The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
EMDR is an individualised intervention that aims to reduce symptoms of a range of mental health disorders including anxiety and PTSD. EMDR aims to assist recovery from these difficulties by promoting access to, and processing of, trauma memories and anxiety provoking stimuli. It helps to bring fear-inducing situations or trauma memories to an adaptive resolution, thereby reducing symptoms of the mental health condition.
EMDR therapy is delivered by trained psychological therapists, once weekly, over 6-12 sessions (50-90 minutes per session). People accessing service can receive fewer or greater number of sessions depending on their need and response to treatment. EMDR therapy sessions apply a structured eight phase treatment approach which are;
- Phase 1: History taking to obtain patient’s full history and flag target memories and triggers for treatment;
- Phase 2: Client preparation to teach patient techniques for affect management, and to introduce patients to bilateral stimulation components including eye movements, hand tapping, and audio stimulation;
- Phase 3: Assessment which involves identifying components (i.e. negative images, and distorted cognitions) of the trauma memory or anxiety provoking stimuli; rating distress levels and sensations triggered by this distress; identifying preferred positive cognition; and rating the validity of preferred cognition. Scales like the Subjective Units of Disturbance (SUD) scale and the Validity of Cognition (VOC) scale are used;
- Phase 4: Desensitisation, this phase enables the patient focus on the trauma memory or anxiety provoking stimuli, and engage with bilateral stimulation (BLS). BLS facilitates the incorporation of new thoughts, associations and sensations, and is continued until distress associated with the memory or stimuli is substantially reduced;
- Phase 5: This installation phase involves strengthening the preferred positive cognition, by enhancing their validity and integration within memory networks;
- Phase 6: A body scan to identify and process residual maladaptive sensations in response to trauma memory or anxiety provoking stimuli;
- Phase 7: A closure phase to ascertain patient stability at the end of session and between sessions; Phase 8: This re-evaluation phase starts the next session and is carried out to assess the patient’s present psychological state, and determine if treatment effects have been sustained. Treatment is then shifted to the next target memory or anxiety provoking stimuli associated with the PTSD or anxiety symptoms.
EMDR doesn’t focus specifically on the alteration of thoughts, beliefs or behaviours associated with the trauma or anxiety provoking stimuli, and it doesn’t include a homework component. EMDR therapy can be delivered to in children, adolescents and adults offered alone or with other therapies.
Fidelity
NICE recommends that EMDR therapy for adults should be delivered by trained practitioners with ongoing supervision, typically over 8-12 sessions (or more if clinically indicated). It is necessary that EMDR therapy is delivered as per validated manual, in a phased manner, and involve repeated within session bilateral stimulation until target memory or stimuli no longer causes distress.
The EMDR Fidelity Rating Scale (EFRS) is used to assess therapist’s adherence to EMDR therapy’s standard eight-phase treatment approach. The current version was completed by Korn, Maxfield, Stickgold, and Smyth, 2018.
Modifiable Components
Eye Movement Desensitization and Reprocessing (EMDR) therapy sessions can be conducted on consecutive days which facilitates treatment completion over a shorter period. In the treatment of PTSD, EMDR has been shown to be effective in reducing PTSD symptoms in patients with psychosis (van Den Berg et al, 2015, https://pubmed.ncbi.nlm.nih.gov/25607833/). Most EMDR research in the treatment of PTSD has been conducted in civilian sample, so EMDR can be considered for treatment in non-combat-related trauma.
Supports - Rating: 3
3 - Somewhat Supported
Some resources are available to support competency development or organisational development but not both
Support for Organisation / Practice
Implementation Support
Implementation support is provided by EMDR Association UK and EMDR Europe (the overarching body for EMDR in Europe). EMDR Association UK provides links to accredited EMDR courses, accredited consultants, and accredited trainers. EMDR Europe provides therapist accreditation following fulfilment of specified criteria, and they ensure that all trainers and training courses meet required standards. EMDR Association UK offers membership access to both EMDR Association UK and EMDR Europe.
