The Status of EMDR Therapy in the Treatment of Posttraumatic Stress Disorder 30 Years After Its Introduction

Abstract

Given that 2019 marks the 30th anniversary of eye movement desensitization and reprocessing (EMDR) therapy, the purpose of this article is to summarize the current empirical evidence in support of EMDR therapy as an effective treatment intervention for posttraumatic stress disorder (PTSD). Currently, there are more than 30 randomized controlled trials (RCT) demonstrating the effectiveness in patients with this debilitating mental health condition, thus providing a robust evidence base for EMDR therapy as a first-choice treatment for PTSD. Results from several meta-analyses further suggest that EMDR therapy is equally effective as its most important trauma-focused comparator, that is, trauma-focused cognitive behavioral therapy, albeit there are indications from some studies that EMDR therapy might be more efficient and cost-effective. There is emerging evidence showing that EMDR treatment of patients with psychiatric disorders, such as psychosis, in which PTSD is comorbid, is also safe, effective, and efficacious. In addition to future well-crafted RCTs in areas such as combat-related PTSD and psychiatric disorders with comorbid PTSD, RCTs with PTSD as the primary diagnosis remain pivotal in further demonstrating EMDR therapy as a robust treatment intervention.

Full text

The Status of EMDR Therapy in the Treatment of
Posttraumatic Stress Disorder 30 Years After Its Introduction
Ad de Jongh
University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
Salford University, Manchester, United Kingdom
University of Worcester, Worcester, United Kingdom
Queen’s University, Belfast, Northern Ireland
Benedikt L. Amann
Institut de Neuropsiquiatria i Addiccions (INAD), Barcelona, Spain
Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), Barcelona, Spain
Autonomous University of Barcelona, CIBERSAM, Spain
Arne Hofmann
EMDR-Institute Germany, Wesseling, Germany
Derek Farrell
University of Worcester, Worcester, United Kingdom
Christopher W. Lee
Murdoch University, Perth, Australia
University of Western Australia, Perth, Australia
Given that 2019 marks the 30th anniversary of eye movement desensitization and reprocessing (EMDR)
therapy, the purpose of this article is to summarize the current empirical evidence in support of EMDR
therapy as an effective treatment intervention for posttraumatic stress disorder (PTSD). Currently, there
are more than 30 randomized controlled trials (RCT) demonstrating the effectiveness in patients with
this debilitating mental health condition, thus providing a robust evidence base for EMDR therapy as a
rst-choice treatment for PTSD. Results from several meta-analyses further suggest that EMDR therapy
is equally effective as its most important trauma-focused comparator, that is, trauma-focused cognitive
behavioral therapy, albeit there are indications from some studies that EMDR therapy might be more ef-
cient and cost-effective. There is emerging evidence showing that EMDR treatment of patients with psy-
chiatric disorders, such as psychosis, in which PTSD is comorbid, is also safe, effective, and efcacious.
In addition to future well-crafted RCTs in areas such as combat-related PTSD and psychiatric disorders
with comorbid PTSD, RCTs with PTSD as the primary diagnosis remain pivotal in further demonstrating
EMDR therapy as a robust treatment intervention.
Keywords: posttraumatic stress disorder (PTSD); eye movement desensitizing and reprocessing (EMDR)
therapy; randomized controlled trials; efcacy
Eye movement desensitization and reprocess-
ing (EMDR) therapy was introduced in 1989
as a treatment for symptoms of posttraumatic
stress disorder (PTSD) with the rst randomized
controlled trial (RCT), conducted by its developer,
Francine Shapiro (1989). In the following 30 years,
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EMDR therapy has not only developed into a mature
therapeutic procedure, but much research has been
conducted regarding its ecacy, mainly involving the
treatment of PTSD. This article aims to address the
question as to what we can say, 30 years after its
introduction, about the current international status
of EMDR therapy when it comes to the treatment
of PTSD. This question will be answered by review-
ing the empirical basis of EMDR therapy regarding
the treatment of PTSD in adults, children, and ado-
lescents, by providing a brief narrative overview of
the available evidence and the current recommenda-
tions of the most important international treatment
guidelines.
