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Eye movement desensitization and reprocessing

Author: Dr Simon Moss

Overview

Eye movement desensitization and reprocessing is a therapeutic technique, discovered and then delineated by Shapiro (2001), primarily to treat post traumatic stress disorder. In short, individuals are invited to form images and thoughts that relate to a previous traumatic experience while attending to the bodily sensations these cognitions evoke. In addition, and specific to eye movement desensitization and reprocessing, the individuals are somehow encouraged to shift their eyes continuously from the left to the right.

Supposedly, if individuals undergo this experience repeatedly, their capacity to process and understand their trauma improves. That is, they integrate their memories or representation of the trauma with other insights, concepts, beliefs, and experiences. As a consequence, memory of the trauma does not merely evoke distress and anxiety, but also elicits many positive or neutral thoughts, images, and sensations as well. Nevertheless, the precise mechanisms that underpin these benefits remain contentious.

Empirical studies have indeed shown that eye movements can diminish the pain and distress that traumatic memories can evoke. Whether these benefits persist after eye movements have ceased, however, remains uncertain.

Furthermore, research indicates that eye movement desensitization and reprocessing can ameliorate the symptoms that usually coincide with post traumatic stress. Nevertheless, some studies indicate that cognitive behavioural therapy is more effective than eye movement desensitization and reprocessing in this endeavor (for a meta-analysis, see Seidler & Wagner, 2006). In addition, some research indicates the eye movements themselves might not be essential-although this contention has been challenged (for a meta-analyses, see Cahill, Carrigan, & Frueh, 1999& Davidson & Parker, 2001).

Benefits of eye movements

Eye movements and vivid images

Several studies show that eye movements might, indeed, diminish the extent to which traumatic images are vivid and distressing (Andrade, Kavanagh, & Baddeley, 2001& Barrowcliff, Gray, Freeman, & MacCulloch, 2004& Kavanagh, Freese, & Andrade, 2001& Merckelbach, Hogervorst, Kampman, & de Jongh, 1994& van den Hout, Muris, Salemink, & Kindt, 2001). In general, these studies show that eye movements, in contrast to no movements or other movements, do alleviate the emotional distress that upsetting images provoke. However, whether these benefits persist after the eye movements have been discontinued remains uncertain (Kavanagh, Freese, & Andrade, 2001).

In a seminal study, conducted by Andrade, Kavanagh, and Baddeley (2001), participants were asked to retrieve several positive and negative events in the past, such as victory in a competition or the death of a relative. While maintaining these mental images, some participants were encouraged to shift their eyes repeatedly. In particular, a letter flashed on alternate sides of the computer screen, and participants fixated on this letter. Other participants instead tapped a spatial pattern on a keyboard. Finally, some participants undertook neither of these activities while maintaining these mental images.

After completing these activities, participants reported the extent to which these images are vivid and elicit positive or negative emotions. These images were most vivid and emotional when no activities had been undertaken and least vivid and emotional when eye movements had been induced.

In a study conducted by Merckelbach, Hogervorst, Kampman, and de Jongh (1994), however, the effect of eye movements and finger tapping did not differ significantly. In their study, participants were exposed to an aversive picture: a picture of a mutilated hand. While this picture was exposed, eye movements were evoked or a tapping activity was introduced. The extent to which the picture was perceived as vivid and distressing decreased over time. Whether this diminution can be ascribed to the eye movements and tapping or merely to habituation over time could not be determined from these data& no control condition was included.

Nevertheless, several other studies have shown that eye movements are more effective than finger tapping (e.g., Kavanagh, Freese, & Andrade, 2001& van den Hout, Muris, Salemink, & Kindt, 2001). These effects, however, do not seem to persist after the eye movements or tapping cease. Kavanagh, Freese, and Andrade (2001), for example, showed that eye movements did not affect whether images seems vivid and distressing one week later.

To explain these findings, researchers tend to allude to visuo-spatial working memory (e.g., Andrade, Kavanagh, & Baddeley, 2001& Kavanagh, Freese, & Andrade, 2001& van den Hout, Muris, Salemink, & Kindt, 2001). That is, they argue this working memory system is limited in capacity. Tasks that demand spatial processing, such as tapping specific patterns of keys, utilize some of this limited capacity. This system, therefore, cannot be devoted solely to maintaining a visual representation of past events, and hence these events seem less vivid. As a consequence, the emotional distress of these images also diminishes.

Furthermore, tasks that demand spatial processing as well as frequent changes in the visual scene, such as eye movements, utilize even more of this store. Hence, eye movements are especially likely to obscure these mental images.

Eye movements and hemispheric activation

According to Shaprio (2001), the pioneer of eye movement desensitization and reprocessing, the eye movements, or other activities as tapping, might shift activation between the hemispheres (see also Stickgold, 2002). To illustrate, the right hemisphere might represent many of the distressing facets of some previous memory. If the left hemisphere is activated, however, some conceptual insights about the event might be evoked instead-principles that were learnt, unexpected benefits, and so forth. If activation shifts between the hemispheres, thoughts and feelings switch between distressing images and neutral cognitions. The images, thus, becomes associated with these cognitions-in other words, integrated with semantic memory. When the images are evoked, many representations, including positive or neutral insights, are also elicited, and the distress subsides.

