Less Than Meets the Eye: Blind Spots in the EMDR Method

Less Than Meets the Eye

Blind Spots in the EMDR Method

Sagi Gottfried

Eye Movement Desensitization and Reprocessing (EMDR) is a structured psychotherapy used primarily in the treatment of post-traumatic stress disorder (PTSD) and other trauma-related difficulties. The method incorporates bilateral stimulation, typically while the client attends to trauma-related material. Bilateral stimulation may involve guided eye movements, alternating auditory tones, or tactile stimulation.

EMDR has also been investigated for conditions beyond PTSD, such as anxiety, depression, phobias, addictions, and life crises. It has also gained research recognition and support from international organizations, including the American Psychological Association (APA 2017) and the World Health Organization (WHO 2013). The U.S. Department of Veterans Affairs and the Department of Defense (VA, DoD 2017) have recognized its efficacy. In Israel, the approach is recognized by the Ministry of Health as an effective method for treating trauma.

Alongside the broad support that EMDR receives among therapists, patients, and professional organizations, critics have argued that several important questions receive insufficient attention in the therapeutic community in Israel. In this review, I will address the central criticisms raised regarding the method. In light of these criticisms, I will review the history of the method’s development, from Francine Shapiro’s first study to the present day, with an emphasis on methodological challenges and relevant research. The aim is to clarify limitations and unresolved questions in ways that may advance professional discussion in the field of trauma.

A Closer Look at the Development of the Method

Shapiro’s initial research on EMDR therapy included 22 participants diagnosed with PTSD. The participants were divided into two groups: a group that received the new eye movement treatment and a control group. In the treatment group, participants were asked to recall a traumatic memory during the therapy. Each participant’s level of distress was measured subjectively by rating distress on a scale from 0 to 100, before and after the intervention. Shapiro reported a 100% success rate in the treatment group and no improvement, or even increased distress in the control group. However, these results were not replicated.

Criticism of the study focused on researcher bias, which were considered problematic even by the standards of the time. Shapiro performed all stages of the study herself, conducted the initial assessment interviews, assigned participants to groups, administered the therapeutic intervention (which was sometimes conducted in her personal home), and even performed the data analysis. The experimental group was treated with additional techniques besides eye movements, such as encouraging positive thoughts and using deep breathing. In contrast, participants in the control group talked about their trauma without incorporating any therapeutic techniques (Herbert et al, 2000).

Shapiro dismissed the criticism regarding experimenter effects, arguing that the effect size was too large to be explained by this. However, I would like to suggest that the effect size may be evidence of substantial experimenter effects arising during the research process, such as the method of assignment to conditions, assessment methods, and data analysis. These effects may lead researchers—sometimes even unintentionally—to provide higher-quality treatment to the experimental group compared to the control group. Further biases may occur in the publication of results, particularly in biases that include post-hoc selection of significant differences while omitting measures where no significant change was observed. For example, a comprehensive meta-analysis by Cuijpers et al. (2020) points to significant biases in EMDR studies. It was found, for instance, that the treatment effect was larger in non-Western countries, where research standards are relatively loose, and in conditions where control groups included a waiting list instead of active treatments.

After studies were published that contradicted Shapiro’s extraordinary claims of success, she responded by blaming the clinicians who conducted the studies, claiming they had not received sufficient training. In addition, she warned that patients might be at risk if treated by therapists without proper training (Shapiro, 1996). This is in contrast to her previous statements, in which she claimed that reading her first article was sufficient to provide treatment. Another interesting fact is that two of the cases that reported treatment failure were first presented in demonstrations conducted by Shapiro at a training seminar for the method. A year later, Jensen (1994) found that EMDR was not effective in treating combat veterans. Shapiro criticized the findings, claiming that Jensen had only completed stage 1, and not stage 2 of the training. However, this criticism is problematic because stage 2 did not exist at the time Jensen conducted his study.

Thus, it seems that Shapiro created an impossible situation for researchers: a demand for fidelity to the protocol, while she continued to change the training requirements post-hoc as an explanation for findings that did not support her. In addition to changes in the nature of the treatment, Shapiro also changed the theory post-hoc when negative information was received in studies. Pitman et al. (1996) tested the contribution of eye movements in treating combat veterans, where patients were assigned to standard EMDR treatment and a treatment condition that included the same protocol without eye movements, but with finger tapping instead. No significant differences were found between the conditions. In fact, in 1994, when Pitman collected and analyzed the data in his study, Shapiro suggested that other methods of bilateral stimulation could be used, such as the therapist’s finger tapping, tapping on the patient’s knees, or bilateral stimulation via sounds. All of these are still considered part of EMDR, meaning that “Eye Movement Desensitization and Reprocessing” no longer requires the use of eye movements.

On Purple Hats and Eye Movements – What Explains the Method’s Efficacy?