In Scotland, anyone delivering psychological therapy supervision should have completed the NES Generic Supervision Competences (GSC) training. There is work ongoing to review the supports for EMDR and this will be updated once concluded.
Start-up Costs
Currently start-up costs include costs of basic training and supervision from EMDR UK. This training covers therapist standard accredited training and 10 hours of supervision. Training cost varies with provider but is typically around £1400. Other costs include practitioner or consultant accreditation fee at £80, practitioner or consultant re-accreditation fee at £45, and trainer accreditation fee at £750. All costs are charged per practitioner. Accredited EMDR practitioners seeking EMDR consultant accreditation are required to contact EMDR association UK for details of the Consultants-in-Training Training course. EMDR association UK should also be contacted for EMDR Association membership fees.
Building Staff Competency
Qualifications Required
Eye Movement Desensitization and Reprocessing (EMDR) therapy is delivered by practitioners with mental health clinical background. These include registered psychologists (e.g. clinical, counselling, educational, and forensic), registered mental health nurses, registered social workers, and psychiatrics. Membership of the EMDR UK Association is required for accreditation. Accreditation is valid for five years.
Training Requirements
Eye Movement Desensitization and Reprocessing (EMDR) training process has different levels. These include;
- Standard accredited training: A seven-day course that covers basic EMDR training. Therapists are required to deliver EMDR therapy to at least three clients within their clinical practice
- Practise EMDR under supervision: Involves supervision from accredited EMDR Europe Consultant, and delivery of EMDR therapy to at least 25 patients within clinical practice. Following this, therapists can apply to become accredited practitioners
- Consultant training: A three-day course that reviews EMDR theory, and covers the accreditation process, competency framework, and consultation process
- After three years of EMDR practise and experience, practitioners who meet training and supervision requirements can apply to become Accredited Consultants
- Specialist training: Practitioners seeking to deliver EMDR to specific groups, e.g. children and adolescent, will undertake specialised EMDR training. Separate eligibility criteria apply.
- Further accreditation requirements must be fulfilled to become accredited EMDR trainer.
Training can be delivered face-to-face or virtually.
Supervision Requirements
Therapists receive supervision during the training process. Supervision is recommended to be provided by accredited EMDR Europe consultant.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
Eye Movement Desensitization and Reprocessing (EMDR) therapy is based on Adaptive Information Processing model. This model proposes that symptoms of trauma and other disorders are a consequence of past disconcerting experiences that cause continued distress because the memories associated with these experiences have not be sufficiently processed. When these inadequately processed memories are triggered, the maladaptive thoughts, emotions, beliefs and sensations that are associated with the traumatic event, and are contained in these memories, are experienced. As a result, symptoms associated with PTSD and/ or other disorders are produced. EMDR therapy therefore focuses on accessing these unprocessed memories, applying bilateral stimulation to help the brain process the memories, and facilitating a reduction of patient’s symptoms.
Children and Young People - Rating: 5
Research Design & Number of Studies
Children and Young People Evidence for PTSD
One RCT compared EMDR (in addition to treatment-as-usual) with treatment-as -usual for the delayed treatment (>3 months) of non-significant PTSD symptoms in children. Three RCTs compared EMDR therapy with waitlist or treatment-as-usual for the delayed treatment (>3 months) of PTSD in children and young people. These three studies were included in meta-analysis. The results have been summarised below. Complete details of studies included in the meta-analyses, and detailed results from the meta-analyses can be found in the NICE guideline evidence reviews 2018.