Some indirect evidence vindicates this possibility. Horizontal eye movements improve episodic memory more than does vertical eye movements or no eye movements at all (Christman, S. D., Garvey, Propper, & Phaneuf, 2003).

Eye movements and orienting

To explain the benefits of eye movements, MacCulloch and Feldman (1996) proposed and validated an intriguing possibility. Specifically, according to MacCulloch and Feldman (1996), when a threat is identified, negative affect escalates, enabling individuals to flee or fight, depending on the necessary response. Subsequently, however, individuals tend to scan the environment again, to uncover other possible threats, called the investigation reflex. This investigation reflex tends to coincide with a more positive affective state--a state that facilitates the cognitive flexibility that investigation entails (e.g., Fredrickson & Branigan, 2005& see The Broaden and Build Hypothesis).

Potentially, according to MacCulloch and Feldman (1996), the eye movements might mirror the investigation component of the orienting response and thus evoke the positive affective states that usually coincide with this reflex. Consistent with this proposition, eye movements do evoke a relaxation response, but only after participants focus on negative rather than positive images. These findings indicate the effects of eye movements do indeed correspond to the orienting response, which is associated with negative instead of positive events (Barrowcliff, Gray, Freeman, & MacCulloch, 2004& Wilson, Silver, Covi, & Foster, 1996).

Overview of mechanisms

Taken together, previous studies indicate that eye movement desensitization and reprocessing might be somewhat effective. The eye movements seem to diminish the emotional distress associated with images or elicit other cognitions. Regardless of the precise mechanism, these changes could enable individuals to relate traumatic events to broader representations, such as other purposes in life or insights. Accordingly, the event is not represented as an isolated memory, but is integrated with other concepts and insights.

In addition, both the anterior cingulate and the left prefrontal cortex are especially active after eye movement desensitization and reprocessing (Levin, Lazrove, & van der Kolk, 1999). According to Levin, Lazrove, and van der Kolk (1999), when these regions are activated, individuals can more readily distinguish actual threats from imagined or perceived threats.

Limited vividness and accessibility

One of the mechanisms that may underpin eye movement desensitization and reprocessing revolves around the possibility that such eye movements may diminish the degree to which a memory is vivid and accessible. To demonstrate, van den Hout, Bartelski, and Engelhard (2013) undertook a study that was intended to examine whether eye movements do indeed limit the vividness and accessibility of retrieved memories.

In this study, participants scrutinized two pictures for a minute. Next, for several minutes, they maintained a mental image of one of these pictures while orienting their eyes towards a either a stationary dot on a screen or a dot that moved in a horizontal direction, like a pendulum. Then, participants completed a task in which fragments of pictures were presented. They needed to identify fragments that had been distilled from either of the two previous pictures. Finally, both before and after this task, participants rated the degree to which the two pictures seemed vivid in their mind. The eye movements reduced the extent to which that picture was perceived as vivid. In addition, the eye movements increased the time needed to recognize a fragment that was distilled from this figure& that is, accessibility of this picture was diminished.

The precise mechanism that underpins the effect of eye movements on the blurring of these memories is uncertain. Perhaps, in working memory, individuals construct an image that integrates the original image with a visual blur, and the resulting blurred image is not especially accessible.

The practice of eye movement desensitization and reprocessing

To implement eye movement desensitization and reprocessing, Shapiro (2001) recommends that practitioners complete a coordinated sequence of phases. First, practitioners should identify and clarify the primary event or episode in the lives of a client that should be subjected to eye movement desensitization and reprocessing--such as the death of a relative or exposure to a tragedy. They should also ask questions about this history of clients, partly to contextualize and to understand this event, as well as discuss a treatment plan.

Second, clients should be encouraged to identify a state or thought that promotes security. That is, they should identify an image, memory, or thought that fosters positive feelings and self esteem. They could identify someone in their life who is always supportive, an aspiration they would like to achieve, or a goal they had fulfilled, for instance. These images or thoughts can be evoked if clients are feelings distressed during subsequent sessions.

Third, clients identify an image that represents the trauma or problem, such as the funeral. In addition, clients should describe some of the bodily sensations this image provokes. Furthermore, practitioners should ask the client to identify a negative and positive thought or cognition that coincides with this image. The negative thought could relate to doubts about themselves. The positive though could relate to insights they gained, for example.

Fourth, the client is asked to form the mental image, while maintaining the negative cognition as well as an awareness of the concomitant bodily sensations or emotions. Next, the practitioner invited the client to follow a moving object with their eyes--perhaps a pendulum, for example--while maintaining these mental images and sensations. The number of eye movements might range from 10 to 30, at a rate of one or two per second. Immediately, afterwards, the client reports any thoughts, feelings, images, or sensations that were elicited during this exercise. Finally, the client completes the same exercise, except they focus their mind on these updated thoughts, feelings, images, and sensations instead. This process continues over several sessions.