Shapiro made an effort to find a scientific explanation that could lend credibility to her claim that eye movements are an essential component of treatment outcomes. Initially, she emphasized the idea of “Adaptive Information Processing,” suggesting the contribution of eye movements in opening a “blockage” in information processing caused by neuronal pathology (Shapiro, 1989b). Later, she proposed alternative forms of bilateral stimulation and adopted the idea of interhemispheric communication in the brain. Lohr (1996) called the way Shapiro presents her theories an “embarrassing form of neuro-cognitive pseudoscience.” Today, there is little scientific support for this hypothesis, and several studies have even refuted it (e.g., Samara, 2011).

An alternative explanation proposed for the therapeutic power of eye movements focused on the hypothesis that dual tasks impair working memory, thereby reducing the vividness and emotional activation of the trauma memory. Although this explanation sounds scientifically grounded, its basis is relatively weak, and there are conflicting findings showing that there is no difference between the use of eye movements and other distraction tasks. Furthermore, although many studies have shown that therapeutic efficacy was not found to be higher in identical therapeutic conditions that do not include bilateral stimulation, the findings remain problematic. Safety behaviors are behaviors that a person performs to prevent or reduce the risk of something they fear. The goal of the behavior is to provide the person with a sense of security. The problem with safety behaviors arises when a person tries to prevent or reduce fears that are disproportionate, or when the cost of the behaviors is higher than the danger itself. In the long run, the person is prevented from learning that the danger is not as they believe (Rachman, Radomsky & Shafran, 2008). In this context, it seems that working memory loading serves as a safety behavior that may impair the effectiveness of the treatment.

Another attempt to explain the efficacy of eye movements lies in the hypothesis that they impair working memory, thereby affecting the vividness and emotional arousal of the traumatic memory during exposure. This effect may, in theory, facilitate treatment completion rates. However, there is no definitive answer on the subject. Various meta-analyses, such as those by Cuijpers et al. (2020), Lewis et al. (2020), and Wright et al. (2024), did not find a significant difference between most trauma-focused methods in dropout rates or treatment completion, including EMDR.

Rosen et al. (2024) note the problem with a method lacking a grounded model, in that positive outcomes do not, by themselves, establish the efficacy of a treatment’s unique component of the treatment. EMDR is a treatment that combines components from evidence-based therapies with a new component whose specific scientific rationale remains disputed. This type of treatment is also called “Purple Hat Therapy” (PHT)—a metaphor introduced by Rosen and Davison (2003). An example of PHT is a person who goes to a doctor with back pain, and the doctor instructs them to wear a purple hat and do an hour of stretching every day, while promising that they will see improvement within a month. The happy patient shares the rapid improvement with their friends, and soon many turn to the doctor asking to purchase the miracle hat.

The term “Purple Hat Therapy” was coined in the context of EMDR, due to the claim that the effects of the treatment are better explained by the components borrowed from other techniques, rather than by the eye movements. In these types of treatments, therapists and researchers ignore the use of effective interventions drawn from research-based methods and emphasize the aspects that have received little empirical evidence for their efficacy, which in fact constitute the “purple hat component.” For example, in EMDR, the patient is asked to follow the therapist’s finger while thinking about the most distressing component of the traumatic memory. In fact, in this treatment, the new component is the eye movements, while the existing and scientifically proven components include imaginal exposure (a unique form of imaginal exposure, due to its brevity, non-sequential nature, and lack of requirement for the patient to narrate the trauma, but requiring attention to bilateral stimulation—and this is still a form of exposure via imagination or memory), and subsequent stages of processing and cognitive restructuring (Rosenfeld & Mclean, 2023). Given a controlled study with comparison to no-treatment control groups, the “purple hat component” could gain the status of an evidence-based treatment. Researchers can choose to publish only the results that promote their agenda, use biased research questions and measures, and thereby shift the burden of proof. Significant results are obtained due to flawed research designs. Since there is no clear mechanism that explains the therapeutic effect of eye movements (or any other form of bilateral stimulation), researchers can assume that EMDR is actually a variation of an exposure method with a “purple hat” component. As McNally (1999) noted, “What is effective in EMDR is not new, and what is new is not effective.”

Thus, although EMDR uses science-based tools, the success of the treatment is attributed to the “purple hat” components, and therapeutic success may be attributed disproportionately to that component. Given the scope of the need for trauma treatments in Israel, one must ask whether it matters why EMDR works, and for whom it is useful, so that public resources can be allocated responsibly. In my view, this understanding is important for several reasons: First, the marketing of EMDR as a faster, better, and easier treatment than others, suitable for a wide range of disorders, is not supported by accepted scientific knowledge. Therefore, it is appropriate for proponents of the method to limit their claims to the scope of extensive and established research, as a trauma-focused treatment, and not view it as a comprehensive solution for every mental difficulty.

