|Eye Movement Desensitization and Reprocessing (EMDR): Exploring a new avenue for sex offender treatment|
|Wineke Smid, Nina ten Hoor, and Kasia Uzieblo|
Eye Movement Desensitization and Reprocessing (EMDR)
was developed more than 25 years ago by the American psychologist Francine
Shapiro (1991). EMDR is an interactive psychotherapy technique in which the
patient recalls a (negative) emotionally charged memory including the
accompanying images, thoughts, and feelings while s/he is instructed to perform
eye movements. The distractor stimuli are usually horizontal hand movements
that the patients must follow with their eyes, but these can also be sounds or
buzzers that are presented alternately left and right. The aim of the technique
is to reduce the vividness and emotional charge of the memories and to make it increasingly
easier to think back objectively to the original event.
Underlying EMDR is the Adaptive
Information-Processing (AIP) model (Shapiro, 2001). This model postulates that
adaptive resolution of experiences involves integration and using an individual’s experience in a constructive manner, as part of a positive
emotional and cognitive schema. When something traumatic happens, this process
is disrupted and the memory is stored in a way that incapacitates necessary
processing. The information remains available in a dysfunctional state, causing
additional stress to the system when triggered. After the initial storage of an
event (a process called consolidation), memories become malleable again during
recall, allowing for new learning processes to be re-encoded or re-written in
memory. Remembering a charged event in combination with the eye movements
ensures that the natural processing system is stimulated.
Another (additional) explanation for the effect of
EMDR is the working memory theory. Because of the limited capacity of the working
memory, the eye movements compete for the limited resources when emotive
memories are recalled, reducing their vividness and emotionality (Engelhard,
van Uijen, & Van den Hout, 2010; Van de Hout et al., 2011a; Van den Hout et.
al., 2011b). This offers the patient the opportunity to give the event a
EMDR is known foremost as an evidence-based and
first-line treatment for traumatic memories (Bisson et al., 2007; National
Collaborating Centre for Mental Health, 2005) that is mostly used to treat
people with PTSD and other trauma-related anxiety complaints – complaints that
have arisen as a direct result of a concrete, negative event, and where
thinking of the event still evokes a strong emotional response. One of the
basic assumptions in EMDR therapy is that most psychopathologies originate in
past trauma. The goal of EMDR is to transform the dysfunctional material or
residue from the past into something functional and useful (Shapiro, 2001). In
line with these assumptions, there is increasing evidence that emotionally
charged memories and images also play an important role in other psychological complaints
such as chronic pain, depression, eating disorders, addictions, and psychosis (Misiak, Krefft, Bielawski, Moustafa, Sąsiadek, & Frydecka,
2017). For this reason, EMDR is being used increasingly and in various
forms to counter these problems and disorders, usually as part of a broader
More experimental is the contribution of EMDR to the
treatment of addiction and compulsion. Miller (2010) developed the
Feeling-State Theory of impulse-control disorders, postulating that
impulse-control disorders develop when positive feelings become linked with
specific objects or behaviors. Together, these form a state-dependent memory,
called a ‘Feeling State.’ For example, a gambler had an intense need to belong.
After winning a lot of money playing poker, the camaraderie that he experienced
afterwards with his friends became linked with the behavior of playing poker.
Subsequently, whenever he wanted to experience the feeling of belonging, he
played poker. The fixated state consisting of a positive feeling (belonging)
linked with a behavior (playing poker) is called a feeling-state. Once established,
the feeling-state is relatively independent of its origin. When triggered, the
intensity of the associated emotions blocks further processing and renders the feeling-state
equally fixating as a traumatic memory. The assumption is that the strong urges
will disappear when the linked positive emotions are desensitized. This is
tantamount to a ‘reverse EMDR’, since it does not involve the desensitization
of negative (traumatic) memories, but instead the desensitization of positive
memories: memories that exert a strong attraction.
There are indications, mainly from clinical case
studies, that EMDR can indeed be applied to reduce unwanted positive emotions
that are linked to problematic behavior. EMDR has, for instance, been
successfully used in the treatment of alcohol and nicotine addiction (Hase,
Schallmayer, & Sack, 2008), compulsive eating (Halvgaard, 2015; Knipe,
2009), gambling addiction (Bae, Han, & Kim, 2015; Miller, 2010, 2012),
compulsive shopping (Popky, 2005), internet addiction (Bae & Kim, 2012),
and sex addiction (Cox & Howard, 2007). However, results are not unequivocally
positive. Some case studies found no positive results (Cecero & Caroll,
2000; Hornsveld, 2009), and a recent controlled clinical trial could not
confirm any promising effects of addiction focused EMDR in alcohol use disorder
(Markus, De Kruijk, De Weert- Van Oene, Becker & De Jong, 2019).
The aforementioned studies suggest that EMDR might
also be helpful in the treatment of sex offenders. There is ample evidence that
sex offenders often have traumatic experiences in their childhood (Levenson, Willis, & Prescott, 2016), and ‘classic’
EMDR can be used to alleviate the symptoms of these traumas (Ricci &
Clayton, 2008; Ricci, Clayton, & Shapiro, 2006). From this perspective,
EMDR would be an adjunctive therapy to address trauma as a responsivity issue (see
Risk-Need-Responsivity model; Andrews & Bonta, 2010), such that by
addressing comorbid trauma, one may be better able to benefit from treatment
for sexual offending. Indeed, we have been having positive experiences with
applying EMDR to tackle the PTSD symptoms in our forensic patients from Van der
Hoeven Clinic (Utrecht, the Netherlands), who have committed sexual offences. Some
small scale uncontrolled studies of patients who had offended against children
and who were themselves abused as children indicate that EMDR treatment,
focusing on their own victimization, led to a reduction in deviant sexual
arousal in the present (Ricci & Clayton, 2008; Ricci, Clayton, & Shapiro,
2006; Gaboraud, 2019). This is by no means conclusive
validation, but it certainly invites further inquiry. In practice, we also
sometimes encounter sex offenders who have committed very serious offenses
(e.g., murder), who are traumatized by their own offense. If this trauma
interferes with treatment responsiveness, EMDR may also be used in these cases.
