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Journal of EMDR Practice and Research, Volume 10, Number 2, 2016 59
© 2016 EMDR International Association http://dx.doi.org/10.1891/1933-3196.10.2.59
least 2 weeks in activities that were previously enjoy-
able. Other symptoms may include low energy, guilt,
feelings of worthlessness, change in appetite and
sleep patterns, inability to concentrate, and suicidal
ideation. According to Shapiro’s (2001) adaptive infor-
mation processing (AIP) model, stressful life events,
loss, or “trauma” suffered in childhood or recently
can be factors underlying depression. Various stud-
ies have found an association between the onset of
depression and traumatic events (e.g., Brady, Killeen,
Brewerton, & Lucerini, 2000) and stressful life events
(e.g., Kendler, Hettema, Butera, Gardner, & Prescott,
2003; Risch et al., 2009).
Depression is medically managed through antide-
pressants. However, in a meta-analysis, Fournier et al.
(2010) concluded that although antidepressants have
only a small advantage over placebos, their usage in-
creases with increase in the severity of depression.
Weight gain as a side effect is also a disadvantage of
the pharmacological treatment (Reid & Barbui, 2010).
Depression is one of the foremost causes of
the worldwide disability and disease burden
(World Health Organization, 2014). It is a
risk factor for suicide (Malone, Haas, Sweeney, &
Mann, 1995). It is frequently comorbid with other
chronic diseases and can exacerbate their health-
related outcome (Moussavi et al., 2007). The U.S. Na-
tional Comorbidity Survey estimated that the lifetime
prevalence of depression is 17%–19%, 12 months
prevalence rate is 2.9%–12.6%, and relapse rate for
those who had earlier episodes is 50%–80% (Kessler
et al., 1994). Laursen, Munk-Olsen, Nordentoft, and
Montensen (2007) linked high mortality to depres-
sion. Chronic depression is often treatment resistant
(Wood & Ricketts, 2013).
The symptoms of depression according to
American Psychiatric Association in the Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.;
DSM-IV-TR; American Psychiatric Association, 2000)
include low mood or sadness and loss of interest for at
ARTICLES
The Efficacy of EMDR in the Treatment of Depression
Yasmeen Wajid Mauna Gauhar
Growing Edge, Islamabad, Pakistan
This study investigated the efficacy of eye movement desensitization and reprocessing (EMDR) psy-
chotherapy in treating the primary diagnosis of major depressive disorder by processing past or present
trauma that was affecting the quality of life. The 26 diagnosed participants were randomly assigned to
6–8 sessions of EMDR treatment or the waiting list control. Beck Depression Inventory-II, Trauma Symp-
tom Checklist-40, and Quality of Life Index Inventory were used at pre- and postassessment to measure
depressive and trauma symptoms and quality of life of the participants for both groups. The targets for
EMDR therapy were selected by the participants determining the negative cognitions most strongly asso-
ciated with reduced functioning and then identifying a related disturbing event. Paired and independent
sample t tests were applied for data analysis. Results showed significant improvements on all measures
with large effect sizes. At 95% confidence interval, the results found EMDR as an effective treatment for
depressive and trauma symptoms and for improving the quality of life of the participants. A generaliza-
tion effect was found for the depressogenic cognitions, with the number and strength of negative beliefs
markedly decreased at posttreatment, even for beliefs not targeted in the therapy. Three-month follow-up
interview with the EMDR participants confirmed that the results had been maintained.
Keywords: eye movement desensitization and reprocessing (EMDR); depression; trauma; quality of life;
generalization effects; treatment outcome
60 Journal of EMDR Practice and Research, Volume 10, Number 2, 2016
Gauhar
protocols. The treatment includes a broad evaluation
of the client’s presenting problem and history; stabili-
zation and preparation of the client; and processing of
the client’s past traumatic memories, current stressful
situations, and future difficulties (Shapiro, 2014).
Theoretically, EMDR psychotherapy is based on
the AIP model (Solomon & Shapiro, 2008). It views
psychopathology in the light of former traumatic
experiences which may be large-T traumas (meeting
PTSD diagnostic criteria) or small-t traumas (dis-
tressing life events). The model posits that memory
networks holding the experiences of trauma seem
unable to connect to other neural networks holding
information of adaptive nature (Shapiro, 2001). These
networks get persistently triggered by various internal
and external stimuli and generate maladaptive re-
sponses (Shapiro, 1995, 2006). The EMDR treatment
uses standardized procedures to connect traumatic
memory networks with more adaptive networks, dur-
ing bilateral sensory stimulations, thus changing the
characteristics of the traumatic memory and bringing
it to an adaptive resolution and transforming associ-
ated cognitions, sensations, and emotions (Shapiro,
2001, 2002; Shapiro & Forrest, 1997). Successful
EMDR treatment alters individuals’ responses to ear-
lier experienced trauma (Shapiro, 2001).
EMDR Treatment of Depression
There have been several studies in which comorbid
depressive symptoms were assessed in studies inves-
tigating EMDR treatment of participants diagnosed
with PTSD. For example, in a randomized con-
trolled trial, van der Kolk et al. (2007) found EMDR
more effective than fluoxetine in reducing PTSD
and depression symptoms. A meta-analysis by Ho
and Lee (2012) determined that EMDR was more ef-
fective at reducing these comorbid depressive symp-
toms than CBT.
