement stage of sleep. Her theory owcs something to Freud’s belief in the shaping power of childhood trauma, something to Milton Erickson’s confidence in rapid schooling, and something to the behaviorist idea that trauma teaches maladaptive lessons that people can unlearn. What’s new is a venturesome, overarching ncuropsychological paradigm based on the idea that most mental disturbances can be described as blocked learning, an after-effect of trauma.

So far, Shapiro’s theory remains only that—a theory. The limited controlled research so far has not proved anything unique to the eye movement. Shapiro herself has gotten similar results from tapping alternate hands on a chair rest, or broadcasting alternating tones in a clients ear, “Everybody is focusing on the eye movement because it looks interesting,” says Howard Lipke, “hut the best guess may be that if you help get the brain to a state where it’s vigilant and alert, and at the same time you call the traumatic material to attention, that material can then be processed.

SO MUCH FOR THEORIES AND Testimonials. Most new therapy movements, from behaviorism and family systems to the primal scream, firewalking and NLP, come decorated with them. All such movements generate exciting case histories, and the first clinician-converts, amazed by their successes, always beat the drum and blow the horn. At training workshops, the videotapes play over and over, and the lame eternally get up from their beds and walk again. In the work- shop revival tent, the first brief miracles however hit or miss or scientifically valid they may eventually turn out to be, shine like well-thumbed beads on a rosary.

Perhaps EMDR’s dramatic successes with PTSD are just another case of this son of suggestion: the perfect miracle for the computer age, with its technocryptic language of information processing and its talk of “readouts” and “installing positive cognitions.” What about research? What about controlled studies and bar graphs and standard deviations above the mean and all the things you slept through in graduate school? How do you control for placebo, for the heightened excitement and optimism of a clinician trying something new, for differences among clients, for the varying intuitive skills of clinicians, and for the unspoken and immeasurable rapport between the two? And how do you dissect something as seamless and subtle and multifaceted as good therapy without killing it, like a bug upon a pin? Does anyone really care why EMDR works, when people who have been unable to sleep for 21) years can now make it through the night? Sometimes, the most well-intentioned research ends up so narrowly drawn that it proves nothing so clearly as Heisberg’s Uncertainty Principle: the presence of the observer changes the thing observed.

These were the questions EMDR faced in 1990, when Shapiro, who had been running what was virtually a one-woman show, began to hold weekend workshops at hotel conference centers around the country. She taught not only the eye- movement technique itself, but a package of clinical skills, including seven hands- on practice sessions. By 1993, a small but influential group of her converts, including research psychologists associated with universities and VA. medical centers, had seen enough patients and put together enough preliminary studies to suggest that EMDR was, in fact, - a watershed treatment for PTSD.

The work of Shapiro’s supporters, much of it not yet published, is a step more scientific than anecdotal case reports and

a good deal less rigorous than controlled, double-blind studies. They show that in actual clinical practice, well-trained therapists achieve significantly better results with EMDR than with traditional treatments fur I’TSD. The most convincing is a yet- unpublished retrospective outcome study by the formerly skeptical VA. psychologist, Steve Silver. He looked at the records of 99 veterans at the Coatesville VA. Center, all of whom received the units standard treatment: a month in the hospital for intensive group and individual psychotherapy. Those who received at least five sessions of EMDR showed more than twice the therapeutic gain of those who had adjunctive biofeedback or relaxation training. The EMDR group had scores that were significantly lower than the others on questionnaires rating anger, anxiety and social isolation, says Silver, who is now one of Shapiro’s strongest advocates. “She doesn’t want to stand up and say we may be on the edge of a revolution in therapy,” he says. “We’ve heard this before from every kook that’s come along. But we’ve got a real phenomenon here, and nobody has an explanation for why this is occurring.”

But Silver adds that when he first began using EMDR, he had “a hodgepodge of results.” Success rates differed from clinician to clinician, and from client to client. EMDR was highly successful, but it wasn’t a magic bullet. “Does everybody feel better after every session? No,” says Howard Lipke. “Some people don’t get much out of it at all. Some get a hit of relief the first time and a lot more in later sessions. And for some people, it brings up whole new areas they don’t want to deal with.”

