A Review of Mobile Applications for Facilitating EMDR Treatment of Complex Trauma and Its Comorbidities

The Research Team

The research team consisted of both experienced EMDR-trained clinicians, licensed professional counselors with no EMDR background, and doctoral students who are unlicensed but have clinical experience. Such a range of experience would help mitigate the effects of an unconscious bias towards any form of therapeutic service delivery.

Mobile App Selection Criteria

EMDR mobile apps were selected and evaluated by the research team over a period of 3 months. The inclusion criteria consisted of mHealth apps that referenced the terms EMDR, Eye Movement Desensitization and Reprocessing, BLS, and eye movements in their titles or descriptions. The research team searched for these apps on both iOS (iPhone, iPad) and Android operating systems, and initially discovered 17 iOS apps and 8 Android apps.

The inclusion criteria were as follows. First, the app had to claim that it was utilizing EMDR techniques or theory. For instance, one of the apps stated that it was inspired by EMDR, but did not claim to utilize any of the techniques or theory, so it was excluded. Second, apps needed to be accessible in order to evaluate them, so they had to be downloadable in the United States, the location of the research team. Three of the apps were not accessible in the United States, and had to be excluded as a result. Third, some apps had multiple versions, for example, there were four versions of EyeMove EMDR Trauma Therapy, so the research team decided to include only the latest and most updated version of each app. Finally, two of the remaining apps were present on both iOS and Android operating systems; hence, only the iOS versions of those apps were included in order to avoid repetition and redundancy.

Selection Process

The research team used a consensus deliberation model to select the final pool of apps to be evaluated. The team examined each of the 25 apps individually to determine whether they met the inclusion criteria for this study, and to determine their applicability. This resulted in a final evaluation pool of 12 apps in total, of which 11 were on iOS and 1 on Android (Figure 1).

FIGURE 1.

Selection process of apps to be evaluated.

Evaluation Criteria

Two divisions of the American Psychological Association (APA), Society for Media Psychology and Technology and Trauma Psychology (Dalenberg, Ardill, & Naish, 2016), conducted a study that rated mHealth apps based on the following criteria: (a) useful for which age groups, (b) easy to download, (c) easy to use, (d) beneficial to motivated user, (e) keeping with scientific literature or knowledge, and (f) reported efficacy evidence.

The original intent was for the team members to use the APA criteria to score the apps in dyads to determine inter-rater reliability; however, it was soon discovered that the APA scoring criteria were insufficient for our purposes. Thus, the research team met weekly to adapt the APA evaluation criteria, based on knowledge and clinical judgment, to include aspects such as the correct implementation of EMDR protocol and theory, additional safety measures, and information on privacy rights. In addition, we rated each of the 12 apps together as a group for both consistency and efficiency. Any disagreements in ratings were discussed as a team until they were resolved. Since the criteria are not numerical, reliability calculation does not apply. The complete set of evaluation criteria used in the current study can be found in Table 1.

Additional Findings Based on Evaluation Criteria

Recommended User. Of the 12 apps that were evaluated, 9 were advertised as for clinician use. However, only five of these apps specifically mentioned that the app should only be used by a trained and licensed practitioner. All the apps were available to be downloaded by anyone who has access to the Google or iTunes stores.

Customizability. Most of these apps provide some degree of customizability, with options for speed, frequency, color, duration, and so on, and three of them had the provision for including session logs.

Bilateral Stimulation. Nine provided a means of both auditory and visual BLS while two provided only auditory BLS. Only five apps suggested the use of headphones to achieve auditory BLS, and one recommended the use of a large screen to achieve full visual BLS. In fact, the most frequent evaluation of the apps we reviewed was that if the app were to be used on a smart phone or iPad for eye movements, the full-range BLS could not be achieved without placing the screen uncomfortably close to the viewer’s face.