In 2013, Wood and Ricketts asserted that although
EMDR has the potential to treat symptoms of primary
depression, the application has not been adequately
researched, and currently, it cannot be considered an
evidence-based treatment for major depressive disor-
der. More recently, Hase et al. (2015) and Hofmann
et al. (2014) conducted controlled matched studies in
inpatient and outpatient settings with patients diag-
nosed with major depressive disorder. All participants
received treatment as usual, and EMDR was pro-
vided as an adjunctive therapy to a matched group.
Results showed significantly better improvement on
symptoms of depression for those participants who
received adjunctive EMDR.
Tol, Barbui, and van Ommeren (2013) suggested that
pharmacological management should be judicially
opted for and only in cases when psychotherapeutic
interventions are ineffective or unavailable or the level
of depression (i.e., concurrent moderate to severe)
requires it.
Cognitive Therapy for Depression
Beck’s (1979) cognitive theory is popularly used to
understand depression. It postulates that negative
thoughts, generated by dysfunctional beliefs, are
usually the major cause of depression. Beck also as-
serted that people with depression selectively attend
to features of their environment, which match their
negative expectations and confirm them. They are
usually inclined to amplify the significance and con-
notations placed on negative events and diminish the
importance and meaning of positive events. All of
these unconscious maneuvers function to help the
person with depression to maintain core negative
beliefs/schemas which contributes toward feelings
of hopelessness about the future even when the evi-
dence stands contrary to it. This process of selective
attention to events is known as faulty information pro-
cessing (Nemade, Reiss, & Dombeck, 2007). Patients
with depression had highly charged dysfunctional at-
titudes or beliefs about themselves that hijacked the
information processing and produced the negative
cognitive bias, which led to the symptoms of depres-
sion (2008).
Cognitive therapy (CT) and cognitive behavioral
therapy (CBT) are considered effective therapies for
depression, significantly reducing relapse recurrence
(Hollon, Stewart, & Strunk, 2006). In a meta-anal-
ysis of 28 studies, Vittengl, Clark, Dunn, and Jarrett
(2007) found that the posttreatment relapse rate was
29% after 1 year and 54% after 2 years. On the con-
trary, the meta-analysis of 70 studies by Johnsen and
Friborg (2015) reported a linear and steady decline
in the effectiveness of CBT across time, with con-
temporary CBT seemingly providing less relief from
depressive symptoms as compared to its effective-
ness reported in previous years.
EMDR
Francine Shapiro introduced eye movement desensi-
tization and reprocessing (EMDR) as a treatment for
posttraumatic stress disorder (PTSD) in 1989. The
therapy has since been scientifically authenticated as a
psychotherapeutic intervention for PTSD (Foa, Keane,
Friedman, & Cohen, 2009). EMDR therapy is an
eight-phase treatment procedure with standardized
Journal of EMDR Practice and Research, Volume 10, Number 2, 2016 61
The Efficacy of EMDR in the Treatment of Depression
to here as small-t traumas), residual debilitating symp-
toms, no medication or any other form of therapy,
and a score of less than 35 on the Dissociative Expe-
rience Scale–II (Bernstein & Putnam, 1986). The in-
clusion conditions also required that the participants
were of sound mind, capable of comprehending the
terms of the study, and were physically capable of
participating in this project. Comorbidity with other
mental disorders and any substance use were the ex-
clusion criteria.
A total number of 52 participants were referred to
the researcher clinician, out of whom 29 met the in-
clusion criteria and were offered the opportunity to
participate in the study. Twenty-three were screened
out because of comorbid PTSD, use of antidepres-
sants, substance use (hash, opium), and/or a score of
more than 35 on Dissociative Experience Scale. Out
of 29, 3 participants declined to join the study without
giving any reason (Figure 1).
Twenty-six participants randomly assigned to ex-
perimental and waiting list were informed about the
study and its purpose. After discussing the treatment
procedure in detail, participants signed the informed
consent forms. The 26 participants ranged in age from
18 to 60 years (M ⫽ 29.38); all had completed high
school, and some had postsecondary education.
Nine participants dropped out during the study.
Three participants from the experimental group did
not turn up for postassessment after completing EMDR
therapy because of law and order situation, some do-
mestic problem, and personal reasons not shared. Six
participants on the waiting list dropped out because of
opting for pharmacological management, loss of mo-
tivation, worsening of symptoms because of delayed
treatment, and logistic problems (see Figure 1).
Procedure
Participants meeting the inclusion criteria were ran-
domly assigned to the waiting list control Group A
and to experimental Group B. Random assignment
was conducted by the research supervisor through
toss of coin (i.e., heads: control, tails: treatment)
without having knowledge of group condition. Par-
ticipants completed pretreatment assessment mea-
sures. The waiting list control participants attended
clinical interview regarding presenting complaints but
received no therapy during the 7 weeks of the study.
The experimental group was provided with six to
eight EMDR treatment session delivered in weekly
sessions. After the study was completed, posttreat-
ment assessment was administered and the waiting
list participants were provided treatment within the
Several case studies have reported positive treatment
outcome when depression was treated with EMDR.