The Status of EMDR With Regard to PTSD
in Adults
Since Shapiro’s rst study in 1989, more than 30
RCTs have been published in which adult patients
with PTSD were randomly assigned to EMDR therapy
and one or more comparators. Studies where PTSD
was the primary diagnosis have compared individ-
ual EMDR therapy to a wait-list condition (Acarturk
et al., 2016; Högberg et al., 2007; Jensen, 1994; Marcus,
Marquis, & Sakai, 1997; Rothbaum, 1997; Van den
Berg et al., 2015, 2018) and a wide variety of active
comparison conditions, including relaxation training,
with/without biofeedback (e.g., Carletto et al., 2016;
Carlson, Chemtob, Rusnak, Hedlund, & Muraoka,
1998); imaginary rescripting (Alliger-Horn, Zimmer-
mann, & Mitte, 2015); counting method (Johnson &
Lubin, 2006); stabilization (Ter Heide, Mooren, Van
de Schoot, De Jongh, & Kleber, 2016), and phar-
macotherapy such as uoxetine (Van der Kolk et al.,
2007) and sertraline (Arnone, Orrico, D’Aquino, & Di
Munzio, 2012). There is also one study that explored
EMDR therapy delivered in a group format for partic-
ipants diagnosed with PTSD (Yurtsever et al., 2018).
In almost all EMDR RCTs on PTSD patients, partici-
pants were civilians, whereas types of trauma (i.e., cri-
terion A experiences) varied widely and ranged from
sexual assault to accidents to life-threatening health
problems.
Regarding the eectiveness, the studies that investi-
gated EMDR treatment of PTSD reported signicant
decreases in PTSD symptoms, with reported reduc-
tions in PTSD diagnosis, ranging from 36% (Devilly
& Spence, 1999) to 94%–95% (Capezzani et al., 2013;
Nijdam, Gersons, Reitsma, De Jongh, & Ol, 2012).
The same holds true for individuals who had addi-
tional other diagnoses besides their PTSD (e.g., Van
den Berg et al., 2015). To this end, there is emerging
evidence that also in cases of severe psychiatric disor-
ders, such as psychosis, in which PTSD is comorbid,
EMDR therapy is capable of producing stable long-
term eects and large eect sizes, with good tolerabil-
ity and results comparable to traumatized individuals
without comorbidity (Van den Berg et al., 2015, 2018).
Comparison of EMDR Therapy With Cognitive
Behavioral Therapy
In 13 RCTs EMDR therapy was compared to cogni-
tivebehavioral therapy(CBT), which,according tothe
World Health Organization (WHO, 2013), is another
rst-choice treatment for PTSD. See Table 1. In these
studies the active treatment was sometimes general
CBT and sometimes trauma-focused CBT (TF-CBT),
which included prolonged imaginal exposure with or
without in vivo exposure (see Table 1). Participants in
these trials comprised 758 individuals with ocially
diagnosed (i.e., according to Diagnostic and Statistical
Manual of Mental Disorders [DSM] or International Clas-
sication of Diseases [ICD] criteria) PTSD, and 298 of
them received EMDR t herapy. In 5 out of the 13 stud-
ies that compared EMDR with a variant of TF-CBT,
no dierence in eectiveness between EMDR ther-
apy and TF-CBT could be detected (Johnson & Lubin,
2006; Laugharne et al., 2016; Nijdam et al., 2012; Roth-
baum, Astin, & Marsteller, 2005; Van den Berg et al.,
2015). However, two studies found that TF-CBT was
signicantly more eective than EMDR therapy (Dev-
illy & Spence, 1999; Taylor et al., 2003), while six
studies found EMDR to be more eective than CBT
(Capezzani et al., 2013; Ironson, Freund, Strauss, &
Williams, 2002; Lee, Gavriel, Drummond, Richards,
& Greenwald, 2002; Power et al., 2002; Rogers et al.,
1999; Vaughan et al., 1994).
