Subject: BHI considers Eye Movement Desensitization and Reprocessing (EMDR) therapy as first-line treatment for adults with Acute Stress Disorder or Post Traumatic Stress Disorder (PTSD). Children and adolescents with a trauma history who have been unresponsive to other interventions have benefited from EMDR. Treatment for children and adolescents follows the same protocols and guidelines as EMDR treatment for adults, but will be approved on a case by case basis, and only as a second- or third-line treatment. Recommended exclusion criteria include any one of the following: 1. Ongoing self-injury 2. Active suicidal or homicidal intent 3. Uncontrolled flashbacks 4. Rapid switching (EMDR is usually not indicated in the presence of a Dissociative Identity Disorder (DID) diagnosis) 5. Physical frailty 6. Need for concurrent adjustment of medication 7. Terminal illness 8. Ongoing abusive relationship 9. Extreme Axis II (especially Borderline, Narcissistic, Antisocial) 10. Serious dual diagnosis (schizophrenia with active substance abuse) Recommended inclusion criteria: 1. Client Readiness/Stability- low risk assessment; low life stressors 2. Rapport- good level of client-clinician trust 3. Emotion Regulation- high level of coping skills to tolerate distress If the above criteria are not met, readiness for EMDR becomes the focus of treatment. During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete. From A Brief Description of EMDR, 2004, EMDR Institute, Inc. 4. Life Supports - caution if client has little supportive network 5. General Physical Health- health enough to withstand treatment Clinical administration requirements: EMDR Trained clinicians may practice EMDR if they are supervised by an EMDR Certified clinician and meet all of the following requirements: Interns/Students Authorized by: Standards of Practice Committee Page 1 of 5
o Currently enrolled in MA program and involved in the practicum and/or internship o On a licensing track working under the supervision of a fully licensed mental health professional o Students who are enrolled in a Master's Level program in one of the following fields must submit detailed information about the program that they completed to in order to determine their eligibility: Art Therapy and Drug & Alcohol Counseling. o Submit documentation in order to determine eligibility Approved Basic EMDR Training: completed coursework, practicum or internship hours, current curriculum vita, letter from current supervisor which includes supervisor s degree information, licensure information and license number o Complete Part I and Part II Basic EMDR Training Licensed Mental Health Professionals o Completion of a Master s or Doctoral Level Graduate Program in the mental health field o Must be licensed or certified through their state or national credentialing board o Clinicians who have completed a program in one of the following fields must submit detailed information to about the program that they completed in order to determine their eligibility: Art Therapy and Drug & Alcohol Counseling and submit their current license or certification through their state or national board in order to determine their eligibility for registering for an Approved Basic EMDR Training. o Complete Part I and Part II Basic EMDR Training EMDR Certification is a voluntary process and not necessary to practice EMDR, but can be pursued through the EMDR International Association (EMDRIA). If clinicians wish to pursue certification, they must meet the requirements through the EMDR International Association, and can only count hours supervised by an EMDR Approved Consultant towards certification. See www.emdria.org for full requirements for achieving Certification, Consultant In Training, and EMDR Approved Consultant status. Summary: A review of scientific literature for the use of EMDR has found that this therapy can be effective for the treatment of PTSD in adults and in some cases, children or adolescents. Van der Kolk, and colleagues (2007) in a randomized clinical trial evaluating the effectiveness of EMDR compared to fluoxetine, and pill placebo for treating PTSD found that EMDR was superior to both control conditions in the amelioration of both PTSD symptoms and depression. Upon termination of therapy, the EMDR group continued to improve while the Fluoxetine participants again became symptomatic. Authorized by: Standards of Practice Committee Page 2 of 5
Bisson and colleagues (2007) conducted a meta-analysis evaluating psychological treatments for PTSD. Thirty-eight randomized controlled trials were included in the meta-analysis. Trauma-focused cognitive behavioral therapy (TFCBT), eye movement desensitization and reprocessing (EMDR), stress management and group cognitive behavioral therapy improved PTSD symptoms more than waiting-list or usual care. There was inconclusive evidence regarding other therapies. There was no evidence of a difference in efficacy between TFCBT and EMDR but there was some evidence that TFCBT and EMDR were superior to stress management and other therapies, and that stress management was superior to other therapies. Edmond and Rubin (2004) assessed the long-term effects of EMDR in adult female survivors of childhood sexual assault (CSA). This study builds upon the findings of a randomized experimental evaluation that found qualified support for short-term effectiveness of EMDR. The authors found that the therapeutic benefits of EMDR for the study s sample were maintained