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From the Department of Psychiatry, Chang Gung Memorial Hospital, Kaohsiung.
Received: Oct. 29, 2004; Accepted: May 3, 2005
Correspondence to: Dr. Nien-Mu Chiu, Department of Psychiatry, Chang Gung Memorial Hospital. 123 Ta-Pei Road, Niaosung
Hsiang, Kaohsiung County, Taiwan. Tel.: 886-7-7317123 ext. 8768; Fax: 886-7-7326817; E-mail: chiune@ms5.hinet.net,
suntf77@yahoo.com
1
Case Report
Synergism Between Mindfulness Meditation Training, and Eye
Movement Desensitization and Reprocessing in Psychotherapy
of Social Phobia
Tzan-Fu Sun, MD; Nien-Mu Chiu, MD
We report on the successful treatment of a psychiatric outpatient with long-term Social
Phobia (SP), at best only marginally responsive to pharmacotherapy. He was treated by Eye
Movement Desensitization and Reprocessing (EMDR) because we suspected that his phobia
derived from emotional trauma. He also received brief training in Mindfulness Meditation
(MM), which enhanced his initially poor response to EMDR. The patient practiced medita-
tion intensively during the treatment period and thereafter, and used it to relieve the distress
that he experienced during both real and deliberately-imagined phobic situations. He recog-
nized this distress pattern as identical to the one he reported to his EMDR therapist while
processing traumatic images. The patient’s condition was much improved at discharge and
he continued to practice meditation during 31/2years of follow-up to sustain his relief. The
two therapeutic approaches appear to be synergistic and useful in treating SP. We also com-
ment on the usefulness of providing brief MM training, especially to highly-motivated
patients. (Chang Gung Med J 2006;29(4 Suppl):1-5)
Key words: eye movement desensitization and reprocessing, mindfulness meditation, social pho-
bia.
Eye Movement Desensitization and Reprocessing
(EMDR) is a brief psychotherapy for anxiety
especially related to traumatic memories.(1) It pro-
ceeds in sessions with a formalized protocol as
patients process specific distressing images in order
to desensitize the related anxiety. The therapist
applies “sets” of bilateral, alternating attention stim-
ulation by visual, tactile or auditory means, such as
right-left hand movements. The patient reports at
intervals on the physical and emotional sensations
that the images evoke and on changes in the images
themselves. During a session considered to proceed
properly, the patient grows emotionally and physical-
ly calmer and more positive in outlook.
Buddhist Mindfulness Meditation (MM) has
found a place in western medicine, notably as the
Mindfulness-Based Stress Reduction (MBSR) pro-
gram,(2,3) which trains patients in groups for 8-10
weeks to observe their physical and mental sensa-
tions in objective concentration, both during
“formal” dedicated periods and “informally” at any
chosen time. At our Psychiatry Outpatient Clinic, we
have supplemented the treatment of some individuals
with brief training in two MBSR components:
“Walking Meditation” (WM) - observing one’s legs
in motion, and “Sitting Meditation” (SM) - seated
and observing one’s breathing but also all other sen-
sations.
The subject of this report was trained in MM in
an attempt to improve his responsiveness to EMDR.
For the latter, we used the bilateral attention stimula-
tion technique called “hand tapping” i.e. alternating
Chang Gung Med J Vol. 29 No. 4 (Suppl)
September 2006
Tzan-Fu Sun, et al
EMDR, MM and social phobia treatment 2
taps above the seated patient’s right and left knees.
CASE REPORT
Mr. L, a 38-year-old Taiwanese civil servant,
was diagnosed with Social Phobia (SP), also known
as Social Anxiety Disorder, at our Outpatient Clinic
in 1996. Over time, he was prescribed various drug
combinations including antidepressants, anxiolytics,
a muscle-relaxant and a β-blocker. However, in 2001
he complained to a new therapist of his continued
and increasing distress upon contact with people
other than his family, especially co-workers. For
example, he could talk with his supervisor only by
phone and feared meeting a colleague on the street,
whereupon he would become flushed and speechless,
as did the startled colleague. He claimed that the
drugs had helped him somewhat, whereas biofeed-
back training had not. We offered him EMDR thera-
py because he thought that his problem had started
after an encounter with his military commander in
1984. However, he could not recall the exact, pre-
sumably traumatic, event. Since he insisted on con-
tinued pharmacotherapy, we prescribed alprazolam
SR 0.5 mg twice a day and moclobemide 150 mg
twice a day. Throughout treatment and follow-up, we
recorded his scores on the Beck Anxiety and Beck
Depression Inventories (BAI/BDI).(4,5)
At the first EMDR session (Day 1), Mr. L
processed the image of his supervisor summoning
him. This evoked feelings of nervousness and anxi-
ety, plus a series of physical discomforts including
hand tremors, “bloodshot” eyes, palpitations, facial
flush, shoulder and temple pain, mouth soreness and
head numbness. However, his processing was
extremely slow. He would get “stuck” in the same
physical sensation and in an unchanging image over
a number of attention stimulation sets, and could not
calm down or process additional images.
Consequently, Mr. L was instructed to practice
one hour of WM daily, followed by one hour of SM.