For example, Uribe, Ramírez, and Mena (2010) found
EMDR had a positive effect both on emotional cogni-
tive processing and on long-term memory conceptual
organization in patients with depression. Bae, Kim, and
Park (2008) provided EMDR treatment to two teenagers
with major depressive disorder related to stressful life
events and found their depressive symptoms decreased
to full remission. Broad and Wheeler (2006) treated an
adult client having depression and attention deficit hy-
peractivity disorder (ADHD) with EMDR and reported
significant decreased level of depression and hypervigi-
lance and improved concentration ability which led to
the discontinuation of medication for depression and
ADHD. Krupnik (2015) successfully treated postpartum
depression by integrating EMDR with his evolutionary-
based treating depression downhill (TDD) therapy.
Grey (2011) treated comorbid severe major depressive
disorder and panic disorder with agoraphobia through
EMDR and found reduction in symptoms of depression
and anxiety.
In the light of earlier literature, it can be asserted
that EMDR has the potential to treat symptoms of
primary depression. However, no controlled study has
investigated the application of EMDR as a stand-alone
treatment for major depressive disorder. Hence, this
study compared EMDR therapy with waiting list for
participants with major depressive disorder. It was hy-
pothesized that (a) for the EMDR participants, there
would be significant postassessment reduction in
scores on depressive and traumatic stress inventories
and a significant postassessment improvement in qual-
ity of life scores after EMDR treatment compared to
pretreatment scores obtained on the same inventories
and (b) there would be significant differences between
waitlist control participants and EMDR participants
on pre- and postassessment change scores of depres-
sive, traumatic stress, and quality of life measures.
Method
Participants
Participation in the study was voluntary, and potential
participants were selected from available client base
and from psychiatric and psychological referrals to an
outpatient facility of Institute of Professional Psychol-
ogy, Bahria University, Karachi Campus, Pakistan.
Participants who met the inclusion criteria were of-
fered the opportunity to participate. Inclusion criteria
included the diagnosis of major depressive disorder
(based on DSM-IV-TR; American Psychiatric Associa-
tion, 2000), exposure to stressful life events (referred
62 Journal of EMDR Practice and Research, Volume 10, Number 2, 2016
Gauhar
eight-phase EMDR therapy, postassessment, and
follow-up.
The Therapist. The study (as an MPhil thesis) was
conducted by the researcher clinician who has been an
EMDR certified practitioner Level II (EMDR Europe)
since 2008 in addition to holding a master’s degree in
applied psychology, diploma and advanced diploma in
counseling, and diploma in clinical supervision.
Treatment Fidelity. This research was supervised
by committee comprising an assistant professor and
two associate professors at Institute of Clinical Psy-
chology, Bahria University, Karachi, Pakistan, from the
time of synopsis presentation to completion of the re-
search. Session logs and transcripts were maintained
and presented to supervisor on fortnightly basis.
Treatment Description. During the first 3 weeks,
participants attended history and preparation phases
Institute of Professional Psychology. Follow-up in-
terviews were conducted by the therapist 3 months
after treatment completion with EMDR participants
to determine if there was any recurrence of depres-
sive symptoms.
EMDR Treatment
Participants assigned to the experimental group re-
ceived six to eight 1-hour EMDR treatment sessions
proved on weekly basis. During the first 2–3 weeks,
they went through first and second phases of EMDR
treatment which focused on history taking and
preparation. After preparation was completed, the
participants received three to five EMDR process-
ing sessions in which they targeted disturbing events
thought to be related to their depressive condition.
Ten experimental group participants completed
Assessed for
eligibility
N ⫽ 52
Excluded:
did not meet criteria
N ⫽ 23
Declined
N ⫽ 3
Randomized
participants
N ⫽ 26
Experimental
group
N ⫽ 13
Control
group
N ⫽ 13
Completed
EMDR
treatment
N ⫽ 10
Attrition
N ⫽ 3
Completed
waitlist
N ⫽ 7
Attrition
N ⫽ 6
Follow-up
interviews
N ⫽ 10
FIGURE 1. Participant flow through study.
Journal of EMDR Practice and Research, Volume 10, Number 2, 2016 63
The Efficacy of EMDR in the Treatment of Depression
that identifies the incidence and severity of depres-
sive symptoms and is sensitive to change in symptoms
(Beck, Steer, & Brown, 1996). The sum of scores on
21 items is compared to cutoff score guidelines in
given at the end of the inventory. The score of 0–13
is minimal range, 14–19 is mild depression, 20–28
is moderate depression, and 29–63 indicates severe
depression.
Trauma Symptoms Checklist-40. The Trauma
Symptoms Checklist-40 (TSC-40) is a 40-item self-
report research measure (Briere & Runtz, 1989). It
evaluates symptoms of trauma, distress, and some as-
pects of posttraumatic stress through self-report and
can yield a total score from 0 to 120 on a 4-point fre-
quency rating scale ranging from 0 (never) to 3 (often).
Respondents have to mark how often they experi-
enced the symptoms of trauma in the last 2 months.
TSC-40 has 6 subscales: Anxiety, Depression, Dis-
sociation, Sexual Abuse Trauma Index, Sexual Prob-
lems, and Sleep Disturbances. It is a relatively reliable
measure with alpha of the subscale ranges from .66
to .77 and alphas of the full scale averaging between
.89 and .91. TSC-33 and TSC-40 also have predictive
validity (Dutton, 1995) with reference to different
variety of traumatic experiences because it seems to
predict perpetration of intimate violence.
Quality of Life Index. The Quality of Life Index
(QLI) measures quality of life in terms of impor-
tance and satisfaction regarding various aspects of
life (Ferrans & Powers, 1984). The QLI produces five
scores: quality of life overall and in quality of life in
four domains, such as health and functioning domain,
psychological/spiritual domain, social and economic
domain, and family domain. The total scale of QLI
has high internal consistency and reliability (alpha co-
efficient range .73–.99; Ferrans & Powers, 1985). QLI
is significantly sensitive to change.