The variety in study outcome is also reected in
the meta-analyses that have been conducted. Most
meta-analyses did not show dierences in eective-
ness between TF-CBT and EMDR for PTSD symp-
toms (e.g., Bisson et al., 2013; Ehring, Morina,
Wicherts, Freitag, & Emmelkamp, 2014, Gerger
et al., 2014; Ho & Lee, 2012), albeit there were some
exceptions (Chen, Zhang, Hu, & Liang, 2015; Khan
et al., 2018). The Chen et al. (2015) meta-analysis
included 11 studies (N= 424) and found that EMDR
therapy was slightly superior to CBT. With regard
to PTSD symptoms, the results suggest that EMDR
might be better for intrusions and arousal severity
(but not for avoidance) compared to TF-CBT. Khan et
al. (2018) had slightly dierent inclusion criteria but
also ended up with 11 studies (n= 547) and revealed
that patients benet more from EMDR therapy than
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TABLE 1. Overview of Controlled EMDR Studies on PTSD in A dults of Which the Results Were Compared to
Those of Trauma-Focused Cognitive Behavioral Therapy
Study
N (EMDR
Condition) Treatment
Number of
Treatment Sessions Main Result
Percentage
Loss of
Diagnosis
EMDR
Patientsa
Vaughan et al.
(1994)
36 (12) • EMDR
•IHT
• R
• W
4 EMDR = IHT = R > W
EMDR > IHT, R
(regarding intrusions)
48
Devilly and Spence
(1999)
23 (11) • EMDR
•TTP
9 EMDR < TTP also at
3-month follow-up
36
Rogers et al.
(1999)
12 (6) • EMDR
•PE
1 EMDR = PE
EMDR > PE
(regarding intrusions)
Not reported
Ironson et al.
(2002)
22 (10) • EMDR
•PE
4 EMDR > PE also at
3-month follow-up
Not reported
Lee et al.
(2002)
23 (10) • EMDR
•PE + SIT
8 EMDR = E+SIT
EMDR > E+SIT
(regarding intrusions)
also at 3-month
follow-up
83
Power et al.
(2002)
105 (27) • EMDR
•PE + CR
4.2 6.4 EMDR = PE+CR also
at 15-month follow-up
Not reported
Taylor et al.
(2003)
60 (15) • EMDR
•PE
•R
8 EMDR = PE = R
EMDR + R < PE
(regarding avoidance
and re-experiencing)
60
Rothbaum et al.
(2005)
74 (20) • EMDR
•PE
• W
9 EMDR = PE > W 75
Johnson and Lubin
(2006)
27 (9) • EMDR
•PE
•CM
• W
6.3
9.7
5.9
EMDR = PE = CM Not reported
Nijdam et al.
(2012)
140 (70) • EMDR
• BEP 16 EMDR = BEP
EMDR more ecient
94
Capezzani et al.
(2013)
21 (21) • EMDR
• CBT 8 EMDR > CBT 95
(Continued)
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The Status of EMDR Therapy in the Treatment

TABLE 1. Overview of Controlled EMDR Studies on PTSD in A dults of Which the Results Were Compared to
Those of Trauma-Focused Cognitive Behavioral Therapy (Continued)
Study
N (EMDR
Condition) Treatment
Number of
Treatment Sessions Main Result
Percentage
Loss of
Diagnosis
EMDR
Patientsa
Van den Berg et al.
(2015)
155 (55) • EMDR
•PE
• TAU
8 EMDR = PE > TAU 60
Laugharne et al.
(2016)
20 (10) • EMDR
•PE
• 12
EMDR = PE Not reported
Note. BEP = brief eclectic psychotherapy; CBT = cognitive behavioral therapy; CM = counting method; CR = cognitive restructuring;
IHT = image habituation training; PE = prolonged exposure; R = relaxation; TTP = trauma treatment protocol;
SIT = stress inoculation training; TAU = treatment as usual; W = waiting list; > indicates “signicantly superior to”; < indicates
“signicantly inferior to.”
aBased upon clinical interview.
from CBT when the reduction of the three primary
symptom clusters of PTSD is concerned. However,
3 months follow-up analysis on four of these stud-
ies (n= 186) showed that this dierential eect was
no longer signicant. In addition, the meta-analysis of
Ho and Lee (2012) evaluated six studies that also inves-
tigated depression outcomes and found a large eect
size, suggesting that EMDR therapy may be more
advantageous for PTSD patients in case of comorbid .