Children and Young People Outcomes
- Significant reduction in PTSD symptoms at endpoint, following delayed treatment for single incident trauma (3)
- Significant reduction in emotional and behavioural problems following delayed treatment for single incident trauma (3)
- Significant improvement in quality of life following delayed treatment for single incident trauma (3)
- Significant reduction in PTSD symptoms following delayed treatment non-significant PTSD symptoms. Effect was observed at endpoint and sustained at 3-months follow-up (4)
Significant reductions in internalising problems, externalising problems, and oppositional defiant disorder symptoms, following delayed treatment non-significant PTSD symptoms. Effects on all three outcomes were observed at endpoint, and were sustained at 3-months follow-up (4)
Children and Young People Outcomes for Anxiety Disorder
There is limited evidence showing the effectiveness of EMDR in children with anxiety disorders. Most of the available evidence (not including case studies) are focused on children/ adolescents with trauma/ PTSD.
Adults - Rating: 5
Adult Evidence for PTSD
One RCT compared EMDR to supportive counselling for the delayed treatment (>3 months) of non-significant PTSD symptoms in adults. Eleven RCTs compared EMDR therapy (alone or in addition to TAU) with waitlist, pill placebo or treatment as usual, for the treatment of PTSD in adults. These eleven studies were included in meta-analyses, and results are summarised below. Complete details of studies included in the meta-analyses, and detailed results from the meta-analyses can be found in the NICE guideline evidence reviews 2018.
Outcomes Achieved
- Significant reduction in PTSD symptoms following early treatment (1-3 months). Significant improvements were observed for multiple incident traumas, at endpoint, 1-month follow-up and 3 months follow-up (1)
- Significant reduction in PTSD symptoms following delayed treatment (>3 months). Significant improvements were observed at endpoint for single and multiple incident traumas (1)
- Significant reversal of PTSD diagnosis following delayed treatment (>3 months) at endpoint for single and multiple incident traumas. Remission remained significant at 1-month follow-up for multiple incident traumas (1)
- Significant reduction in dissociative symptoms and anxiety symptoms following delayed treatment for single incident trauma (1)
- Significant reduction in depression symptoms following delayed treatment (>3 months), at endpoint for single and multiple incident traumas. Significant reduction in depression symptoms was sustained at 1-month follow-up for multiple incident trauma (1)
- Significant reduction in functional impairment following delayed treatment (>3 months) for single incident trauma (1)
- Significant reduction in PTSD symptoms in adults with below threshold PTSD symptoms. Effect was observed following delayed treatment (>3 months) (2)
Adult Evidence for Panic Disorder
Some of the best available evidence demonstrating the effectiveness of EMDR in the treatment of panic disorder are mentioned below.
- The first study was a two-arm, parallel, non-inferiority, randomized controlled trial (RCT) that compared EMDR to Cognitive Behavioural Therapy (CBT) in the management of panic disorder (Horst et al, 2017). The study was conducted in the Netherlands, and included 84 adults, aged 18-65 years, with primary diagnosis of panic disorder. EMDR was delivered over 13 weekly sessions, each lasting about 60 minutes.
- The second study was an RCT conducted in USA (Goldstein et al, 2000). The study evaluated the effectiveness of EMDR in 46 adults (aged 18-65) diagnosed with panic disorder of at least one-year duration, with agoraphobia. EMDR was delivered over six 90-min sessions, over an average of 4 weeks.
- The third study was also an RCT conducted in USA (Feske and Goldstein 1997). The study evaluated the effectiveness of EMDR in 43 adults (aged 20-54 years) with a diagnosis of primary panic disorder, for at least a year, with agoraphobia. EMDR was offered over six sessions, i.e. one information-gathering session followed by five EMDR sessions (one 2-hour and four 90-min sessions), delivered over an average of 3 weeks.
- The fourth study was a pilot comparison of EMDR and CBT conducted by a researcher in Italy (Faretta, 2013). The study included 20 adults (aged 20-50 years) with diagnosis of panic disorder, with or without agoraphobia, who were non-randomly assigned to receive either interventions. Delivery format for EMDR was not described.
