The Efficacy of EMDR Early Interventions

What Is the Time Frame for Early Intervention?

“Early intervention” is a term used to describe psychotherapeutic interventions that are conducted shortly after a recent traumatic incident. As a consequence of the confusion and difficulties for research continuity following the changes made in the diagnostic categories from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to DSM-V (Yehuda et al., 2015), the guidelines differ on whether they conceptualize early intervention as being provided only during the first month, or during the first 3 months post-trauma. See Table 1. Although the time period for “early intervention” has varied slightly from one treatment guideline to another, there is “reasonable consensus in the traumatic stress field that a three-month window is sensible as a time frame for defining an intervention seeking to prevent disorder or ameliorate early reactions/symptoms as ‘early intervention’” (Dr. Neil Roberts, Personal communication, 2017). However, as noted by Dr. Roberts, “with many life changing traumas, this window is less meaningful.”

The time frame for early intervention has been conceptualized within the EMDR community, by F. Shapiro's (1995) hypothesis that traumatic memories remain unconsolidated for 2–3 months post-trauma and that fragments are stored as isolated incidents, thus requiring treatment to address multiple targets. In her 2018 text, she extended the time frame for “as long as 6 months after natural and manmade disasters in locations in which conditions have not returned to normal and there has been no window of post-disaster calm/safety” (p. 225). Jarero and Artigas (2018) have expanded on the concept of “ongoing trauma,” theorizing that symptoms are maintained or exacerbated when there is no posttrauma safety period with continuing retraumatization and recommended that in situations of ongoing trauma (e.g., cancer, war, refugees, natural disasters), the protocols for early intervention can be effectively applied even after some years.

A number of studies provide supportive evidence that EMDR early intervention protocols effectively reduce symptoms related to life-changing or traumatic events characterized by ongoing disruption and retraumatization (Acarturk et al., 2016; Jarero, Givaudan, & Osorio, 2018; Saltini et al., 2017; Yurtsever et al., 2018). However, it is important to note that there is a large body of research showing that standard EMDR procedures can be used for survivors of protracted events such as war and cancer (e.g., Faretta, Borsato, Civilotti, Fernandez, & Pagani, 2016; Hurley, 2018).

In contrast to Jarero and Artigas's (2018) prolonged memory consolidation theory is McFarlane et al.'s staging approach. Instead of problems with memory consolidation, they see a “progressive recruitment of symptoms and related biological abnormalities across time and with repeated exposures especially in emergency service personnel and military populations” (p. 3). See McFarlane, Lawrence-Wood, Van Hooff, Malhi, and Yehuda (2017) for a summary of a “substantial body of evidence” supporting their position.

The Trajectory of Posttraumatic Response

There are wide variations in individual response to a recent critical incident. Some will have high levels of distress or unremitting symptoms; others may experience prolonged subclinical distress, impacting their quality of life with a risk of secondary complications; a substantial minority will develop debilitating psychological and/or physical disorders; and some will only have disturbances emerging much later (Bryant, Creamer, O'Donnell, Silove, & McFarlane, 2011; Kearns, Ressler, Zatzick, & Rothbaum, 2012; McFarlane et al., 2017; Shalev et al., 2016). However, the majority of those exposed to trauma recover spontaneously, with no clinical diagnosis. From the perspective of EMDR's adaptive information processing (AIP) model (F. Shapiro, 2018), we can say that the individual's inherent AIP system naturally and effectively processed memories of the traumatic event. Nevertheless, various studies (e.g., Morina, Wicherts, Lobbrecht, & Priebe, 2014; Santiago et al., 2013) have reported that about 40% of those who develop PTSD do not experience spontaneous recovery.

It is also important to note that PTSD is only one of the disorders that can develop following trauma. Bryant et al. (2011) reported prevalence of the following disorders comorbidly or independently at 12 months posttrauma: PTSD 10%, major depressive disorder 16%, general anxiety disorder 11%, as well as phobias and panic. In addition, there are those who may develop PTSD months or even years after the event (McFarlane et al., 2017; Utzon-Frank, Breinegaard, Bertelsen, Borritz, & Hurwitz Eller, 2014).