Fifth, sometimes this process could undermine the original positive thoughts. If so, another positive thought about the event is evoked. Regardless, clients are often asked to imagine the traumatic event and the positive thought simultaneously-to fuse these representations.

Finally, some traditional processes can be considered as well, such as offering further information and support.

Other applications

Eye movement desensitization and reprocessing is also applied to many other disorders or domains. This technique, for example, has been applied to alleviate personality disorders (Manfield, 1998) and anxiety disorders (De Jongh & Ten Broeke, 1998), for example. Nevertheless, the efficacy of eye movement desensitization and reprocessing in these contexts has not been established systematically, beyond isolated case studies.

Related techniques

Emotional freedom techniques

Emotional freedom techniques represent another paradigm that is intended to curb anxiety disorders, such as PTSD and specific phobias (e.g., Brattberg, 2008& Church, 2010& Flint, Lammers, & Mitnick, 2006& Waite & Holder, 2003& Wells, Andrews, Carrington, & Baker, 2003). These techniques integrate the principles of acupressure, desensitization, exposure, and many other principles. In essence, individuals are asked to imagine a traumatic and fearful event as vividly as possible while tapping a variety of acupressure points (Craig, 1999).

To illustrate, Wells, Andrews, Carrington, and Baker (2003) applied this technique to treat specific phobias. In particular, participants were asked to form an image of an animal in which they had developed a phobia of a small animal, such as a rat. In addition, they were instructed to form an image of various associations with this animal, such as the sounds they emit or their whipping tail. While they maintained this image, they lightly tapped a specific point on their body, supposedly the end of a meridian, 6 to 8 times. These points are located under the lip, under the nose, under the eye, on the side of each eye, on the beginning of each eyebrow, on the top of each rib cage, on each clavicle, under each arm, and the towards the top of all fingers and thumbs except the ring fingers. Furthermore, before each sequence of tapping, they were asked to repeat a statement like "despite this phobia, I deeply and completely accept myself" while rubbing a specific point on their chest.

Relative to vivid images that were coupled with diaphragmatic breathing, emotions freedom techniques tended to diminish the distress that such feared animals evoke, both immediately and six to nine months later. That is, while approaching or imagining the animal, they reported less fear and distress. The intervention also reduced the pulse rate that was elicited by exposure to the animal, but not to a more pronounced extent than diaphragmatic breathing.

Other studies have also indicated that emotional freedom techniques can reduce anxiety disorders. Karatzias, Power, Brown, McGoldrick, Begum, Young, Loughran, Chouliara, and Adams (2001) showed that emotion freedom techniques and eye movement desensitization and reprogramming diminished symptoms of PTSD to similar degrees.

The mechanism that underpins these benefits have not been firmly established. Originally, emotion freedom techniques were assumed to somehow adjust and overcome disturbances in the energy systems of the body, by stimulating the ends of meridians (Craig, 1999). Indeed, stimulation of these points have been shown to promote the release of serotonin in the prefrontal cortex and amygdala (Ruden, 2005) as well as increase the production of beta endorphins (Cabyoglou, Ergene, & Tan, 2006). Yet, as one study showed, tapping other regions of the body or even observing these tipping movements on a doll generate similar levels of benefits (Waite & Holder, 2003).

Other mechanisms have also been proposed. These techniques may evoke a form of relaxation or hypnosis, partly because of the repetition, facilitating desensitization and exposure (Wells et al., 2003). Unfortunately, the research has yet to be precise enough to distinguish these mechanisms. Indeed, most of the studies in this field are limited. For example, the treatment and control condition differ on too many characteristics, impeding the capacity of researchers to reach definitive conclusions.

Interactive metronome therapy

Interactive metronome therapy was designed to overcome cognitive decline or physical impairments in various populations, such as individuals who have suffered traumatic brain injury or stroke (see Koomar, Burpee, DeJean, Frick, Kawar, & Fischer, 2001& Nelson, MacDonald, Stall, & Pazdan, 2014). In essence, participants execute various movements in time with a beat. They may clap their hands to trigger a sensor worn on the palm or tap alternating toes on a floor sensor. Each time the patient depresses a sensor, the computer provides an immediate auditory feedback, indicting the degree to which their response was too early or late.

This experience is intended to facilitate dendritic sprouting and other processes that are vital to learning and development. In particular, repeated experience with predictable temporal relationships between sensory inputs and motor outputs has been shown to enhance the production of key neurotransmitters, such as dopamine, norepinephrine, and acetylcholine. Consistent with this assumption, interactive metronome therapy, in addition to standard rehabilitation care, improves cognitive performance on a range of tasks in people who had suffered traumatic brain injury (Nelson et al., 2014).

Likewise, Hill, Dunn, and Dunning (2011) applied interactive metronome therapy, coupled with occupational therapy, to a range of stroke patients. Patients received 60 minutes of therapy a day, three times a week, over 10 weeks. The 60 minutes entailed occupational therapy with or without interactive metronome therapy. The interactive metronome therapy improved quality of life and decreased physical impairment.

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Last Update: 6/28/2016