Another slightly less rigorous study, by Roger Solomon, a psychologist with the Washington State Patrol in Olympia, Washington, showed that EMDR produced significant gains for railroad workers involved in crossing accidents. Out of 60 workers who went to Solomon’s “critical incident” weekend seminar offering peer support and teaching coping skills, half were also treated with EMDR.

Afterward, the EMDR group scored significantly lower on measures of anxiety and other signs of post-traumatic stress, and their distress continued to decline at a six-month follow-up.

“I have many examples of guilt-ridden, depressed railroaders with intrusive imagery of horrible phenomena,” says Solomon, who has also treated policemen, Secret Service agents and truck drivers, all of whom witnessed or participated in fatal shootings, hostage-takings and bloody accidents. “With LMDR, the images become more distant and in some cases tend to fade. People come to realize they did the best they could and it was not their fault. And it sticks. I ask people how it’s going, months or years down the road and the results are stable.”

These reports from clinical practice confirm the over-all experience of those Shapiro has trained. In 1992, Lipke sent questionnaires to 1,200 people who had been trained in EMDR Out of the 400 who returned them, 73 percent said they found EMOR “more effective” than other treatments they used; only 4 percent found it less effective.

Perhaps the most informal study of all took place under disaster conditions in August 1992, after Hurricane Andrew hit southern Florida. Sixteen hundred square miles were flattened; most of the houses had not yet been rebuilt. You could drive for an hour and see only destruction. Ruth Knowles Grainger of Miami, the only therapist in Florida then trained in EMDR, quickly marshalled nine volunteer therapists to fly in from California and Ohio. They gave one or two EMI)R sessions to more than 100 people in classrooms and shelters and city halls—wherever they could find a quiet corner. At the same time, Grainger assembled a research study similar to Shapiro’s original thesis. Before treatment, the hurricane victims rated their distress at an average of 8 on a 1- to-10 scale. After treatment, the average distress self-rating in the hurriedly composed research project had dropped to 1.4, but the figure rose to nearly 3 after a month, and to 3.6 after three months - an increase that Grainger attributes to the continuing stress of living in devastated southern Florida. “I don’t think it’s a decay of the effect,” she says. ‘We’re talking about people who are still living in trailers in their driveways and in cars on the streets. We recently discovered a whole group of people in the swamps, virtually living on minnows out of the canals. The media have forgotten about us, but as much help is needed now as ever, so that people can get their anxiety down, so that they can think”.

One woman whom Grainger treated several months after the hurricane had spent a half an hour trapped behind her blown-open front door, unable to reach her 8-year-old child. She came to therapy because she could not stop crying and was so distraught that she’d looked for a gun to shoot the contractor who was rebuilding her home. In therapy, she recalled the image of black, ominous clouds rolling down her street, ready to engulf her and her home. After a few passes of EMDR, the picture changed. “The clouds are still black and rolling,” she said. “But they’re coming to a screeching halt at the end of my street.” As the EMDR continued, the clouds progressively lightened. The woman rated her distress at 0 on a 0-to-b scale. “I still see clouds, but they’re sort of pale blue and gray,” she said, “Now I see the shiny part around the edge of the clouds. I see the sun rising behind them.”

IT IS A LAW OF PHYSICS THAT FOR every action there is an equal and opposite reaction; there is a law of scientific revolution that anything that advertises itself as a paradigm shift and a major advance will produce an equally vehement and opposite counter response. EMDR is no exception. For the past three years, Shapiro, and EMDR, have run a gauntlet of attacks at conferences and in professional newsletters. They began in 1990, in the person of Corydon Hammond, an associate professor at the University of Utah School of Medicine and president of the American Society of Clinical Hypnosis (ASCH).