Early Interventions

Early intervention tends to have three main purposes: to treat PTSD symptoms, to prevent the exacerbation of these symptoms, and to prevent the development of PTSD (and other disorders). Although there is no single treatment intervention that is currently recommended for all trauma-exposed individuals, various forms of cognitive behavioral therapy (CBT) are recommended in almost all categories. Debriefing is no longer recommended by the National Institute for Health and Clinical Excellence (NICE, 2018) and the current standard of “psychological first aid” has little systematic evidence to support it (Yehuda et al., 2015). Three treatment guidelines, which analyzed the effectiveness of early interventions for adults, included EMDR therapy in their analyses. These guidelines were published by the World Health Organization (WHO, 2013), the UK NICE (2018), and the International Society for Traumatic Stress Studies (ISTSS, 2018). A more detailed examination of the treatment guidelines and evaluation of EMDR early interventions can be found later in this article.

Individual EMDR Early Interventions

The EMDR early interventions with RCT supporting evidence include three individual therapy protocols. These protocols are all characterized by a current trauma focus, with multiple target fragments.

Guidelines for Children and Adolescents

EMDR early intervention is not recommended in any guideline for children and adolescents, because there are no RCTs providing EMDR treatment within 3 months of the traumatic event for children and adolescents. However, EMDR therapy is recommended in the guidelines (with some conditions) for children and adolescents for treatment of PTSD. See Barron, Bourgaize, Lempertz, Swinden, and Darker-Smith (2019), De Jongh, Amann, Hofmann, Farrell, aand Lee (2019), and Dominguez and Lee (2019) for discussion of EMDR treatment of children and adolescents with PTSD in this issue.

The 2013 WHO Guidelines for Adults

At the time of the WHO analysis, there was only one EMDR RCT with adult participants (Jarero et al., 2011), which had provided treatment within the first month post-trauma and EMDR was assessed as lacking sufficient evidence. Only trauma-focused cognitive behavioral therapy (TF-CBT) was recommended for treatment within the first month. See Table 1. After the first month, for adults with PTSD, the WHO committee gave standard recommendations for individual or group TF-CBT, EMDR, and stress management, noting that the quality of evidence for CBT and EMDR was “moderate.”

The 2018 NICE Guidelines for Adults

The NICE guidelines (2018) for PTSD addressed two main categories of adult intervention—prevention (for the first month post-trauma, and for those with subclinical symptoms) and treatment (early treatment during months 2 and 3, and delayed treatment after 3 months). In this article, we discuss prevention and early treatment (within months 2 and 3). The NICE PTSD guideline analysis of EMDR delayed treatment is discussed in two articles in this issue by Dominguez and Lee, and De Jongh, Amann et al.

NICE defined prevention as interventions provided to at-risk adults, with a diagnosis of acute stress disorder/acute stress reaction, or clinically important PTSD symptoms (within 1 month of the traumatic event) or with subthreshold symptoms. In evaluating EMDR prevention, the NICE committee included only two studies in their analyses: Gil-Jardiné et al. (2018) for prevention within the first month, and Lytle, Hazlett-Stevens, and Borkovec (2002) for standard EMDR treatment of those with subclinical symptoms. At least three EMDR RCTs that provided intervention in the first month for clinically important PTSD symptoms were overlooked or excluded by NICE: Tarquinio et al. (2016), Jarero et al. (2011), and Jarero et al. (2015). In their summary recommendation, the NICE guidelines did not recommend EMDR for adults within 1 month of the traumatic event or for adults with subclinical symptoms after 1 month. The guidelines recommended cognitive processing therapy, cognitive therapy for PTSD, narrative exposure therapy, and prolonged exposure therapy (NICE, 2018). See Table 1.

In the early treatment domain, the NICE committee identified only one RCT (Jarero et al., 2013) providing EMDR treatment within 2–3 months post-trauma. The E. Shapiro and Laub (2015) study was excluded because of small sample size. Jarero et al. (2015) and E. Shapiro et al. (2018) studies were not mentioned and were omitted. Since there was only one EMDR early treatment study, the committee extrapolated “from the stronger evidence for EMDR more than 3 months after trauma,” and recommended “considering EMDR between 1 and 3 months after a non-combat-related trauma … if the person has a preference for EMDR” (NICE, 2018, 1.6.18). The NICE guidelines recommended cognitive processing therapy, cognitive therapy for PTSD, narrative exposure therapy, and prolonged exposure therapy. See Table 1.