Second, EMDR therapists spend a great deal of time learning mechanisms that are not effective for change, which can impair their ability to make effective changes in the relevant parts if the treatment does not work. That is, instead of, for example, adjusting the exposure or cognitive restructuring, they may focus the change on the type of bilateral stimulation and its speed. In fact, Shapiro herself said that she was looking for a model to explain the effects of EMDR, not the mechanisms for change (Shapiro & Solomon, 2017, p.29). This approach prefers eclectic rather than convergent information, which confirms but cannot refute the basic theoretical assumptions—which increases the risk of a Type I statistical error (finding false positive results). Additionally, the focus on pseudo-scientific mechanisms and their unquestioning acceptance by the clinical community harms the scientific and professional image of the field of psychology and hinders focused research on mechanisms of change (Rosenfeld & Mclean 2023).

Keeping an Eye on the Origins of the Method

Rosen (2023) offers a review of the origins of the EMDR method and presents the controversial basis upon which the method was developed in its early days. In his article, he presents the beginning of the method’s development, as described in the first article published by Dr. Francine Shapiro in 1989. In the book, Shapiro notes that during the period when she was dealing with cancer, while walking in the park near her home, she felt distress that reminded her of her illness. At that moment, she noticed that at a certain point the disturbing thoughts began to disappear on their own, without her taking any intentional action to do so. According to her, after deep self-examination, she noticed that her eyes were darting rapidly from side to side. After this accidental discovery, Shapiro began to test the therapeutic potential of eye movements with volunteers and patients. In the years 1981-1988, Shapiro was a doctoral student in psychology at an unofficial college, whose degrees were not recognized and no longer exists today, called the “Professional School of Psychological Studies.” This institution was dubbed at the time with the dubious nickname “degree mill” (Carroll, 2004). The discovery of EMDR occurred exactly at the time when Shapiro was looking for a topic for her doctorate.

Unfortunately, it seems that the existing scientific evidence does not support the veracity of Shapiro’s background story, due to the fact that independent eye movements are physiologically invisible—people cannot notice their own eye movements even if they direct their awareness to it (Clarke et al 2017, Moses & Hart, 1987). You can try for yourself to walk around, while thinking positive and negative thoughts, and check if you noticed a pattern in your eye movements. Rosen (1995, from Rosen 2023) tried this with six subjects, who did not succeed. In response to this publication, Shapiro promised on the EMDR therapist group mailing list a critical response by an “expert researcher in the field of perception.” Such a response was indeed published by perception researcher Robert Welch (1996), who sharply criticized Rosen for the anecdotal inference he made, after reviewing the relevant research. Welch argued that Shapiro, who had a great interest in understanding her own behavior, along with a unique sensitivity to unexpected phenomena and the determination to investigate them in depth, possessed the qualities required to notice saccadic eye movements¹. In light of these warm praises, it is puzzling that Welch chose not to mention a relevant conflict of interest—the fact that he was married to Francine Shapiro².

Moreover, in my view, Welch reviewed the scientific literature in a distorted manner to support a claim that is scientifically incorrect. For example, when Welch referred to the study by Brindley and Merton (1960) to support his claims, he ignored the content of the study, which found that people are unable to sense their eye movements. This finding is even highlighted in the title of the article: “The absence of position sense in the human eye.” Also in 2017, Clarke et al. reviewed this topic in their article “People are unable to recognize or report on their own eye movements.”

An alternative explanation for Shapiro’s discovery theory focused on her connections to the NLP method as a conceptual basis for the use of eye movements in EMDR. In 1985, two years before the walk in the park described in the origin story, Shapiro was involved in selling health products and conducting NLP workshops. To promote her business, Shapiro published an article in the popular magazine “Holistic Life.” The article dealt with NLP theories on a variety of topics, including the importance of eye movement patterns. Shapiro wrote: “One of the findings of NLP is that all people in all cultures (except the Basque nationality) show how they think through their eye movements… even without saying a word, if you watch their eye movements carefully, you can know if they are seeing an image, hearing, or feeling something. In addition, you can know if people are remembering something or thinking a thought” (Shapiro, 1985, pp. 41-43 in Rosen 2023)³.

In another article published that same year in the LA Times magazine, Shapiro explained that NLP therapists can access how people think and experience the world through the diagnosis of body language cues, including eye position. Shapiro wrote: “Calm breathing and side-to-side eye movement signifies that a person is in an auditory processing state” (Mclean 1985). At the end of the interview, details were published about Shapiro’s NLP workshops, which were held in collaboration with John Grinder, one of the developers of the method. These quotes demonstrate Shapiro’s great interest in eye movements and their importance in her eyes as a significant component in NLP. In addition, they raise questions about the psychological and scientific aspects of her view, especially considering that she was then a student in her fourth year of her doctorate. Although NLP was rejected by the scientific community overwhelmingly even before the publication of Shapiro’s article (Sharpley, 1984; Leikind & McCarthy, 1985 in Rosen 2023), it seems that Shapiro confuses in her words between unsubstantiated statements and scientific facts. She even accepts unfounded claims in NLP without scientific support, despite conflicting evidence and without a theory supporting their plausibility.