“1 was getting a call every week or so from somebody asking me about EMDR”, says Hammond. Two or three people were wildly excited, saying we were never going to have to use hypnosis or sodium amytol again. It sounded like the next trendy thing that was going to sweep the country with wild claims of flawless perfection. It sounded like NLP.”

Hammond had read Shapiro’s original article, seen a videotape, and tried out the eye-movement technique with two clients who had multiple personality disorder (MPD). His clients showed some improvement, he says, but much of it had evaporated by the next week. He wrote an article for the ASCH newsletter, cautioning practitioners against using EMDR before research proved its usefulness, and he spoke out repeatedly against it at conferences. He was concerned that EMDR would be seen as a rapid cure-all, he says, and was especially dubious about its use with people with MPD or other dissociative disorders. Such people, he says, are already adept at splitting themselves off from emotionally painful memories. EMDR, he warns, could simply encourage them to dissociate more.

“I think it may have some effectiveness, but I have serious doubts that it’s going to live up to its overzealous billing. There is more to adequately resolving trauma than desensitizing feat and anxiety,” says Hammond. “We also have to work through feelings of hurt, guilt and anger toward the self and others. I don’t think that is adequately done with a quick-and-dirty technique,”

In the letters sections of The Behavior Therapist and other professional Journals, clinicians have questioned Shapiro’s method, her scientific soundness, her training, her research, her ethics and her personal style. They were insulted by her attempts to keep EMDR out of the hands of those she hadn’t personally trained, and they felt she was making outrageous claims before adequate research had been done. Skeptical critics focused not Only on F.MDR but on Shapiro herself—a strong, rather serious and unknown woman from California who burned with the conviction that she was on the edge of a “quantum leap in psychotherapy” Unlike Virginia Satir—an earlier female pioneer who delicately and charmingly picked her way through the thickets of this male-dominated field---Shapiro isn’t disarming; she bristles when she is attacked, Some people have found her overcontrolling She responded with long rebuttals to the newsletters, detailing her position.

In 1992, several behavioral therapists wrote a furious letter to The Behavior Therapist after they attended a three hour presentation on EMDR at a conference. Shapiro, they wrote, had handed out promotional flyers for her own workshops but refused to give them enough details to teach them to use the technique on their own. “A number of disturbing clinical, research, professional and ethical issues were raised,” wrote four behavior therapists and researchers from Massachusetts General Hospital. They suggested the workshop not be rescheduled unless Shapiro became willing to provide technical instruction in EMDR.

Even some of Shapiro’s strongest supporters disagree with her on the issue of training. “I think it’s a little absurd,” says Joseph Wolpe. He believes that most well-trained behavior therapists could easily use EMDR. “She didn’t train me,” he says, “And that applies to quite a few other people that I know.”

Shapiro says her restrictions on training were the result of reports of cases like that of a young Pennsylvania girl who had been given a little EMDR by an untrained psychologist to help her deal with the emotional aftermath of a rape. The girl seemed to relax, went home, couldn’t stop crying for 24 hours and was eventually hospitalized. In another case, a California man—a client of behavioral psychologist John Marquis—tried it on himself at home while picturing a truck accident. He flashed hack to a time he had nearly been struck by a train and had a panic attack that he couldn’t control for half an hour.

Sandra Paulsen, a Honolulu psychologist with a cognitive behavioral practice, got a sketchy EMDR lesson from another therapist in 1991 and received no cautions about the need for training. She tried it out with a client, and before she knew what was happening, the woman, who had survived a major car wreck, was crawling across the office carpet, apparently reliving the experience of escaping from her flaming car.

Paulsen’s cognitive training had not prepared her for the violent emotional catharsis. “I didn’t know where to go. I tried to calm her down,” she says. “I am very fervent now that people need to be trained, whatever their previous training, because EMDR is very powerful.” Paulsen got herself to California for training the next weekend ended up taking both levels of EMDR training and has since become a specialist in working with clients who have been multiply traumatized.