While a number of meta-analyses have been pub-
lished that report large eect sizes, both with regard
to the eectiveness of EMDR therapy itself and the
ecacy of EMDR in comparison with other thera-
pies, it should be noted that some studies suered
from poor methodology. In their 2002 analysis, Max-
eld and Hyer (2002) identied lack of treatment
delity (e.g., Jensen, 1994), non-blinding of asses-
sors (e.g., Lee et al., 2002), and inadequate randomi-
sation processes (e.g., Devilly & Spence, 1999) as
common decits in the EMDR literature. Such
methodological issues reduce the condence in the
robustness of the scientic support for EMDR and
have impacted the recommendations made by some
treatment guidelines. For example, American Psy-
chological Association (APA, 2017) was less positive
in their recommendations regarding EMDR therapy,
stating “There is low strengthof evidence of a medium
to large magnitude benet for the critical outcome of
PTSD symptom reduction,” APA, 2017, p. 42. (See also
Dominguez & Lee, 2017, 2019)
The Status of EMDR With Regard to PTSD in
Children and Adolescents
The ecacy of EMDR therapy has also been stud-
ied in children and adolescents. A number of RCTs
have been conducted with children and adolescents
with trauma-associated symptoms, showing signi-
cant reductions in presenting problems. Details can
be seen in recent reviews (Barron, Bourgaize, Lem-
pertz, Swinden, & Smith, 2019; Beer, 2018) and a
meta-analysis (Moreno-Alcazar et al., 2017). Only four
RCTs (n= 216 in total) have been conducted with
EMDR (n= 145) and one or more control conditions
(three used a wait-list control condition) for children
and adolescents that were formally diagnosed with
PTSD (Ahmad, Larsson, & Sundelin-Wahlsten, 2007;
Chemtob, Nakashima, & Carlson, 2002; De Roos
et al., 2017; Diehle, Opmeer, Boer, Mannarino, & Lin-
dauer, 2015; see Table 2). The results of these four
studies suggest that EMDR therapy is superior to
wait-list control conditions, at least equally eective
in reducing PTSD symptoms compared to TF-CBT
(see also De Roos, Rommelse, Knipschild, Bicanic, &
De Jongh, 2019), while one study found EMDR ther-
apy to be more ecient (De Roos et al., 2017; see
“Discussion” section). A large proportion, ranging
from 45% (Diehle et al., 2015) to 93% (De Roos et
al., 2017), did not fulll the diagnostic criteria imme-
diately following treatment.
Of note is that the quality of these studies on
EMDR pertaining to PTSD in children and adolescents
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show some limitations. For example, half of the stud-
ies presented in Table 2 lacked follow-up assessments
(Ahmad et al., 2007; Diehle et al., 2015), and only half
of the studies reported on loss of PTSD diagnoses.
Therefore, while the existing research shows promise,
these methodological problems, and the small num-
ber of studies on the eectiveness of EMDR regarding
children with PTSD, limit the condence that can be
placed in making strong statements. As discussed in
the next section, these issues also explain why some
published guidelines have been circumspect so far on
the ecacy of EMDR in this target group.
EMDR Therapy and the Treatment Guidelines
As highlighted earlier, WHO recommended EMDR
therapy—in addition to TF-CBT—as a rst-choice
treatment for PTSD (WHO, 2013). The recent guide-
lines released by the US Department of Veterans
Aairs in collaboration of the Department of Defense
(Department of Veterans Aairs and the Depart-
ment of Defense, 2017) and the International Soci-
ety of Traumatic Stress Studies (ISTSS Guidelines
Committee, 2018) recommend EMDR therapy along
with a series of variants of CBT therapy, particularly
prolonged exposure (i.e., imagery and in vivo) as
rst-line treatments for PTSD, for both adults and
children. In contrast, the new treatment guideline
of the APA (2017) gave EMDR therapy a condi-
tional recommendation and a lower rating than
CBT (see Table 3). Although the National Insti-
tute for Health Care and Care Excellence (NICE,
2018) recommended EMDR therapy for adults after
3 months post-trauma, they placed restrictions on its
use with children and adolescents with early trauma,
and for those with combat-related trauma. They
stated, “The evidence suggested EMDR was not eec-
tive in people with military combat-related trauma,
and this is in contrast to all other included trauma
types for which benets were observed” (NICE,
2018).