Analysis
A mixed model between group and within group re-
search design was employed to analyze the data. Sta-
tistical analysis through SPSS Version 20.0 was carried
out for within group and between group mean com-
parisons for experimental and control groups. Pair
sample and independent sample t test were applied
to test the formulated hypothesis. The effect size was
calculated through Cohen’s d.
Results
The data was screened for missing values so that
those could be reported and accurate results could
of EMDR. They provided history about the origin of
their disorder and learned containment exercises such
as relaxation breathing and safe place imagery use so
that they could deal with high level of physical and
emotional distress if it came up. In the following three
to five sessions, the participants experienced EMDR
treatment sessions.
Standard protocol was used during the EMDR
sessions with a slight modification in Phase 3 during
target assessment. In standard protocol, the identifi-
cation of negative cognition follows identification of
the traumatic event. In our modification, participants
identified the negative cognition most strongly associ-
ated with reduced functions and then identified the
related events. To accomplish this, we provided clients
with a list of self-referencing negative and positive be-
liefs (as used in EMDR therapy, from Shapiro, 2001)
and asked them to rank the negative beliefs according
to how each affected their functioning. Following this,
participants identified the related disturbing event and
completed the standard assessment phase.
The desensitization phase was carried out with
minimal interference from the researcher clinician.
During the installation phase, the concentration was
on full integration of client’s positive self-assessment
with targeted information. Completion of installation
phase was followed by body scan. When successful
installation of positive installation was achieved and
when the positive future template was used where
it was necessary, the session was closed on debrief-
ing the client about processing which may carry on
between sessions. If the processing of the targeted
material could not be completed in a given session,
participants were assured that it would be taken up
in the following session. Clients were encouraged to
self-regulate between sessions through containment
exercises or writing a diary. In the reevaluation phase,
previously targeted material was assessed by the cli-
ent for its resolution, and if new material surfaced, it,
too, was processed and integrated with new learning
regarding self. Before ending the treatment, an evalua-
tion was made regarding the processing of all targeted
events in relation to past, present, and future and cli-
ents adjustment to his social role.
Assessment
Data was collected at pre- and posttreatment for
experimental group and pre- and postassessment
waiting list for control group on the following three
measures:
Beck Depression Inventory II. The Beck Depression
Inventory-II (BDI-II) is a 21-item self-report measure
64 Journal of EMDR Practice and Research, Volume 10, Number 2, 2016
Gauhar
the mean scores dropped from 24.90 (SD ⫽ 4.84) to
3.60 (SD ⫽ 4.50), a significant decrease, t(9) ⫽ 9.789,
p ⫽ .000. This was a large effect size with Cohen’s d
of 3.10. On the TSC-40, there was a significant differ-
ence in mean scores from pretreatment (M ⫽ 55.40,
SD ⫽ 14.58) to postintervention (M ⫽ 9.60, SD ⫽
7.79), t(9) ⫽ 11.131, p ⫽ .000 with large effect size,
d ⫽ 3.47. There was also significant improvement in
scores on the QLI, t(9) ⫽ 6.734, p ⫽ .000. Postinter-
vention quality of life scores (M ⫽ 19.80, SD ⫽ 2.40)
were significantly higher than preintervention quality
of life score (M ⫽ 13.82, SD ⫽ 2.40) with large treat-
ment effect, d ⫽ 2.13.
Comparison of Pre- and Postassessment
Differences Between Experimental and
Control Groups
Independent t tests were conducted to compare the
mean difference scores (i.e., changes between pre- and
postassessment of experimental group participants
[n ⫽ 10] and the control group participants [n ⫽ 7];
see Table 1). On the BDI-II, the mean change score
of the experimental group (M ⫽ ⫺21.30, SD ⫽ 6.88)
was significantly larger than that of control group
(M ⫽ ⫺5.85, SD ⫽ 10.15), t(9) ⫽ 9.789, p ⫽ .001, with
large treatment effect size, d ⫽ 1.97, indicating that
the experimental group showed a significant larger
decrease in depression compared to control group. On
the TSC-40, the mean difference score of the experi-
mental group was significantly larger (M ⫽ ⫺29.47,
be calculated. Descriptive and inferential analyses were
carried out through t-test application and effect sizes
were calculated. Three participants from the experi-
mental group (n ⫽ 13) and 6 participants from the wait-
ing list control group (n ⫽ 13) dropped out of the study,
and the analyses were conducted on data provided by
17 participants (N ⫽ 17) who completed the study.
Demographics
Demographic data was collected through demo-
graphic interview forms. The mean age of the 17 par-
ticipants was 29.4 years; 7 participants were male. The
participants included in the study belonged to diverse
educational and professional backgrounds, and eight
had completed graduate school. There were two
medical doctors, two psychologists one businessman,
two administration managers, two human resource
managers, five students, two unemployed, and one
house wife. Only one participant belonged to a lower
income group. Seven were married, one divorced, and
nine unmarried.
