Effects of the EMDR Couple Protocol on Relationship Satisfaction, Depression, and Anxiety Symptoms

1. Identifying the Problem

2. Preparation for EMDR CP

This phase is the “preparation phase,” which is the second phase of the standard EMDR protocol. The couple attends the sessions together. Unlike individual EMDR therapy, the therapist focuses primarily on the relationship. The “safe place” exercise from the individual EMDR protocol is included in the EMDR CP. This is a place where the relationship and the couple feel safe together.

Bidirectional stimulation: It is applied to both individuals at the same time. It will be useful to finalize this application method during the safe place formation.

3. Assessment

In the standard EMDR procedure, phase 3 is referred to as the “assessment phase.” In this phase, the target memory for each session is determined. The target memory should be a collective memory. It can be either a traumatic incident both experienced as external to the relationship, or a traumatic event or conflict between the couples. Even though a memory that is considered a traumatic memory for one spouse may not be a traumatic memory for the other, the partner is also asked to provide information on the target memory, including the worst image, negative cognition (NC), positive cognition (PC), validity of cognition (VOC), emotions, Subjecitive Unit of Disturbance (SUD) score, and bodily sensations.

The NC and PC in the EMDR CP differ from the self-referencing ones used in individual EMDR treatment. In this CP, the cognitions refer to the relationship (see Figure 1). Each spouse gives a separate personal rating for the validity of their preferred PC, indicating how true their cognition feels to them, using the VOC scale (1 = not valid, 7 = totally true). Each spouse also rates the extent of disturbance of the memory with the SUD scale (0 = neutral, 10 = worst possible). The SUD and VOC scores are collected as per standard EMDR procedures (see Figure 1).

Figure 1.

Flow chart of participants included in the study.

4. Desensitization

During this phase, bidirectional stimulation is applied at the same time to the couple. The purpose is to provide the integration of the target memory to adaptive memory network. Bidirectional stimulation is performed by the method preferred by the couple. The worst-scene question asked in EMDR for couples aims to find the common worst scene in this protocol. At the end of each memory set, the therapist requests both partners to briefly express the reminiscence and then notes them. The length and speed of the set which are suitable for both partners are determined by the therapist.

5. Installation

In the standard EMDR protocol, phase 5 is called “installation.” In this phase, by ensuring that the traumatic memory is matched with positive cognition (about the relationship), the goal is to strengthen positive thoughts about their relationship. The individual VOC scores are examined to evaluate the effectiveness of the treatment.

6. Body Scanning

The body-scanning phase applied in individual sessions is implemented to both partners at the same time. At this stage, while the couple is sitting, one is seated in a suitable position to give bilateral stimulation to the other, and to then touch each other. It is important that they sit together, so that they may feel safe. The couple may be guided to change the position to sit face to face without holding hands, but tapping the knees of each other. If abreaction is observed in this position again, they sit side by side without touching each other and they are given separate bidirectional stimulation. One EMDR device can be shared. In that case, one is given the headset, while the other uses the hand apparatus. In the case there is no availability of an EMDR device, they can tap their own knees, or the rapid eye movement exercise can be used. The speed of the bidirectional stimulation is determined by the therapist.

7. Closure

Each session ends with phase 7, called “closure” in the standard EMDR protocol and “windup” in the CP. The therapist provides feedback to the couple, reminds them of resources they can use during the coming week, asks them to repeatedly perform the safe place exercise together when needed, and explains possible post-session processes. Feedback is expected from the couple. Positive relationship cognitions are discussed; developments and success during the process are highlighted.

8. Reevaluation

The following session starts with discussion of the previous session, progress made toward goals, and relevant events over the previous week. The target for that day’s session is identified, and treatment continues with phase 3 or 4, as appropriate.

Study Design

The clients who applied for couple therapy were evaluated by the program therapist to determine if they met inclusion criteria for the EMDR CP. This evaluation was conducted at intake and after each of the first two phases. Phase 1 included an initial couple session for history taking and treatment conceptualization, and phase 2 provided individual sessions with each partner for additional history taking, plus, if needed, individual EMDR treatment. After this, the couples to be included in the study were asked to sign an informed consent form. Assessment measures were administered before starting the protocol's phase 3, at the end of the treatment, and at 3 months post-treatment. Couples received no additional treatment after completing the protocol. Measures included the Relationship Satisfaction Scale, Beck Depression Inventory, and Beck Anxiety Inventory. The obtained data were processed into the data set and subjected to appropriate statistical analysis.