Table 1 shows the 13 studies that compared EMDR
to CBT in treating adults with an ocially established
PTSD diagnosis, while Table 2 shows the four studies
that compared EMDR to CBT in treating children. Of
the 13 adult studies, 9 were included in the guidelines
published by the WHO (2013), 2 in the APA (2017),
7 in NICE (2018), and 12 in the ISTSS (2018) treatment
guidelines.
TABLE 2. Overview of RCTs (Any Control Condition) on EMDR for PTSD in Children and Adolescents
Study NTreatment
Number of
Treatment
Sessions
Percentage Loss
of Diagnosis
EMDR Patients
Immediately
After TreatmentaMain Results
Ahmad
et al.
(2007)
33
(17)
• EMDR
• WL 8 Not reported EMDR > WL
Chemtob
et al.
(2002)
32
(32)
• EMDR
• WL/delayed
treatment
3 Not reported EMDR > WL
Diehle et
al. (2015)
48
(25)
• EMDR
• TF-CBT 845 EMDR = TF-CBT
De Roos
et al.
(2017)
103
(54)
• EMDR
• CBWT
• WL
493 EMDR, CBWT> WL
EMDR = CBWT
EMDR >CBWT
(regarding eciency)
Result maintained at
3-month and 1-year
follow-up 
Note. CBWT = cognitive behavioral writing therapy; PTSD = posttraumatic stress disorder; RCT = randomized controlled trial;
TF-CBT = trauma-focused cognitive behavioral therapy; WL = waiting list; > indicates “signicantly superior to”; < indicates
“signicantly inferior to.”
aBased upon clinical interview.
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The Status of EMDR Therapy in the Treatment

TABLE 3. Overview of the Most Recent Treatment Guidelines Recommending EMDR Therapy
Guideline Target Group Year Recommendation
WHO Adults 2013 “Should be considered” with moderate quality of evidence
WHO Youth 2013 “Should be considered” with low quality of evidence
Veterans Aairs and US
Department of Defense
Adults 2017 Recommendation with strong evidence
APA Adults 2017 “Suggested,” but not recommended
NICE Youth 2018 Only if they do not respond to or engage with trauma-focused CBT
NICE Adults 2018 During months 2 and 3 post-trauma, “Consider EMDR” after a
non-combat-related trauma if the person has a preference for
EMDR. EMDR is recommended for treatment more than 3
months after a non-combat-related trauma.
ISTSS Adults 2018 Strong recommendation
ISTSS Youth 2018 Strong recommendation
Note. APA = American Psychological Association (APA, 2017); CBT = cognitive behavioral therapy; ISTSS = International Society of
Traumatic Stress Studies (2018); NICE = National Institute for Health Care and Care Excellence (NICE, 2018); WHO = World Health
Organization (WHO, 2013).
Inconsistencies Between the Different
Treatment Guidelines
At this present moment there is a striking lack of con-
sistency between international treatment guidelines
for PTSD—raising the question as to why this may be
the case.
There are several factors to consider. Firstly,
while sometimes it is simply not clear which studies
formed the basis of the treatment recommendation
(e.g., VA/DOD, 2017), the authors of most of the
guidelines used dierent inclusion and exclusion cri-
teria (i.e., scoping question) for the studies selected
for their respective systematic literature searches,
which then impacted their subsequent meta-analyses
and nal recommendations. For instance, the authors
of the NICE (2018) and ISTSS (2018) guidelines,
in their assessment, excluded studies in which par-
ticipants with PTSD had severe psychiatric comor-
bidities. This led, for example, to the exclusion
of the largest EMDR outcome study on PTSD
that has been carried out to date (Van den Berg
et al., 2015, 2018, n= 155), as the participants
suered from a psychotic disorder in addition to
their PTSD. The same study was also excluded
in the meta-analysis underlying the APA guide-
lines, as they included only RCTs for their analy-
sis that had been conducted before 2012 (5 years
prior to the date that the guidelines were issued). If
this study would have been included in this meta-
analysis, conducted for APA, this probably would
have led to a recommendation similar to that for
TF-CBT. In the comments to feedback on the rst
draft of the guideline, the APA guideline com-
mittee wrote, “The panel decided to maintain its
conditional recommendation for EMDR, with the
caveat that there is greater uncertainty about this
recommendation than for other recommendations
and with future meta-analysis the recommendation
could be strong” (APA, 2017, p. 57).