Comparison of Pre- and Post Treatment
Assessment Scores Within the
Experimental Group
Paired t test was conducted on the mean pre- and
post treatment assessment scores of the experimen-
tal group participants (Table 1). Results showed sig-
nificant improvement on all measures. On the BDI-II,
TABLE 1. Pre- and Postassessment Mean Scores
Beck Depression Inventory-II
Control Experimental
M(SD)M(SD)
Preassessment 30.29 (9.25) 24.90 (4.84)
Postassessment 24.43 (12.38) 3.60 (4.45)
Change scores (post- and preasssessment) ⫺5.86 (10.16) ⫺21.30 (6.88)
Quality of Life Index Inventory
Preassessment 13.05 (2.13) 13.82 (2.02)
Postassessment 13.52 (4.11) 19.90 (2.40)
Change scores (post- and preassessment) 0.46 (2.62) 6.08 (2.85)
Trauma Symptoms Checklist-40
Preassessment 58.00 (4.56) 56.47 (6.77)
Postassessment 51.86 (5.66) 27.00 (7.45)
Change scores (post- and preassessment) ⫺6.14 (19.35) ⫺29.47 (13.01)
Journal of EMDR Practice and Research, Volume 10, Number 2, 2016 65
The Efficacy of EMDR in the Treatment of Depression
Follow-Up Interviews
In the 3-month follow-up interviews with the partici-
pants of experimental group, all participants reported
an improved sense of well-being and stated that they
had not experienced any recurrence of depressive
symptoms.
Discussion
This study is the first randomized controlled study to
assess the efficacy of EMDR as the primary treatment
for major depressive disorder. The findings of the study
provide preliminary support for EMDR as a primary,
effective, and short-term therapy for major depressive
disorder, with effects maintained at 3-month follow-up.
Ten experimental group participants received six to
eight weekly EMDR treatment sessions. The seven
SD ⫽ 13.01) than that of control group (M ⫽ ⫺6.14,
SD ⫽ 19.35), t(15) ⫽ –5.076, p ⫽ .000, with large
treatment effect size, d ⫽ 1.57. Similarly on QLI, the
experimental group showed a significantly greater im-
provement in quality of life (M ⫽ 6.08, SD ⫽ 2.85),
compared to control group (M ⫽ 0.46, SD ⫽ 2.62),
t(15) ⫽ 4.13, p ⫽ .000, with large effect size, d ⫽ 2.16
(see Table 1).
Changes in Cognitions
Mostly at the end of fourth session, and beginning
of the fifth session, experimental participants were
asked to rerate the cognitions (not memories) which
they had rated before beginning EMDR treatment
(Table 2). It is apparent that the ratings of cognitions
which were not directly targeted in treatment changed
during treatment, suggesting generalization effects.
TABLE 2. Reduction in Depressogenic Cognition Because of Generalization Effect of EMDR
EMDR
Participant
Level of
Depression
on BDI-II at
Pretreatment
Number of
Negative
Cognitions at
Pretreatment Target Belief
Number of
Sessions
Number of
Negative
Cognitions at
Posttreatment
Memories of
Stressful Events
Mr. K Borderline 12 Not okay to
show emotion
8 3 Verbal/physical abuse
unable to defend self
Mrs. F Moderate 17 I am stupid 8 4 Neglect, physical/
sexual abuse, difficult
marriage
Miss I Moderate 3 Not good
enough
6 1 Childhood parental
neglect, molestation
Miss Severe 4 I don’t belong 8 1 Childhood parental
neglect, molestation
Miss L Borderline 6 I am not lovable 6 2 Anger issues, critical
parenting, parental
discord
Miss N Moderate 9 I am shameful 7 3 Sexual abuse relationship
difficulties
Miss S Moderate 8 I am different 8 3 Parental criticism, sexual
abuse
Miss Zb Severe 14 I am
permanently
damaged
8 3 Loss of both parents,
broken relationships
Miss R Severe 10 I am shameful 8 4 Childhood abuse,
broken relationship
Mr. W Moderate 5 I should
have done
something
6 2 Death of girlfriend in
road accident
Note. BDI-II ⫽ Beck Depression Inventory-II.
66 Journal of EMDR Practice and Research, Volume 10, Number 2, 2016
Gauhar
EMDR. Participants shared memories of parental ne-
glect, abuses, loss, and broken relationships. Frustaci,
Lanza, Fernandez, di Giannantonio, and Pozzi (2010)
suggested that such disturbing memories can be ef-
fective targets for EMDR processing because the life
events could be related to the onset or recurrence of
depressive episodes.
In our research, it appeared that the first memory
acted as a gateway to other dysfunctional memory
networks and also to associated negative beliefs. When
one memory got processed, another linked memory
would surfaced and would become the target of
EMDR for processing. As the targeted beliefs were
processed and closure was made, in the following ses-
sion, new targeted negative beliefs were identified for
processing. However, participants stated that many
of the other negative beliefs, which they had identi-
fied at the beginning of treatment, no longer felt true
(see Table 2). The shift in the validity of the targeted
cognition seemed to generalize to other untreated
negative cognitions.
Generalization Effects. It seemed that stressful
memories of different events were not only linked
together but they were also contributing to various
negative beliefs and that together, these memories
and beliefs maintained the participants’ depressive
state. Apparently, the treatment effect—with the
transformation of the initial negative cognition and
installation of positive beliefs/cognitions—had a
generalized effect and played a role in the reduction
of the number of negative beliefs and consequently
depressive symptoms. The participants in the experi-
mental group showed marked improvement after the
first desensitization session. The reason might be that
the irritants that caused depression were small-t trau-
mas and not the PTSD Criteria A events.