Participants

Fifty couples applied for treatment. From 50 couples, 40 met initial inclusion and exclusion criteria, and they started phase 1. Following seven dropouts and exclusion of five couples determined to be unsuitable, 28 couples started phase 3. There were 18 couples (18 females and 18 males) who completed the protocol and their data are included in the analyses (see Participant Flow Chart, Figure 1).

The study was conducted at the Institute of Behavioral Sciences in Davranis Bilimleri Enstitusu, Istanbul, Turkey, between 2016 and 2020. The research was approved by the Istanbul Gelişim University Ethics Committee with the IRB approval number 2020-31-35. Participants were included in the study on a voluntary basis as per the inclusion and exclusion criteria.

Inclusion criteria at initial assessment:

Exclusion criteria at initial intake:

Assessment

Suitability assessments were conducted by the treating therapist in phases 1 and 2.

Assessments were conducted with standardized measures before starting phase 3 of the protocol, at the end of treatment, and 3 months after the end of treatment. They were administered by Ceren Kurtay Doğan.

Treatment

The participants received the EMDR CP. It was provided in eight to 22 weekly sessions, of 90 minutes duration, over a 6-month period. Treatment ended when all the target memories in the couple’s therapy plan are addressed. Couples did not receive any additional treatment at the institute or from any other therapist during the 3-month follow-up period.

Therapist

All treatment was provided by the second author, Ceren Kurtay Doğan, an experienced psychologist, who developed the EMDR CP. She is trained in various therapy orientations, such as EMDR (Europe Accreditation), sexual therapy, child and adolescent EMDR applications (Level 1), schema therapy, Imago therapy, and strategic family therapy.

Statistical Analysis

All statistical analyses of the study were made via SPSS 22.0. Descriptive analyses were performed as mean ± standard deviation for continuous variables and as a frequency and percentage for categorical variables. Repeated measures ANOVA was used after checking the parametric assumption to compare the values of the scales of the participants in repeated measurements. Effect size is calculated with partial eta squared (η²). Student t-test was used after testing to meet the parametric assumptions in comparing the continuous variables between the two groups. In all analyses, p = .05 dual was used as the cut-off value for statistical significance.

Attrition

Ten of the 28 couples who began treatment did not complete the study. Three dropped out at the end of the first session, four between sessions 1–5, and three after the sixth session. Various reasons were cited for leaving the study and included moving out of the city, ending the relationship, and COVID.

SUD and VOC Scores

In EMDR therapy, the SUD and VOC scores are taken at the beginning and end of each reprocessing session. A statistically significant difference was found in the comparison of SUD and VOC values before and after the session for each memory (p < .001). The mean SUD values were found to be 6.69 ± 1.53 before the session and 0.17 ± 0.38 at the end of the session (t = 56.144, p < .001, d = 4.184). The mean of VOC values was 3.20 ± 1.06 before the session and 5.88 ± 0.32 at the end of the session (t = −48.071, p < .001, d = −3.582).

Psychometric Scores

As can be seen in Table 2, the participants reported significant positive changes on all three psychometric scales at posttreatment, with results maintained at 3-month follow-up. On the Relationship Satisfaction Scale, pre–post and pre-follow-up comparisons found a significant statistical difference in all participants (F(2, 70) = 974.931, p < .001, η² = 0.948), for both female (F(2, 34) = 592.269, p < .001, η² = 0.955) and male (F(2, 34) = 394.593, p < .001, η² = 0.944) groups (Figure 2).

Figure 2.

Change of Relationship Assessment Scale by EMDR.

On the Beck Depression Inventory, pre–post and pre-follow-up comparisons found a statistically significant difference in all participants (F(2, 70) = 59.148, p < .001, η² = 0.385), for both female (F(2, 34) = 50.316, p < .001, η² = 0.532) and male (F(2, 34) = 18.202, p < .001, 0.268) groups (Figure 3). Mean scores were in the mild range at pre-treatment, and in the minimal range at post-treatment and follow-up.

Figure 3.

Change of Beck Depression Inventory by EMDR.

On the Beck Anxiety Inventory, pre–post and pre-follow-up comparisons found a statistical significant difference for all participants (F(2, 70) = 55.116, p < .001, η² = 0.258), for both female (F(2, 34) = 22.722, p < .001, η² = 0.205) and male (F(2, 34) = 31.869, p < .001, η² = 0.336) groups (Figure 4). Mean scores were in the moderate range at pre-treatment, and in the mild range at post-treatment and follow-up.