Shapiro at first decided that EMDR was complex and occasionally dangerous. It required hands-on practice; otherwise, it was like a power saw let loose in the hands of a medieval carpenter. In late 1990, she expanded her training to two weekends, made people who took it sign a pledge not to teach EMDR to others, stopped distributing her original article, issued cautionary updates to trainees and found specialists to act as consultants to people she had trained.

“When you go in and use what I consider the most powerful method we have to date at activating traumatic material, it’s important to use really good clinical skills,” warns Virginia Lewis, a clinical psychologist and senior research fellow at MRI, who chairs the EMDR Professional Issues Committee. “How stable is this person? Do they have good impulse control? Are they at risk for suicide? If I believe EMDR is appropriate at a given moment, I will use it. Otherwise, I err on the cautious side.”

Shapiro says that the training is crucial for learning how to keep a client from dissociating or cutting short the intense reliving of trauma that EMDI{ can precipitate. The trick, Shapiro says, is to keep the client anchored in present time, while keeping the memories flowing; it’s trickier than it sounds. “I didn’t realize at first how much emotionally disturbing material it could open up, and how dangerous it could be for people who have suffered multiple traumas,” she says.

“If you have a rape victim who goes hack to an earlier molestation, you need to continue the processing, not stop them in the middle or have them dissociate,” says Shapiro. “If you stop someone in the middle of remembering a suicide, they may go home and reattempt. An incest victim may go home with sensations and emotions, but no images, and that’s when suicides and hospitalizations can occur.”

Negative feedback also came from researchers who had not joined the rush of enthusiasm over EMDR. An unpublished comparative outcome study at Pennsylvania State University in 1992, using students who said they’d experienced trauma, failed to produce the positive results of Shapiro’s original thesis, it found essentially no difference in results between a session of EMDR and a nondirective counseling session.

And this year, Roger Pitman, a researcher associated with the VA. and Harvard Medical School, completed one of the most closely controlled EMDR studies so far. Pitman got moderate hut statistically significant improvements with Vietnam War combat veterans after EMDR sessions—and almost the same results when clients recalled their memories, tapped rhythmically on an armrest, and stared at a spot on the wall while their therapists waved their hands, EMDR style, in front of their eyes. Both sets of results, Pitman said, were about equal, and produced fewer negative side effects than flooding, a more commonly used PTSD exposure technique he’d extensively studied.

‘Psychologists who work with PTSI) have grasped at EMDR,” says Pitman. “It’s a sign of the difficulty they experience treating a fairly intractable condition. EMDR was extensively marketed before it was adequately tested and now we’re finally entering the testing phase. It’s very much up in the air whether its going to he found any more efficacious than any of the existing treatments for PTSD.”

Other oppositional voices have arisen in other parts of the VA medical system. In 1990, Art Blank, national director of the nation’s 200 Veterans’ Outreach Centers, restricted EMDR’s use to his department’s 50 psychologists. He considers it an unproven cognitive- behavioral technique that only psychologists are sufficiently trained to use. “This treatment has been discovered accidentally and does not have any known theoretical rationale,” says Blank, a psychiatrist and Vietnam War veteran, “Even the founder says that she doesn’t know what the basis for the effects are—if there are any.”

NO MATTER HOW MUCH LIP Service is given to the importance of research, the fact remains that most new approaches are practiced without it. Medical and psychological fads often sweep the country without much knowledge of their risks—like lobotomy, routine hysterectomy, breast implants, the Dalkon Shield, aversive shocks for autistic children, and even, on a far smaller scale, Gestalt marathons and the “leaving-home” approach to families with schizophrenic members. They all seemed like good ideas at the time. Ordinary people, often desperate for healing and trusting our good intentions, continue to be unwitting research subjects in uncontrolled national experiments. For all the complaints about Shapiro’s overcontrolling style, she may in fact be a little ahead of the curve on this issue. Even the limited research on EMDR is far more than what was available when Gregory Rateson first advanced the double-bind theory of schizophrenia, or when paradoxical interventions and other family systems practices were loosed upon the world.