EMDR Theory and Protocol. There was very limited information regarding recommendations to clinicians or clients about the proper use of EMDR or of the specific app to facilitate EMDR. With regard to EMDR practice, only six apps provided any basic information of EMDR or AIP as conceptualization for treatment. Ten apps did not address the EMDR protocol while one provided an inaccurate representation of the EMDR protocol. Three apps utilized guided sessions and one of these provided directions that are inconsistent with recommendations suggested by EMDR protocols. The apps seemed to equate EMDR with bilateral sensory stimulation and only Anxiety Release Based on EMDR clearly provided any information about AIP theory.

Symptoms and Diagnoses. In providing information on symptom relief, five apps identified specific symptom presentations, such as anxiety and mood. Only one of the apps addressed dissociative disorder, and suggested that a consumer experiencing this should seek professional help.

Safety and Confidentiality Measures. Six of the apps provided additional guidelines for safe and accurate use. However, the types of safety concerns that are typically presented at EMDR trainings were not addressed by any of the applications, including the risk of increased symptoms where there are skill deficits in regulation. None of the apps had any additional safety measures to prevent a client from using these apps without the presence of a clinician.

Disclosure Statement. Another significant finding when using these EMDR apps is related to data security and privacy. None of the apps included an informed consent. Further, there was little information provided on third party access or developer accountability. The apps neither disclosed information on business associates who will have access to the data collected nor what happens to the information collected by the apps. BSDR Player was the only app out of the 12 apps evaluated to have an explicit end user legal agreement. The agreement states that the app’s provider reserves the right to collect and use data and other related information for software updates and support reasons. The agreement also states that efforts will be made to anonymize the information.

Additionally, most of the apps did not collect information regarding session content directly although a few apps provided options for storing session data and sending emails directly through the app. Given that the consumer has to be registered with Google or iTunes stores in order to download the app, a direct link between the individual accessing the app and the account exists. This may enable a potential disclosure of identifiable data. Moreover, it was not possible to obtain any information regarding the development of apps or the background knowledge on efforts involved in creating the apps without reaching out directly to developers.

Overall Recommendation

The consensus of the research team was that none of the current EMDR apps should be utilized by clients due to the safety risks associated with their use. The risk of dissociation, emotional dysregulation, and/or decompensation may vary by individual, but even a low risk could be damaging without the presence of a trained EMDR practitioner. Moreover, we did not find any of the apps to be practical as a stand-alone tool for clinician use. A clinician would have to be able to provide a structured environment to administer the EMDR protocol with the appropriate equipment and technology. If the right environment and safety measures could be provided, we would only recommend 6 of the 12 apps as beneficial tools for clinician use.

Clinician Recommendations for App Usage

Of the 12 EMDR mHealth apps that were reviewed, 6 were found to be beneficial for use by clinicians as a tool when providing EMDR treatment for clients. These six apps are available on iOS software, and one of the apps has an Android version. These six apps were found to adequately meet the requirements in facilitating dual attention if utilized with the aid of headphones and a large screen. The use of a large screen and seating the client at an appropriate distance is recommended to provide adequate range of motion for visual BLS, and the use of stereophonic headphones is necessary for auditory BLS. Clinicians choosing to use these apps should be trained in monitoring subtleties of emotional dysregulation or dissociative features to ensure that the client is not overwhelmed while using the apps.

It is also important that the clinician closely examines the policies of the provider to understand the utilization of client data collected by the app. It is recommended that the provider policies be disclosed to the client as part of the informed consent process for overall treatment. It is important to share with the client whether the app’s provider has established a specific agreement around the use of identifiable information that is entered into the app (American Psychological Association Practice Organization, 2013). Additionally, the client should be informed that passive data collected by the app might have individually identifiable information that does not fall under the purview of HIPAA unless used by a covered entity (Secretary, 2008).