The guidelines also handled the methodological
limitations dierently. For example, NICE excluded
studies with small sample sizes, ISTSS removed stud-
ies with too few sessions, and APA removed studies
with methodological limitations, viewed as “high risk
of bias.”
Conclusion
Regarding the status of EMDR therapy 30 years after
its introduction, we can conclude that, with regard
to PTSD, EMDR therapy can be used as an interven-
tion of rst choice because there is sucient scientic
support for its ecacy. Although some studies have
found no dierence in the eciency of EMDR and TF-
CBT for symptoms of PTSD (e.g., Diehle et al., 2015),
there are indications suggesting that EMDR ther-
apy may require fewer sessions than CBT (De Roos
et al., 2011; Jaberghaderi, Greenwald, Rubin, Zand,
& Dolatabadi, 2004; Nijdam et al., 2012). This notion
is most strongly supported by the results of a study
in which the researchers clocked the duration of the
trauma treatments using a stopwatch, thereby show-
ing that patients who received EMDR therapy lost
their PTSD diagnosis signicantly faster than CBT
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Jongh et al.

(2 hours and 20 minutes versus 3 hours and 47
minutes; De Roos et al., 2017).
EMDR’s possible eciency advantage would sug-
gest cost savings compared to treatment with TF-CBT.
This hypothesized cost dierential was directly tested
in one study that investigated the health-economic
benets of treatment with EMDR therapy. Results
suggest that adding EMDR treatment to standard care
for individuals with PTSD (in case psychosis is comor-
bid) would yield higher savings than adding TF-CBT
(-1574 Euro and -422 Euro per patient per 6 months,
respectively; De Bont et al., 2019).
What is needed for EMDR therapy to ensure that it
will continue to be recommended as a rst-line ther-
apy in future PTSD treatment guidelines? There are
some categories of traumatic events for which the sci-
entic evidence of EMDR therapy is still weak com-
pared to CBT. This includes combat-related PTSD
and children with PTSD. Given that the systematic
reviews identied only a few large RCTs and signi-
cant statistical heterogeneity, improving the quality of
EMDR research remains an important issue to ag. It
is clear that the empirical groundwork of EMDR ther-
apy based on RCTs in this area is still rather weak and
more studies are needed.
In conclusion, EMDR therapy is generally consid-
ered to be an evidence-based therapy that can be
applied for both adults and children in the case of
PTSD. Of note, future well-crafted RCTs in areas
such as combat-related PTSD and psychiatric disor-
ders with comorbid PTSD are warranted. Further-
more, RCTs where PTSD is a primary diagnosis also
remain necessary to ensure that in the future, treat-
ment guidelines EMDR therapy will continue to be
recommended as a rst-line therapy for PTSD.
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Disclosure. Ad de Jongh receives income from published
books on EMDR therapy and for the training of postdoc-
toral professionals in this approach. Benedikt Amann is
the Chair of the EMDR Europe Research Committee and
has received fees for providing training in EMDR in work-
shops and national and international EMDR congresses.
Arne Hofmann receives income from book publications on
EMDR and training licensed professionals in this approach.
Chris Lee receives fees for providing training in trauma
therapies. Derek Farrell has no relevant nancial interest or
aliations with any commercial interests related to the sub-
jects discussed within this article.
Correspondence regarding this article should be directed
to Ad de Jongh, Gustav Mahlerlaan 3004, 1081 LA Amster-
dam, the Netherlands. E-mail: a.de.jongh@acta.nl
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