over an 18-month period. This study also suggested that EMDR did so more efficiently and provided a greater sense of trauma resolution than did routine individual therapy. Ironson and colleagues (2002) conducted a randomized clinical trial to compare EMDR with prolonged exposure (PE) for PTSD. Twenty-two participants ranging in age from 16-62 years were randomly assigned to PE or EMDR and were assessed at baseline, after six sessions, and at three-month follow-up. The authors concluded that both PE and EMDR appeared to work well to reduce PTSD symptoms and to generate treatment gains that were maintained at three-month follow-up. It was also noted that EMDR appeared to be better tolerated, as indicated by a lower drop-out rate and lower Subjective Units of Distress Scores (SUDS) during the initial session. Chemtob et al. (2002) conducted a randomized clinical trial to examine the usefulness of brief-psychosocial treatment for children with disaster-related PTSD. Thirty-two children who met criteria for PTSD received three sessions of EMDR. In this study, the children showed large reductions in levels of symptoms of PTSD. The Wait-List group, once treated, also showed a reduction in symptoms similar to the results of the first group treated. Davidson and Parker (2001) evaluated EMDR in a meta-analysis of 34 studies. The results indicated that EMDR appears to be better than no treatment. In addition, EMDR appears to be better than non-specific treatments. It was noted that EMDR did not appear to be more effective than other exposure techniques. Devilly, et al. (1999) conducted a randomized clinical trial for the purpose of comparing EMDR with a cognitive behavioral treatment (Trauma Treatment Protocol, TTP) for treatment for PTSD. Data was collected at pre-treatment, post-treatment, two-week and three-month follow-up. Twenty-three participants completed treatment. The authors concluded that the results indicated the TTP approach to more effective than EMDR Authorized by: Standards of Practice Committee Page 3 of 5
statistically and clinically, however this study had a small number of participants and a large percentage were lost to follow-up (3 dropped from TTP; 6 dropped from EMDR). Professional Societies/ Organizations: The American Psychiatric Association (APA) Guidelines for PTSD and Acute Stress Disorder (APA, 2004) stated that EMDR belongs within a continuum of exposurerelated and cognitive behavior treatments. EMDR employs techniques that may give the patient more control over the exposure experience. APA stated that like many of the studies of other cognitive behavior and exposure therapies, most of the well-designed EMDR studies have been small, but several meta-analyses have demonstrated efficacy similar to that of other forms of cognitive and behavior therapy. The National Institute for Clinical Excellence (NICE) Clinical Guideline for PTSD (NICE, 2005) states that all people with PTSD should be offered a course of trauma-focused psychological treatment (trauma-focused cognitive behavioural therapy [CBT] or eye movement desensitisation and reprocessing [EMDR]). These treatments should normally be provided on an individual outpatient basis. The Veterans Health Administration, Department of Veteran s Affairs, and Department of Defense (VA/DoD) have developed Clinical Practice Guidelines for Management of Posttraumatic Stress (2004). After reviewing the available literature on EMDR, the guidelines conclude that Overall, arguments can reasonably be made that there are sufficient controlled studies that have sufficient methodological integrity to judge EMDR as effective treatment for PTSD. The American Academy of Child and Adolescent Psychiatry (1998) stated that although there has been some empirical evidence of the effectiveness of EMDR in adults, there have not been any controlled studies evaluating the risks and benefits of EMDR in children and adolescents. References: American Academy of Child and Adolescent Psychiatry (1998). Practice parameters for the assessment and treatment of children and adolescents with Posttraumatic Stress Disorder. Accessed June 1, 2007. Available at URL address: http://www.aacap.org/page.ww?section=practice+parameters&name=practice+parame ters Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. The British Journal of Psychiatry 190, 97-104. Chemtob, C. M., Nakashima, J., & Carlson, J. G. (2002). Brief treatment for elementary school children with disaster-related posttraumatic stress disorder: A field study. Journal of Clinical Psychology, 58(1), 99-112. Authorized by: Standards of Practice Committee Page 4 of 5
Davidson, P. R. & Parker, K. C. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting Clinical Psychology, 69(20), 305-316. Devilly, G. L. & Spence, S. H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal of Anxiety Disorder, 13(1-2), 131-157. Edmond, T. & Rubin A. (2004). Assessing the long-term effects of EMDR: Results from an 18-month follow-up study with adult female survivors of CSA. Journal of Childhood Sexual Abuse, 13(1), 69-86. Ironson, G., Freund, B., Strauss, J. L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58(1), 113-128. Van der Kolk, B., Spinazzola, J. Blaustein, M., Hopper, J. Hopper, E., Korn, D., & Simpson, W. (2007). A randomized clinical trial of EMDR, fluoxetine and pill placebo in the treatment of PTSD: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68, 37-46. Authorized by: Standards of Practice Committee Page 5 of 5