Concerns

Our review reinforced several concerns we had from the onset of the study about the use of apps in assisting EMDR delivery. mHealth apps can be downloaded by anyone even if the app states as clinician use only. When making a layperson their own change agent with no background knowledge in EMDR, there is the potential for a harmful increase in the symptoms of complex trauma and comorbidities, such as dissociation or the use of substances. These disturbances will be attributed to EMDR even though it is not EMDR that is being applied. Severe disturbances in the absence of clinician oversight have the potential to halt natural information processing both in and out of treatment settings and in the long run will prevent adaptive resolution of disturbing material. Without the theoretical foundation that underpins EMDR or lacking a supportive relationship with a therapist, there is currently no evidence to support the use of such an app to increase access to treatment or to facilitate therapy. Moreover, some of the apps included more detailed information on their purchasing page or website, but the same information was not contained directly in the app and could easily be overlooked by the user.

Cyber Security and Data Privacy Risks. The use of technology and mHealth apps raises important questions on privacy and security of health information collected by the apps. There are challenges involved in safeguarding electronic health information, as the collected health information is being sold to companies for advertising, marketing, and behavior tracking purposes (U.S. Department of Health and Human Services, 2016). HIPAA security standards are not necessarily extended to the Internet of Things, in which mobile devices and wearable sensors are creating large databases of information on individual behavior. The recent repeal of FCC’s privacy laws enables internet providers to use sensitive information, such as location, browsing history, app usage, and the contents of communications without explicit opt-in consent from consumers (Legislative Background, 2017). This repeal of privacy laws increases the cyber security risk, in which customers have no control over the privacy of personally identifiable sensitive data.

Additionally, to foster a seamless experience across devices for customers, companies like Google collect personal information and use it for cross device tracking. Since the information from wearable devices is not covered by HIPAA, the consumer can receive targeted health-related ads on all personal and work-related computers and mobile devices. There is very little transparency on such tracking activities; hence, denying consumers opt-out options serves to increase the risk of privacy violations (Park & Skoric, 2017). The Office of the National Coordinator for Health Information Technology has determined that security standards, such as encryption to maintain confidentiality of health data, identity proofing, risk assessment, and audit capabilities, can be consistently overlooked by noncovered entities, such as mHealth app developers (U.S. Department of Health and Human Services, 2016).

While no singular federal agency is currently responsible for oversight of mHealth apps, there are some policies at the federal and state level that govern the privacy of the individual’s health information. The FCC’s task force, Connect2HealthFCC, is charged with regulating biosensors and mHealth apps, but can only regulate apps used by HIPAA covered entities. The FDA has some oversight of the mHealth apps with overlapping responsibility with the FCC. However, the FDA does not regulate entities that distribute mobile apps, such as iTunes and Google Play store, as these entities are not considered to be medical device manufacturers. As noted earlier, the data collected by these apps are not protected by HIPAA. In case any of the identifiable information of the users is compromised, The Federal Trade Commission (FTC) must be notified and the FTC has 60 days to notify users of any breach, which is the only body that seems to have any jurisdiction over the mHealth apps distributed by the app stores. To further complicate the national picture, every state has its own set of policies and regulations that monitor the use of mobile technology. State laws can be more rigorous than federal laws, but are complicated by interjurisdictional issues, such as the location of the user and the appropriate state agency.

Recommendations for EMDR App Development

On the basis of the aforementioned recommendations, the ideal EMDR app would include a clear description of policies related to privacy and security, which the clinician can share with the client as part of the informed consent process. The app would also include a clear disclaimer on both the purchase page (in the app store of either iOS or Android software) and the app’s welcome screen, stating that the app is only meant for clinician use. To regulate this, the app should require a confirmation of provider status as a security measure prior to opening. This could include a fingerprint sign-in, National Provider Identifier (NPI) number, or license number. On launching, the app would include a clear reminder that for optimal visual BLS, the use of a large screen and seating the client at an appropriate distance is required, and for adequate auditory BLS, the use of stereophonic headphones is necessary.