Meanwhile, thousands of solo practitioners continue to explore new applications for EMDR—with a variety of emotional splinters and family difficulties; with survivors of sexual abuse, political torture and Central American massacres; and with depression, agoraphobia, obsessive-compulsive disorder and MPD.

So far, anecdotal reports suggest that EMDR works best with healthy adults who have suffered a single trauma—a car accident, a mugging, a hurricane. Agoraphobia and other phobias have also responded simply and well. Curt Rouanzoin, a southern California clinical psychologist, tried EMDR with a man who was terrified of driving on freeways. After a single session that brought back a memory of an embarrassing childhood incident when the family car broke down, the man came back to report he’d driven to San Diego.

With people for whom major and minor traumas have been woven into the very fabric of their personality and memory, EMDR has turned out to be a much slower process, and sometimes a double-edged sword. California family therapist Landry Wildwind reports good results using EMDR to treat depression; she used it, along with other approaches, in what she described as “a four-year rescue operation” with a chronically depressed woman. The woman has found a good job, remarried, had a child and is close to quitting therapy, Wildwind says, but it has certainly not been a one-session cure.

In cases of obsessive-compulsive disorder, EMDR has been used with only marginal results. For reasons not understood, one long-time amphetamine user became extremely anxious and had to he hospitalized after an EMDR session. Therapists also report limited success with clients who are extremely hostile and controlling, those who don’t like intense emotions or arc afraid of losing psychiatric disability benefits, and those who believe that their bad feelings are somebody else’s fault.

Perhaps the most delicate cases have involved incest survivors whose traumas in childhood were repeated and often brutal. EMDR can help, Shapiro says, but the work must be carefully paced. “You’re not going to reprocess an entire history of incest in one to three sessions,” she says. “You try to have the gentlest approach, and don’t turn it into a marathon run. You have to be very careful about how much the individual can integrate, and at what pace.”

Many incest victims have missed out on life skills that other children naturally acquire because they felt so isolated and powerless when they were growing up. Once they are no longer preoccupied with their troubling memories, they may discover they do not know how to date, how to say no or how to assert themselves at work or in their relationships. These skills cannot be taught by doing EMDR alone; they require practice and developing new habits. “The therapist may need to weave in assertiveness skills and suggest a dating or a job training group” Shapiro says It’s a tapestry—not only a matter of realigning threads where they’re misaligned, hut finding where the threads are missing altogether and weaving them in.”

As time goes on, new issues may be uncovered that have little to do with incest: a fear of failure, perhaps, or a fear of success. Other interpersonal issues may emerge, “People may spontaneously find themselves being more assertive, and then bump up against people who don’t want them to be,” says Shapiro. “You may have to explain family issues to them, or brainstorm strategies for action.”

Some incest survivors have survived devastating experiences by splitting themselves into semi-independent ego- states or full-blown multiple personalities. Unless all of the alter personalities have been identified and carefully prepared for EMDR, Shapiro says, they can emerge disconcertingly in the middle of the session. Sandra Paulsen was in the middle of an EMDR session one day when a client said to her, ‘Who are you, why am I here, and why are you waving your finger in my face?”

In 1992, Shapiro sent a special cautionary issue of the EMDR newsletter to everyone she’d trained, urging them to screen carefully all potential EMDR clients, in a history-taking that could take one or two sessions, for dissociative disorders and MPD. Only previously qualified specialists who had taken both basic and advanced EMDR training should attempt to use EMDR with such clients, she wrote.

THERAPISTS USING EMDR REPORT A hodgepodge of results, with effortless advances with some clients, and none with others. “I sort of expected people to be running out of my office cured,” says Michael Elkin, a Boston family therapist who went to an EMDR workshop. “That hasn’t happened.” Others come back from the EMDR training in a nimbus of excitement that carries over to their first clients. There’s a certain energy and enthusiasm that comes through the training,” says Steven Gross, a family therapist in Mann County, California. “Ninety-seven percent of the time, people were getting really dramatic experiences in the training, probably because most of us had done some inner work and were already primed. When I came Out of the training, I carried a lot of that energy with me, and I enjoyed the results of it.’’