Observations that EMDR’s positive treatment ef-
fects generalize to untreated memories are frequently
reported. For example, Shapiro (2014) wrote, “Given
that EMDR treatment effects generalize to similar
memories, it is unnecessary to process each disturb-
ing event” (p. 75). In a study by Yurtsever et al. (2014),
participants indicated that the distress of untreated
memory images had decreased after processing a tar-
geted memory with EMDR. Our study may be the
first study to show that this generalization effect ex-
tends also to negative cognitions.
Targeting Memories of Stressful Life Events
EMDR treatment provided in this study targeted
memories of stressful life events (small-t trauma).
control group participants received no treatment for
7 weeks. Results showed that the mean scores of ex-
perimental group (within and between) showed sig-
nificant reduction in the symptoms of depression and
trauma and improved quality of life after EMDR treat-
ment, with effects maintained at 3-month follow-up.
Our results extend the findings of the earlier men-
tioned case studies, and the Hase et al. (2015) and
Hofmann et al. (2014) controlled studies and support
the efficacy of EMDR in the treatment of major de-
pressive disorder. It is noteworthy that remission in
depressive symptoms was achieved after six to eight
EMDR sessions. Although the Hofmann et al. (2014)
study provided a mean of 6.9 EMDR sessions, in that
study, EMDR therapy was adjunctive and participants
received treatment as usual for a mean total of 44.5
treatment sessions.
Changes in Negative Cognitions
According to Beck (1979), depression is the result
of faulty cognition about the self, the world, and
the future. Ehlers and Clark (2000) observed that
traumatic memories produce a certain belief about
the faultiness of “the self ” in relation to the traumatic
incidence(s). The AIP model (Solomon & Shapiro,
2008) postulates that memories of stressful events
are dysfunctionally stored, and these dysfunctionally
stored traumatic experiences leads to psychological
illness. Thus, we assumed that traumatic experiences
and their dysfunctionally stored memories lead to
faulty cognitions which cloud perceptual windows
and that depressive illness is experienced as a result.
We hypothesized that if negative beliefs could be
worked on (through processing the memories of the
contributing events) and be replaced by positive be-
liefs, there would be relief from symptoms. EMDR’s
AIP model posits that resolving memories of stressful
events (Shapiro, 2001) will provide relief from emo-
tional trauma (Shapiro & Maxfield, 2002). Hence,
the target for EMDR in this study was the negative
belief system that seemed to have been acquired and
maintained through experiencing small-t traumas and
which was related to depression.
During the assessment phase, the participants in
the experimental group identified several negative
beliefs (see Table 2). They were asked to rank those
beliefs according to severity from most to least. They
then selected one belief that they wanted to process at
the onset. The participants were then asked to focus
on the selected negative belief and identify any associ-
ated memory that came up for them. In case of several
memories, they were asked to choose one as target for
Journal of EMDR Practice and Research, Volume 10, Number 2, 2016 67
The Efficacy of EMDR in the Treatment of Depression
also investigate the use of EMDR in treating small-t
traumatic experiences producing depression in chil-
dren, adolescent, and older populations.
References
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th ed., text rev.).
Washington, DC: Author.
Bae, H., Kim, D., & Park, Y. C. (2008). Eye movement de-
sensitization and reprocessing for adolescent depres-
sion. Psychiatry Investigation, 5(1), 60–65. http://dx.doi
.org/10.4306/pi.2008.5.1.60
Beck, A. T. (Ed.). (1979). Cognitive therapy of depression. New
York, NY: Guilford Press.
Beck, A. T. (2008). The evolution of the cognitive model of
depression and its neurobiological correlates. The Ameri-
can Journal of Psychiatry, 165(8), 969–977. http://dx.doi
.org/10.1176/appi.ajp.2008.08050721
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). BDI-II,
Beck depression inventory: Manual (2nd ed.). Boston, MA:
Harcourt Brace.
Bernstein, E. M., & Putnam, F. W. (1986). Development,
reliability, and validity of a dissociation scale. The Journal
of Nervous and Mental Disease, 174(12), 727–735.
Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini, S.
(2000). Comorbidity of psychiatric disorders and post-
traumatic stress disorder. The Journal of Clinical Psychiatry,
61, 22–32.
Briere, J., & Runtz, M. G. (1989). The Trauma Symptom
Checklist (TSC-33): Early data on a new scale. Journal of
Interpersonal Violence, 4, 151–163.
Broad, D. R., & Wheeler, K. (2006). An adult with child-
hood medical trauma treated with psychoanalytic psy-
chotherapy and EMDR: A case study. Perspectives in
Psychiatric Care, 42, 95–105. Retrieved from http://udini
.proquest.com
Dutton, D. G. (1995). Trauma symptoms and PTSD-like
profiles in perpetrators of intimate violence. Journal of
Traumatic Stress, 8, 299–316.
Ehlers, A., & Clark, D. M. (2000). A cognitive model of
posttraumatic stress disorder. Behaviour Research and
Therapy, 38(4), 319–345.
Ferrans, C., & Powers, M. (1984). Quality of Life Index.
Retrieved from http://www.uic.edu/orgs/qli/
Ferrans, C., & Powers, M. (1985). Quality of life index:
Development and psychometric properties. Advances in
Nursing Science, 8, 15–24.
Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A.