The ideal EMDR app would be user-friendly with customizability options, such as options for dot color, size, shape, speed, frequency, duration, movement pattern, and options for sounds, background, and logs. The app should involve a certified EMDR practitioner in its development process to enhance the effectiveness of the app, so as to better regulate its adherence to the theory, purpose, and accurate application of the treatment protocol of EMDR. Moreover, the ideal EMDR app would include a description of the symptoms and diagnoses it addresses, and would ensure adequate BLS. It is important that the app also include a precautionary note about the possibility for increased symptom severity while using the application. The ideal EMDR app would include interactive features to provide a list of sources and additional resources for the clinician and/or client. Finally, the ideal EMDR app would present research evidence that it is effective in achieving its goal, which would require that the app have been tested using real clients and clinicians to study the effectiveness of the app in facilitating psychotherapy change.

EMDR mHealth apps need to be made clinically sound and socially responsible. They ought to include strategies to address the needs of those individuals with severe mental health issues. Protocols must be in place to deal with suicidal ideation, self-harm, and other crisis situations. Priority needs to be given to maintaining data validity, reliability, and the integrity of the information collected from the apps. If involved in cross device tracking, the provider must be transparent about the data collection and use practices, include opt-out choices, and ensure security of sensitive data (Federal Trade Commission, 2017). The FTC recommends the use of “Guiding Principles on the Privacy and Security of Personal Wellness Data” issued by Consumer Electronics Association, which should be mandatory for all noncovered entities.

Limitations of This Study

Limitations exist within the research design of this study. The study focused on a clinical understanding of the apps’ usefulness according to clinical criteria. It may have been interesting to ascertain how, or even by which criteria, laypeople would have assessed the helpfulness of the apps, as it may be that laypeople have different motivations for pursuing technologically assisted help. Moreover, this review did not evaluate the clinical effectiveness of the apps as there is currently no literature that would have allowed us to do this. Further, it was not possible, with the information given, to assess the cultural implications of app use. Low cost and the ubiquitous availability of iOS devices have changed everyday life. The cohort of individuals who are natives of these devices have found ways to seamlessly incorporate them into their lives more readily than is true for cohorts who came of age before smart technology. There is a dearth of literature addressing the cultural aspect of technology pertaining to technology natives compared to technology adopters, and that is a significant research gap that should be addressed. Finally, the information that we obtained about the apps was limited to what was provided on the apps themselves. We did not contact any of the developers of these apps for further information. However, in doing it this way, we experienced the apps the same way that any individual with access to them would experience them.

Future Directions in Technology Usage for EMDR

Growth in mobile technology, wearables, sensor digital technology, and big data has enabled easy delivery of tele-healthcare. Given that wearable devices can automatically track sleep patterns, heart rate, respiratory rate, blood pressure, body temperature, and physical exercise (Munos et al., 2016), technology can be used to support clinician perspectives and to corroborate information shared by clients in session. The advent of Artificial Intelligence has helped humanity to overcome cognitive limitations in decision making, and Knowledge Acquisition research is attempting to develop thinking machines by using widely shared knowledge and heuristic knowledge (Dreyfus, 1987).

In the near future, technology may be used in EMDR treatment where clinicians can use high-resolution cameras to gather eye movement information, changes in skin tone, breath rates, and so on, to signal when clients are reaching their tolerance levels during treatment. Through trial and error, the mobile device or computer can be trained to learn from experience. The above-mentioned method could potentially be used in remote and in-person sessions by modifying the technology used. When using EMDR during online sessions or self-administration, a camera can be used to track eye movements along with other inputs, from wearable devices, to monitor dissociative features or dysregulated behavioral cues. To train the app for accuracy, clinician-initiated trials can collect data to record experiences of clients while they access traumatic material. Blood oxygen level activity in the brain (Felmingham et al., 2008) may be used as additional input to identify cognitive disturbances such as dissociation, assuming wearable devices are eventually designed to perform positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) scans. In those cases, perhaps the mHealth app of the future could intervene with a grounding technique adapted for the client user during session providing an in-the-moment individualized treatment intervention.