The 2018 ISTSS Guidelines

The ISTSS (2018) Treatment Guidelines defined early psychological intervention as occurring within the first 3 months postevent, and they distinguished between single-session interventions and multiple-session interventions. For multiple-session early treatment interventions, provided within the first 3- month posttrauma, the guidelines gave standard recommendations to TF-CBT, cognitive therapy, and EMDR for the treatment of PTSD symptoms in adults (ISTSS, 2018, p. 16). In this category, the ISTSS (2018) guidelines considered four EMDR RCTs (Jarero et al., 2011; Jarero et al., 2015, E. Shapiro & Laub, 2015; E. Shapiro et al., 2018). The Jarero et al. (2013) study appears to have been overlooked. See Table 1.

For single-session interventions, provided within 3-month post-event, the guidelines evaluated three EMDR studies (Gil-Jardine et al., 2018: Jarero et al., 2011; Tarquinio et al., 2016). They made no strong or standard recommendations for any single-session treatment, but single-session EMDR therapy and the Group 512 PM group program were the only treatments to be recognized as having “emerging evidence of efficacy for the prevention and treatment of PTSD symptoms in adults” (ISTSS, 2018, p. 15). See Table 1. (Note: Group 512 PM is “based on debriefing but supplemented with cohesion training exercises” such as games requiring team cooperation [ISTSS, 2018, p. 22]).

Comparison of the Guidelines

EMDR early intervention is recommended in the ISTSS guidelines but poorly represented in the NICE treatment guideline (see Table 1). While the WHO guideline recommends it for PTSD treatment after 1-month post-trauma, and the ISTSS gives it a standard recommendation for use in the first 3months posttrauma, NICE states that it should not be used in the first month, and should only be used during months 2 and 3 if requested by the patient. The differences in the guidelines appear to be a result of the varying definitions of “early intervention,” the timing of the guidelines, and which studies were included in the guideline analyses.

Early intervention was seen by WHO as occurring within the first month posttrauma. NICE viewed “prevention” as occurring within the first month posttrauma, and “early treatment” as occurring within months 2 and 3. ISTSS defined “early psychosocial interventions” as occurring during the first 3 month posttrauma but differentiated between single- and multiple-session interventions. These narrow categories mean that the whole body of EMDR work was never evaluated in a single analysis, and that the full picture of EMDR's effectiveness during the first 3 months posttrauma was not assessed in any guideline.

At the time of the WHO (2013) guidelines, there was only one published RCT for EMDR early intervention (Jarero et al., 2011). There were, however, seven RCTs available during the 2018 evaluations conducted by NICE and ISTSS. The ISTSS guidelines included six studies, and omitted the Jarero et al. (2013) study, which was not mentioned and apparently overlooked. However, the NICE (2018) guidelines included only two studies and omitted five. They excluded one study (E. Shapiro & Laub, 2015) because of small sample size (less than 10 participants per arm), one study was published after their analysis (E. Shapiro et al., 2018), and three were not mentioned (Jarero et al., 2011; Jarero et al., 2015, Tarquinio et al., 2016). It is unclear whether the inclusion of these studies would have increased the confidence of the NICE committee in EMDR early intervention. Nevertheless, the exclusion of these studies indicates that NICE did not have all the information needed to adequately assess EMDR early interventions. The only guideline that included most of the EMDR early intervention RCTs was ISTSS (2018), and that committee gave EMDR a standard recommendation for adults during the first 3 months. This recommendation seems to the most fully informed, having evaluated the largest number of available studies, and therefore the most reliable.

Recommendations for Clinicians

There are major differences between the recommendations made in the ISTSS and NICE guidelines. It is apparent that the ISTSS guideline was more comprehensive and more inclusive, including three studies in the single session analysis and four studies in the multi-session analysis. Its standard recommendation for EMDR multi-session treatment, during the first 3 months posttrauma, was based on four EMDR studies. NICE included only one EMDR study in each of two analyses (prevention in the first month, and early treatment in months 2 and 3). The ISTSS guideline therefore should be considered more reliable, and clinicians should feel confident in relying on the ISTSS's directions.