In 1997, Shapiro published a book in collaboration with Forrest, under the title: “EMDR: The Breakthrough Therapy for Overcoming Anxiety, Stress, and Trauma.” On the back cover, the sentence was quoted: “Independent studies have recently found efficacy of up to 90%,” supposedly by the American Association for the Advancement of Science (AAAS), a respected association in the United States. In private correspondence conducted by Rosen in 1997, he asked to check the quality of the quote and was told by representatives of the association that they do not recognize the EMDR method and do not know where the quote came from. McNally (1999) reported that the AAAS investigated the statement in the book and concluded that the source of the quote is in things Shapiro herself said in a radio interview sponsored by the association. In other words, the praising quote was said by Shapiro herself—about herself. A year later, Shapiro was reprimanded after doing a similar exercise with the Association for Advancement of Behavior Therapy.

Near the time of the publication of Shapiro’s first article, in which she presented the EMDR treatment (then called EMD), NLP theories were considered by the scientific community as pseudoscience and unfalsifiable. It is possible that this negative image, combined with Shapiro’s strong belief in NLP, led her to disconnect herself from these sources and declare her discovery as new and independent. Thus, in my view, Shapiro’s origin story, about the revelation in the park where she miraculously understood the contribution of eye movements, warrants scepticism. It ignores Shapiro’s background, which can better explain the interest she developed in the therapeutic use of eye movements.

Lack of Superiority Over Other Methods

The importance of eye movements in EMDR remains controversial. In many meta-analyses, including that of Wright et al. (2023), no significant difference was found between EMDR and other treatment methods. Consistent with these findings, a meta-analysis by Davidson & Parker (2001) compared EMDR treatment with eye movements to an EMDR condition without eye movements, and no difference was found between the conditions. In the meta-analysis by Lee & Cuijpers (2013), a larger effect was found for treatment with eye movements, but most of the articles in the meta-analysis were on patient groups that did not have a clinical disorder, and the sample size was small. In the meta-analysis by Cuijpers et al. (2020), these findings were not replicated. The use of eye movements, one of the central components of the method, was not found to be clinically effective in dismantling studies (Van Veen et al. 2019; Sack et al, 2016) as necessary—EMDR treatment was effective even without eye movements or without a condition of alternative bilateral stimulation.

In disorders other than post-trauma, comparisons between EMDR and cognitive therapies and exposure therapies show only a moderate advantage. When only studies with a low risk of bias were included, the effect size was close to zero. In addition, the meta-analysis suggested that EMDR’s effects were largely short-term, and tests conducted after three months or more did not indicate a significant therapeutic effect. The meta-analysis points to no significant advantage for EMDR over other evidence-based methods in treating problems such as depression, eating disorders, alcoholism, schizophrenia, OCD, bipolar disorder, and behavioral disorders. All studies in the meta-analysis, except one, were found to have a high risk of bias, and therefore it is very difficult to rely on the information as reliable evidence for the efficacy of EMDR in this context.

In summary, EMDR is sometimes perceived as a magic solution in the world of therapy, but a critical examination reveals the gap between the promises and the scientific evidence. It can be suggested that its popularity stems from the desire to find a single answer for treating complex mental difficulties. The article reviews the structural difficulties in the theory underlying the method and the questions regarding the proven efficacy of the central component in EMDR—bilateral stimulation. Although the method has gained widespread recognition as an effective approach for treating post-traumatic disorders and other mental difficulties, it should be remembered that some of the findings that led to its popularity may be based on partial or inaccurate data. There are many factors that contributed to the widespread adoption of EMDR, but in light of all the claims above, there is still not enough evidence or a science-based mechanism to justify the moving of fingers by therapists in front of their patients’ eyes (Rosen & Pankratz 2024).

Notes

1. The tracking movements required in EMDR, contrary to Shapiro’s conceptualization, are not saccadic movements but are defined as Smooth pursuit.
2. A similar conflict of interest in Shapiro’s career occurred with her previous husband, Gerald Puk, who was a committee member for her doctoral approval, even though he was not a staff member at the “Professional School of Psychology,” this without proper disclosure regarding their personal acquaintance.
3. At the bottom of the article, Shapiro is described as having “advanced degrees in literature and psychology,” however, Shapiro’s doctorate in psychology was received only in 1988, 3 years after the article was published.

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This article was originally published in Hebrew on Psychology Hebrew.