(Eds.). (2009). Effective treatments for PTSD: Practice guide-
lines from the International Society for Traumatic Stress
Studies (2nd ed.). New York, NY: Guilford Press.
Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S.,
Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010).
Antidepressant drug effects and depression severity: A
patient-level meta-analysis. JAMA, 303(1), 47–53.
We considered that these experiences may have
played a major role in the triggering and maintenance
of depression. Research support for this position is
found in the Risch et al. (2009) study that reported a
significant association between major depression and
small-t traumas. Similarly, Kendler et al. (2003) stated
that stressful life events such as loss and humiliation
that adversely affect the core values about self can
be directly linked to the risk of experiencing depres-
sion. Our focus on targeting memories of stressful life
events had been guided by the AIP model (Solomon
& Shapiro, 2008) that postulates that dysfunctionally
stored memories of small-t traumas lead to psycho-
logical illness, and when adaptive resolution is experi-
enced as result of processing small ts through EMDR,
remission in symptoms is observed.
Treatment Tolerance. EMDR treatment was gen-
erally well tolerated by almost all participants. Mild
emotional arousal was observed in one participant
who managed it through breathing/relaxation, and
no adverse effects were observed. An explanation
could be that hyperarousal is a core symptom of
PTSD and may not be witnessed when EMDR is ap-
plied to pathogenic memories not related to PTSD
(Hofmann et al., 2014; see Table 2).
Conclusion
The results of this study found preliminary support
for EMDR as an efficacious therapy in the treatment
of major depressive disorder, with significant im-
provement on trauma, quality of life, and depression
inventories after only six to eight sessions. Despite the
fact that the study was limited by the sample size and
requires replication, it is the first randomized con-
trolled trial that used EMDR as the primary treatment
for major depressive disorder. In other controlled
studies, EMDR was adjunctive to other psychother-
apy and/or psychopharmacological treatment such as
antidepressants (e.g., Hase et al., 2015). Observing the
rapid effectiveness of EMDR in this study, it can be hy-
pothesized that EMDR could perhaps provide relief
from depression in less time compared to other treat-
ments. We also documented a large decrease in nega-
tive cognitions, with a generalization effect reducing
the number of untreated negative cognitions.
The modified EMDR protocol used in this study
needs further exploration. The results of this study
also point toward an expanded scope of EMDR. It
is recommended that future studies investigate its
effectiveness in treating affect disorders or other psy-
chological disorders in which the symptoms can be
related to stressful life events. Future research could
68 Journal of EMDR Practice and Research, Volume 10, Number 2, 2016
Gauhar
Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V.,
& Ustun, B. (2007). Depression, chronic diseases, and
decrements in health: Results from the World Health
Surveys. Lancet, 370(9590), 851–858.
Nemade, R., Reiss, N., & Dombeck, M. (2007). Cog-
nitive theories of major depression—Aaron Beck. Re-
trieved from https://www.mentalhelp.net/articles/
cognitive-theories-of-major-depression-aaron-beck/
Reid, S., & Barbui, C. (2010). Long term treatment of de-
pression with selective serotonin reuptake inhibitors and
newer antidepressants. British Medical Journal, 340, c1468.
Risch, N., Herrell, R., Lehner, T., Liang, K. Y., Eaves, L.,
Hoh, J., . . . Merikanagas, K. R. (2009). Interaction
between the serotonin transporter gene (5-HTTLPR),
stressful life events, and risk of depression: A meta-
analysis. JAMA, 301, 2462–2471.
Shapiro, F. (1989). Efficacy of the eye movement desensiti-
zation reprocessing in the treatment of traumatic mem-
ories. Journal of Traumatic Stress, 2, 199–223.
Shapiro, F. (1995). Eye movement desensitization and reprocess-
ing: Basic principles, protocols, and procedures. New York,
NY: Guilford Press.
Shapiro, F. (2001). Eye movement desensitization and repro-
cessing (EMDR): Basic principles, protocols and procedure
(2nd ed.). New York, NY: Guilford Press.
Shapiro, F. (2002). Paradigms, processing, and personality
development. In F. Shapiro (Ed.), EMDR as an integra-
tive psychotherapy approach: Experts of diverse orientations
explore the paradigm prism (pp. 3–26). Washington, DC:
American Psychological Association Press.
Shapiro, F. (2006). New notes on adaptive information process-
ing with case formulation principles, forms, scripts, and work-
sheets. Hamden, CT: EMDR Humanitarian Assistance
Programs.
Shapiro, F. (2014). The role of eye movement desensitiza-
tion and reprocessing (EMDR) therapy in medicine:
Addressing the psychological and physical symptoms
stemming from adverse life experiences. The Permanente
Journal, 18(1), 71–77.
Shapiro, F., & Forrest, M. S. (1997). EMDR: The breakthrough
therapy for overcoming anxiety, stress, and trauma. New
York, NY: Basic Books.
Shapiro, F., & Maxfield, L. (2002). Eye movement desen-
sitization and reprocessing (EMDR): Information pro-
cessing in the treatment of trauma. Journal of Clinical
Psychology, 58, 933–946.
Solomon, R. M., & Shapiro, F. (2008). EMDR and the adap-
tive information processing model. Journal of EMDR
Practice and Research, 2(4), 315–325. http://dx.doi.org/
10.1891/1933-3196.2.4.315
Tol, W. A., Barbui, C., & van Ommeren, M. (2013). Man-
agement of acute stress, PTSD, and bereavement: WHO
recommendations. JAMA, 310(5), 477–478.