Adult Outcomes for Panic Disorder
Compared to wait-list control, or active comparator in the non-inferiority studies, the following outcomes were observed;
- Severity of panic disorder in EMDR group was non-inferior to the CBT group at post-treatment (Horst et al, 2017; Faretta, 2013), and at 1-year follow-up (Faretta, 2013)
- Significantly reduced panic severity (Goldstein et al, 2000) and panic frequency at post-treatment (Feske and Goldstein, 1997). Significantly greater reduction in panic frequency at post-treatment and 1-year follow-up, in favour of EMDR, was also reported in EMDR and CBT comparison study (Faretta, 2013)
- Significantly reduced scores on measures of agoraphobia at post-treatment (Goldstein et al, 2000; Feske and Goldstein, 1997)
- Significantly reduced general anxiety and depression at post-treatment (Feske and Goldstein, 1997)
Quality of life in in EMDR group was non-inferior to the CBT group at 3-months post-treatment (Horst et al, 2017)
Need
Comparable Population
Eye Movement Desensitization and Reprocessing (EMDR) therapy is an individualised intervention used to assist recovery from psychological trauma and other distressing life experiences. EMDR therapy can be delivered to children, adolescents, and adults. In adults, evidence of effectiveness of EMDR in the treatment of PTSD comes from seventeen RCTs that were evaluated in meta-analyses. Also in adults, evidence of effectiveness of EMDR in the treatment of panic disorders (with or without agoraphobia) comes from three RCTs and one pilot study. The studies were conducted in Italy, Netherlands and USA, and included adults aged 18-65 years. In children and adolescents, evidence of effectiveness of EMDR in the treatment of PTSD comes from two RCTs that were conducted in the Netherlands. The studies included children aged 4-18 years with trauma related symptoms or PTSD diagnosis. Outside of case-studies, there is limited evidence showing the effectiveness of EMDR in children with anxiety disorders.
Desired Outcome
In the treatment of PTSD, EMDR has been shown to reduce PTSD symptoms, reduce symptoms of comorbidities associated with PTSD (including depression and anxiety), and reverse PTSD diagnosis following early (1-3 months) or delayed treatment (≤ 3months). Effects have been sustained at follow-up. In the treatment of panic disorders, EMDR has been associated with significant improvements across several outcomes including panic severity, panic frequency, depression, anxiety, and quality of life. Some of the effects have been sustained at 1-year follow-up.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Eye Movement Desensitization and Reprocessing (EMDR) therapy is an individualised intervention used to assist recovery from a range of mental health conditions, including anxiety and PTSD. EMDR therapy was founded on Adaptive Information Processing model which focuses promoting access to, and processing of, trauma memories and anxiety provoking stimuli for the purpose of bringing them to an adaptive resolution. EMDR therapy can be delivered to in children, adolescents, and adults.
Priorities
Eye Movement Desensitization and Reprocessing (EMDR) therapy focuses on accessing target unprocessed memories, applying bilateral stimulation to help the brain process the memories, thereby facilitating a reduction of patient’s symptoms.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Eye Movement Desensitization and Reprocessing (EMDR) therapy is delivered by practitioners with mental health clinical background. These include registered psychologists (e.g. clinical, counselling, educational, and forensic), registered mental health nurses, registered social workers and psychiatrics. Counsellors/ psychotherapists, GPs, as well as clinical and counselling psychologists in their final year of training who meet specific requirements can deliver EMDR. Practitioners can receive specialist training to support EMDR delivery to children and adolescent. Therapists undergo EMDR training and supervision at several levels, to become accredited practitioners, accredited consultants or accredited trainers. Membership of the EMDR UK Association is required for accreditation. Accreditation is valid for five years. EMDR therapy is delivered (to people accessing service) once weekly, over 6-12 sessions (50-90 minutes per session).
Technology Support
Therapist trainings can be delivered face-to-face or virtually.
Administrative Support
EMDR therapy is delivered (to people accessing service) once weekly, over 6-12 sessions, with each session lasting 50-90 minutes.
Financial Support
Start-up costs include costs of basic training charged at around £1400, accreditation fee at £80, re-accreditation fee at £45, and trainer accreditation fee at £750. EMDR association UK should be contacted for cost of Consultants-in-Training Training course, and membership costs.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