At first, Gross says, he saw opportunities everywhere to use EMDR, and it worked very well, But over time as the workshop receded into the past and newer enthusiasms took its place, his results declined. Now, he tries EMDR out with most clients, hut only uses it regularly with about 20 percent. It’s a minor hut powerful tool in an armamentarium that includes gestalt, hypnotherapy arid Ericksonian hypnosis.

For therapists trained in family systems, I3MDR underscores the necessity of carefully coordinating family and individual work. ln one case supervised by Braulio Montalvo, one of the founders of structural family therapy, EMDR was used with a child who had lived through an earthquake and became terrified of going to school. At first, Montalvo says, the therapist investigated, in classic systems style, whether the mother was clinging and holding on to her child and somehow reinforcing and maintaining his school phobia. That turned out not to be the case, and the therapist tried EMDR. “And lo and behold nothing else was needed,” says Montalvo.

But in another case Montalvo supervised, a woman worked repeatedly with FMDR on memories of abuse by her uncle in childhood, and still remained terrified. She had not told her therapist that the uncle continued to harass her mother, and she was afraid if she told anybody, her mother might he murdered. “When EMOR doesn’t yield the expected relief, it’s almost mandatory to come up for air and look at the contemporary family processes,” concluded Montalvo. “The therapist assumed the traumatic events were back there.. - but they were not back there. The abuser was terrorizing the patient’s mother in the contemporary world. The client was presenting as though the offending stimuli was back there, hut the refueling was occurring now.

“The technique has its power and will do something in terms of cleaning the slate as Shapiro claims. But life is complex and there’s more to it than traumatic memories.”

LIKE A PAIR OF HIGH-SPEED SKI boots, or space shoes made for jumping ridges on the moon, EMDR looks odd at first. It will take time for it to find a home within existing worldviews and methods. As its clinical applications are increasingly refined, it will face a new set of questions: When does it work best? For what kind of clients? And for what kind of therapists?

In the right hands, with the right clients, at the right moment, EMDR clearly can he a powerful tool. But the individual therapist is an important variable too:

technique and technician areas intimately joined as Siamese twins. In a field full of people guided by the intuitive, the most rigorous scientific research will not force the acceptance of a practice that seems mechanical or fails to speak to the relationship needs that motivate people to become therapists in the first place. For the moment, EMDR wiII only take root among people comfortable with the uncertainty of its still-developing theory, its robotic neuropsychological language, and the odd, sometimes tiring mechanics of waving one’s fingers repeatedly in client’s faces.

“Stylistically, it isn’t my stuff yet,” says Michael Elkin. “I don’t have a clue how it works; I think there’s really something there, hut I don’t know how to integrate it yet with what I already know.” Other therapists who have already found EMDR effective have painfully had to revise their previous thinking. ‘For some people, this is clearly more effective than a completely traditional, nondirective approach,” says Philip Manfield, an experienced psychologist who used to work primarily within the object relations tradition. EMDR, he found, can save clients weeks or months of depression as they come to terms with the painful truths of their childhood. But he is still not sure if it goes as deep as his long-term work, which few people can afford these days. “It’s upsetting,” says Manfield, who sometimes finds himself in conflict with former colleagues. “I’m having to integrate this new material, and it’s hard to wear more than one hat.”

Such expansion of intellectual boundaries—.and the integration of formerly suspect psychological perspectives—may be one of the side-effects of the spread of EMDR. Psychoanalysts are integrating a more aggressive cognitive style into their work; behaviorists have discovered the labyrinth of childhood; and family therapists have found a way to work effectively with individual childhood issues without getting bogged down.

But whatever EMDR’s virtues and limitations finally prove to be, some clinicians just aren’t going to like doing it, and others will. And while the scientific debate continues, the primary experiments will continue to take place daily in the individual therapist’s office, and in the wider laboratory of their clients’ lives.