Uribe, M. E. R., Ramírez, E. O. L., & Mena, I. J. (2010). Ef-
fect of the EMDR psychotherapeutic approach on emo-
tional cognitive processing in patients with depression.
The Spanish Journal of Psychology, 13(1), 396–405.
Frustaci, A., Lanza, G. A., Fernandez, I., di Giannantonio,
M., & Pozzi, G. (2010). Changes in psychological symp-
toms and heart rate variability during EMDR treatment:
A case series of subthreshold PTSD. Journal of EMDR
Practice and Research, 2, 26–40.
Grey, E. (2011). A pilot study of concentrated EMDR: A
brief report. Journal of EMDR Practice and Research, 5(1),
14–24.
Hase, M., Balmaceda, U. M., Hase, A., Lehnung, M., Tu-
mani, V., Huchzermeier, C., & Hofmann, A. (2015). Eye
movement desensitization and reprocessing (EMDR)
therapy in the treatment of depression: A matched pairs
study in an inpatient setting. Brain and Behavior, 5(6),
e00342. http://dx.doi.org/10.1002/brb3.342
Ho, M. S. K., & Lee, C. W. (2012). Cognitive behaviour
therapy versus eye movement desensitization and re-
processing for post-traumatic disorder: Is it all in the
homework then? European Review of Applied Psychology,
62(4), 253–260.
Hofmann, A., Hilgers, A., Lehnung, M., Liebermann, P.,
Ostacoli, L., Schneider, W., & Hase, M. (2014). Eye move-
ment desensitization and reprocessing as an adjunctive
treatment of unipolar depression: A controlled study.
Journal of EMDR Practice and Research, 8(3), 103–112.
Hollon, S. D., Stewart, M. O., & Strunk, D. (2006). Endur-
ing effects for cognitive behavior therapy in the treat-
ment of depression and anxiety. Annual of Review of
Psychology, 57, 285–315.
Johnsen, T. J., & Friborg, O. (2015). The effects of cogni-
tive behavioral therapy as an anti-depressive treatment
is falling: A meta-analysis. Psychological Bulletin. 141,
747–768. http://dx.doi.org/10.1037/bul0000015
Kendler, K. S., Hettema, J. M., Butera, F., Gardner, C. O.,
& Prescott, C. A. (2003). Life event dimensions of loss,
humiliation, entrapment, and danger in the prediction
of onsets of major depression and generalized anxiety.
Archives of General Psychiatry, 60(8), 789–796.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson C. B.,
Hughes, M., Eshleman, S., . . . Kendler, K. S. (1994). Life-
time and 12-month prevalence of DSM-III-R psychiatric
disorders in the United States. Results from the National
Comorbidity Survey. Archives of General Psychiatry, 51,
8–19.
Krupnik, V. (2015). Integrating EMDR into a novel evolu-
tionary-based therapy for depression: A case study of
postpartum depression. Journal of EMDR Practice and Re-
search, 9(3), 137–149.
Laursen, T. M., Munk-Olsen, T., Nordentoft, M., &
Mortensen, P. B. (2007). Increased mortality among
patients admitted with major psychiatric disorders:
A register-based study comparing mortality in unipolar
depressive disorder, bipolar affective disorder, schizoaf-
fective disorder, and schizophrenia. The Journal of
Clinical Psychiatry, 68(6), 899–907.
Malone, K. M., Haas, G. L., Sweeney, J. A., & Mann, J. J.
(1995). Major depression and the risk of attempted sui-
cide. Journal of Affective Disorders, 34(3), 173–185.
Journal of EMDR Practice and Research, Volume 10, Number 2, 2016 69
The Efficacy of EMDR in the Treatment of Depression
World Health Organization. (2014). Global burden of dis-
ease (GBD). Retrieved from http://www.who.int/
healthinfo/global_burden_disease/gbd/en/
Yurtsever, A., Konuk, E., Akyuz, T., Tukel, F., Zat, Z.,
Acarturk, C., & Çetinkaya, M. (2014, June). Early EMDR
interventions with Syrian refugees in Turkey R-TEP and
G-TEP. Paper presented at the 15th EMDR European
Conference, Edinburgh, Scotland.
Correspondence regarding this article should be directed
to Yasmeen Wajid Mauna Gauhar, Growing Edge, Office
6 Aagaz plaza, F-8 Markez, Islamabad 44000, Pakistan.
E-mail: maunagauhar@hotmail.com
Van der Kolk, B. A., Spinazzola, J., Blaustein, M. E., Hop-
per, J. W., Hopper, E. K., Korn, D. L., & Simpson, W.
B. (2007). A randomized clinical trial of eye movement
desensitization and reprocessing (EMDR), fluoxetine,
and pill placebo in the treatment of posttraumatic stress
disorder: Treatment effects and long-term maintenance.
The Journal of Clinical Psychiatry. 68, 37.
Vittengl, J. R., Clark, L. A., Dunn, T. W., & Jarrett, R. B.
(2007). Reducing relapse and recurrence in unipolar
depression: A comparative meta-analysis of cognitive-
behavioral therapy’s effects. Journal of Consulting and
Clinical Psychology, 75(3), 475–488.
Wood, E., & Ricketts, T. (2013). Is EMDR an evidenced-
based treatment for depression? A review of the litera-
ture. Journal of EMDR Practice and Research, 7(4), 225–235.