The research for EMDR early intervention has been conducted using three individual treatment protocols: F. Shapiro's Recent Event Protocol (1995), E. Shapiro and Laub's R-TEP (2008), and Jarero et al.'s EMDR-PRECI (2011). These protocols share similarities but differ in various ways. It is not possible to know if they differ in effectiveness, as there has been no direct comparison of the treatments, and the research supporting each treatment was conducted with different populations. Clinicians may want to examine the protocols to determine if one is a better fit for their own personal use.

Clinicians should be aware of the limitations in the existing research base. There is no evidence that individual EMDR early intervention is effective for children or adolescents, and there is only one case study showing EMDR early intervention to be effective for one individual with combat trauma (Wesson & Gould, 2009). Therefore, therapists considering EMDR early intervention for these populations should be conservative, consider that this still an experimental application, and carefully monitor the client's response to treatment.

Although there has been no RCT evaluating EMDR group treatment as an early intervention, there are at least nine case studies which showed the effectiveness of EMDR-IGTP (Artigas et al., 2014), primarily with children in disaster situations. Although these results are compelling, the study design does not control for other factors that may have caused the positive outcome, such as group interaction, therapist attention, and passage of time. Therefore, it cannot be concluded that EMDR-IGTP is efficacious. EMDR-IGTP and G-TEP (E. Shapiro, 2012) have both been applied for treatment of ongoing stress beyond the 3-month early intervention window, with preliminary evidence from RCTS showing them to be effective. In that regard, the provision of EMDR group treatment is an exciting development for clinicians, as it extends the availability of treatment to larger numbers of clients and in different contexts (e.g., community centers, clinics).

Some clinicians may want to wait to see if a recently traumatized client shows spontaneous recovery—a common occurrence. However, EMDR clinicians should keep in mind that, according to the AIP model (F. Shapiro, 2018), unprocessed traumatic memories can be triggered at a later time, causing subsequent impairment and distress. The model predicts that successful processing of distressing memories should not only eliminate current symptoms, it should also prevent the development of debilitating psychological disorders such as PTSD and depression. There are also anecdotal reports of the development of resilience and growth (Rost, Hofmann, & Wheeler, 2009; Sang Won et al., 2017; Smith-Lee Chong, 2015; Zaghrout-Hodali, Ferdoos, & Dodgson, 2008). In addition, clinicians could consider the perspective of McFarlane (2009), who views PTSD as “part of a complex psychobiological process that leads to the emergence of the disorder in the weeks, months, or years after the event” (p. 85). He asserts that the sensitized psychobiological system is left vulnerable, especially to additional exposures, therefore risk remains even when there may only be subclinical symptoms, and he recommends early treatment. This view converges well with the AIP model that suggests early EMDR intervention may prevent the accumulation of unprocessed trauma memories.

Recommendations for Researchers

Even though there are now seven RCTs showing support for EMDR early intervention, there are still substantive gaps in the evidence base for EMDR early interventions. For example, in the ISTSS analysis of the four wait-list comparison studies, standard mean differences ranged from 0.74 (1.57, .09) to 4.89 (6.56, 3.22). The test for overall effect was significant, Z = 2.80, p = .005, but, there was also significant heterogeneity I² = 88%, and the committee identified high risk of bias in these studies. Although the mean effect size was large enough to be classified as “clinically important,” the committee assessed the quality of evidence as “very uncertain about the estimate.” It is recommended that future trials adhere to the highest standards for clinical research, following established methodological guidelines such as those of the Consort 2010 guidelines for randomized research (http://www.consort-statement.org/).

It is imperative that researchers focus on evaluating EMDR's efficacy in the treatment of recent trauma to prevent PTSD and to reduce/eliminate PTSD symptoms. In order to investigate whether EMDR early intervention prevents PTSD, RCTs must evaluate whether participants are subsequently diagnosed with PTSD. To achieve this, researchers should conduct diagnostic assessments at posttreatment and follow-up, with clinician administered measurements, comparing the status of those who received EMDR treatment and those who had no treatment or a comparison treatment. In addition, it is recommended that research using participants with subclinical symptoms or ongoing trauma use measures that will assess the possible beneficial effect of treatment, such as quality of life, health inventories, missed days of employment, and number of medical appointments. It is also essential that some RCTs be conducted with children and adolescents, and that RCTs be conducted to evaluate group therapy as an early intervention.