We surmised that this might enhance his response to
EMDR because of the state of concentrated observa-
tion shared by MM and EMDR,(1) and because both
hand-tapping EMDR and SM involved a seated,
eyes-closed (as per Mr. L’s choice) posture. Our
instructions were brief and simple, taking about 10
minutes out of the two hour session. They were
based on the therapist’s own long-term practice and
study. However, appropriate instructions exist in
print.(2,6)
Indeed, in each of two subsequent EMDR ses-
sions (Day 11 and Day 23), Mr. L readily processed
several images (e.g. his startled colleague’s flushed
face). Each full session lasted about 90 minutes,
including a brief review of his MM experience. He
reported that he had complied with our instructions,
and that MM calmed and relaxed him. Most notably,
he recognized that the sudden, disabling distress that
overwhelmed him during actual phobic episodes
comprised the same specific sensations that he expe-
rienced and reported sequentially during EMDR. He
would also deliberately imagine himself in phobic
situations, thereby evoking his familiar distress syn-
drome, and would observe it mindfully until it sub-
sided.
At this time, Mr. L chose to concentrate on MM
for six weeks. At his therapist’s suggestion, he would
on occasion retreat during an actual phobic experi-
ence to observe his distressing sensations until they
subsided. At discharge, we replaced the last planned
EMDR session with a discussion of his MM and
general situation. He considered himself much
improved and reported that he now communicated
face-to-face with his supervisor. In addition, he no
longer tried to conceal his workplace anxiety. He
also credited his formal and informal MM practice
with greatly improving his general disposition and
interpersonal relationships. His BAI score had
dropped from a starting value of 26 (high “mild-
moderate”) to seven (“normal”) and his BDI score
had dropped from 12 (“moderate”) to three (“mini-
mal”).
Following his discharge in late 2001, we have
seen Mr. L monthly to review his condition and
renew his prescriptions. His phobia has decreased
markedly, with temporary setbacks attributable to
circumstances such as family illness. He meditated
daily for one year and then shifted his formal medita-
tion to once or twice a week. He agreed to have his
drug regimen decreased to the point of eliminating
moclobemide and reducing alprazolam by 25%. His
BAI/BDI scores were consistently at the bottom end
of “normal/minimal”, with final scores of 3/0.
DISCUSSION
Our results are in line with reports on EMDR’s
Chang Gung Med J Vol. 29 No. 4 (Suppl)
September 2006
Tzan-Fu Sun, et al
EMDR, MM and social phobia treatment
3
usefulness in treating various phobias(7-9) and on MM
producing relief from anxiety disorders, including
panic disorder with agoraphobia,(10) and stress-related
anxiety.(11) However, there have been no published
reports linking these therapies to SP. For Mr. L, both
approaches appear to have worked synergistically in
successfully treating this disorder.
We suggest that the acquisition of mindful
observation skills enhanced Mr. L’s response to
EMDR, which initiated his relief from phobia. In
addition, his EMDR experience helped him recog-
nize his specific distress pattern. He confronted pho-
bic situations by mindful observation, much as others
had used this skill to prevent the recurrence of
depression brought on by specific situations.(12)
Moreover, Mr. L actually appeared to “practice”
EMDR on his own, by deliberately imagining him-
self in phobic situations and processing them mind-
fully.
As we indicated, our decision to try MM to
improve the effectiveness of EMDR was intuitive.
However, Shapiro noted that the nonevaluative
“observer” stance that EMDR sought to cultivate in
the distressed patient was also inherent to Eastern
Meditative Practices.(1) She also suggested that suc-
cessful EMDR involved a patient cultivating a state
of “mindful experience/being,” as formulated by
Teasdale.(13) We have previously discussed the thera-
peutic potential of combining EMDR and MM in a
report on a geriatric inpatient.(14) However, for that
patient, MM was used to relieve a profound depres-
sion due to age-related ailments. In addition, the
patient’s fear of surgery was eliminated by EMDR
but he was able to respond to this therapy only after
prolonged, intensive and calming MM practice. The
present report proposes that the combination of
EMDR and MM is useful in treating a specific, well-
defined disorder. As we noted, Mr. L believed that
the drugs he took did him some good before he start-
ed EMDR/MM psychotherapy, and that they helped
to maintain and even enhance his subsequent
improvement. We cannot comment on this issue
beyond reiterating that significant improvement
occurred only after psychotherapy had been started.
We considered our geriatric inpatient’s MM
training to equal the MBSR training protocol in
depth and duration but for Mr. L and other outpa-
tients we have been able to offer only brief traing.
Nevertheless, several of such patients have adopted
MM as a way of life with considerable benefit. Like
Mr. L, they practiced MM in a self-directed, intro-
spective and intelligent way. For example, another
outpatient - himself a medical professional - has
credited his three years of sustained MM (also ini-
tially combined with EMDR) with curing an anxi-
ety/depression complex whose manifestations ranged
from intense conflict with his father to fear of dri-
ving to work (TFS: Unpublished results).
As we have noted,(14) the therapeutic and theoret-
ical validity of EMDR has been a subject of contin-
ued controversy.(15,16) Indeed, in our practice we have
found EMDR to be, in some cases, ineffective and
even counterproductive, and in others only temporar-
ily effective. However, we also consider it to have
produced lasting relief in cases of distress due to
traumas such as burglary, breakup of a romantic rela-
tionship, bereavement and witnessing a spouse’s sui-
cide (TFS: Unpublished results).
Acknowledgement
We thank Abraham A. Held, Ph. D., Professor
Emeritus of Biological Sciences at the City
University of New York, for editorial help.
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38 (EMDR: Eye Movement Desensitization and
reprocessing) EMDR
EMDR EMDR
EMDR
EMDR (2006;29(4
Suppl):1-5)
93 10 29 94 5 3 833 123 Tel.: (07)7317123
8768; Fax: (07)7326817; E-mail: chiune@ms5.hinet.net, suntf77@yahoo.com