Figure 4.

Change of Beck Anxiety Inventory by EMDR

A comparison of psychometric scores of female and male participants found no differences between sexes, except on the Beck Depression Inventory, where a statistically significant difference was found before EMDR therapy, with women reporting greater depression (t = 2.112, df = 34, p = .042) (see Table 2).

Suitability

Couples were assessed for suitability in phases 1 and 2 by Ceren Kurtay Doğan. EMDR CP is suitable for those couples who are motivated and engage with therapy for trauma that has affected their relationship.

Individual sessions are important for suitability. The most important aim at individual sessions is why the couple is participating at the therapy, whether it is to ease the divorce or improve the relationship. This protocol is appropriate for the couples who are willing to improve the relationship. One of the reasons for attrition in this study was a decision to end the relationship.

The EMDR Couple Protocol

The most important difference of this protocol from many other EMDR protocols is that the partners are taken to the session at the same time and bidirectional stimulation is performed simultaneously. Couples who receive the EMDR CP have the opportunity to oversee, accept, recognize, and witness each other’s recovery process during the session as they deal with the common wounds that have occurred in the relationship individually and with one another. The therapist plays the role of a facilitator who determines the sequence and the framework in the session most of the time. While the sequence and framework are very important, the core factor is the couple’s experience of shared recovery from their mutual wounds and all the possible emotional and physical contacts that occur during the sessions.

An important view that influenced the development of the protocol is Hendrix’s (2007) Imago Relationship Theory. He stated that childhood experiences and traumas have an important effect on the choice of spouse/partner. He said that the relationship provides them the opportunity to recover from childhood experiences and traumas. Imago couple therapy claims that this is why people choose partners who resemble their parents, and who will cause similar wounds or trigger their trauma (Hendrix, 2007). Hendrix’s Imago theory can be used to understand many relationship conflicts. This view is supported by Moreno (1953), who stated that an individual who develops symptoms within social relationships will also recover via social relationships.

Another crucial hindrance in advancing couples therapy is the partners’ personal resilience. Individual needs or past traumas of partners can prevent mutual work with couples (Astor & Sherman, 1997). An important advantage of the EMDR CP is that it evaluates the partners individually and from an AIP perspective, and applies individual EMDR treatment before working together, if needed. In this way, precautions are taken regarding the potential problems arising from the personal histories of the partners, and that may arise during the couple sessions.

From these points of view, the EMDR CP is a critical intervention for many couples who are eligible to work with this protocol. It can open a blocked therapy process by resolving old familiar detrimental patterns, which had previously prevented progress in therapy and resulted in repetitious cycles. The protocol is a technique, which can be integrated into the therapy process by therapists who work with any couple therapy approach.

Limitations

The results of the study should be evaluated within some limitations, together with the couple’s originality and strengths. The most important limitation is the fact that there was no randomized control group in the study. Another important limitation is the limited priority sampling. In addition, the limited sample size is a hindrance to generalization of the results. Also, the couples’ reasons for applying to therapy were not examined. Another important limitation is that the study had no waitlist control group or a comparison group in which a different couple therapy was applied. Therefore, it is not possible to rule out other possible causes for the treatment outcome, such as the passage of time alone, or the time the couple spent together. No mental trauma scales were used in this study. EMDR and AIP theory offer a trauma-focused perspective. In her AIP model, F. Shapiro (2007) hypothesizes that an internal information processing system has evolved to allow people to reorganize their responses to disturbing life events and their initial dysfunctional memories toward an adaptive state. Her AIP theory predicts that improvement would result from the EMDR CP. However, the improvement in the effect on traumatic stress as an intervening variable could not be measured in this study because there was no psychological trauma scale. Another limitation is the loss during treatment of 10 of the 28 couples. Although this seems to be a high rate, it should be noted that the COVID-19 pandemic occurred during the study period. It is also a likely that the risk of attrition is greater in couple therapy, compared to individual treatment, due to couple separations and couple problems.

Conclusion

This study provides preliminary evidence that the application of the EMDR Couple Protocol may increase the couple’s relationship satisfaction, for both female and male partners, and may decrease their levels of depression and anxiety. It makes an important contribution to the limited literature on EMDR couple applications. Further studies are considered necessary to evaluate the effectiveness of the EMDR CP, and its possible effects on various variables.