Besides the common occurrence of childhood trauma,
about half of all sex offenders have substance use issues (Kraanen & Emmelkamp, 2011). If regular addiction
treatment fails, therapists might consider targeting these issues with the Millers
Feeling State protocol. More importantly, patients may describe their sexual
offending behavior itself as addictive or compulsive behavior that involves (overwhelming)
Feeling States, such as exhibitionism or child pornography consumption. Moreover,
the incentive motivational model (IMM; Smid & Wever, 2018) describes deviant
sexual arousal as the emotional enhancement of sexual arousal by means of the
deviant stimuli. This suggestion implies that Feeling States could be at the very
core of deviant sexual arousal and EMDR may help reduce this arousal.
To date, there are no published studies evaluating
the use of EMDR directly targeting deviant sexual arousal. But there are some
indications that this might work. In a recent laboratory experiment with 80
graduate students (Bartels, Harkins, Harrison, Beard, & Beech, 2018),
horizontal eye movements did reduce the vividness, positivity, and arousing
effect of both memory- and imagination-based sexual fantasies. In our clinical
practice at De Waag (outpatient) and Van der Hoeven Clinic (inpatient)
treatment centers in the Netherlands, we have had some promising experiences
with directly targeting deviant sexual arousal with EMDR. In order to advance
our knowledge regarding the utility of these techniques, we have started an RCT
assessing the effects of EMDR treatment of exhibitionists. We will be
presenting the preliminary results at the upcoming ATSA conference (T-2 in the
ATSA conference brochure: http://www.bit.ly/2NsNkUk).
All in all, there are several reasons to further explore
the use of EMDR in the treatment of sex offenders. An added bonus that facilitates
studying the efficacy of this treatment technique is that it is generally
short, 5 to 10 sessions, and few negative side effects appear to be reported
(Whitehouse, 2019). And although EMDR might not be applicable for everybody (for
instance some patients are unwilling or unable to get really involved in this
technique), there seem to be few contraindications for inclusion. Even patients
with various severe mental disorders such as autism spectrum disorders (Lobregt-van
Buuren, Sizoo, Mevissen, & de Jongh, 2019), psychosis (Valiente-Gómez,
Moreno-Alcázar, Treen, Cedrón, Colom, Perez, & Amann, 2017), or
intellectual disabilities (Karatzias, et al., 2019) have been known to
successfully engage in EMDR treatment and benefit from it.
As we look forward to the results of our RCT, we
are also curious if any of our international colleagues have any ideas or
clinical experiences to share regarding the use of EMDR in sex offender treatment.
Bae, H., Han, C., & Kim, D. (2015). Desensitization of
triggers and urge reprocessing for pathological gambling: A case series. Journal
of Gambling Studies, 31(1), 331-342. Doi: 10.1007/s10899-013- 9422-5
Bae, H., & Kim, D. (2012). Desensitization of triggers
and urge reprocessing for an adolescent with internet addiction disorder. Journal
of EMDR Practice and Research, 6, 73-81. Doi: 10.1891/1933- 3220.127.116.11
Bartels, R. M., Harkins, L., Harrison, S. C., Beard, N.,
& Beech, A. R. (2018). The effect of bilateral eye-movements on sexual
fantasies. Journal of Behavior Therapy
and Experimental Psychiatry, 59, 107-114. Doi: 10.1016/j.jbtep.2018.01.001
Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S.,
Richards, D., & Turner, S. (2007). Psychological treatments for chronic
post-traumatic stress disorder: Systematic review and meta-analysis. British
Journal of Psychiatry, 190, 97–104. Doi: 10.1192/bjp.bp.106.021402
Cecero, J. J., & Carroll, K. M. (2000). Using eye
movement desensitisation and reprocessing to reduce cocaine cravings. American
Journal of Psychiatry, 157, 150-151.
Cox, R. P., & Howard, M. D. (2007). Utilization of EMDR
in the treatment of sexual addiction: A case study. Sexual Addiction & Compulsivity,
Engelhard, I. M., Van Uijen, S. L.,
& Van den Hout, M. A. (2010). The impact of taxing working memory on negative and
positive memories. European Journal of
Psychotraumatology, 1, 5623.
Gaboraud, E. (2019). Dissociation
et dimension victimaire chez un pédophile: la thérapie EMDR peut-elle aider?. European Journal
of Trauma & Dissociation, 3(1), 63-68.
Halvgaard, K. (2015). Single case study: Does EMDR
psychotherapy work on emotional eating? Journal of EMDR Practice and
Research, 9, 188-197. Doi: 10.1891/1933-318.104.22.168
Hase, M., Schallmayer, S., & Sack M. (2008). EMDR
reprocessing of the addiction memory: Pretreatment, posttreatment, and 1-Month
of EMDR Practice and Research, 2, 170-179.
Hornsveld, H. (2009). Casus 25: Nog
Eentje – Daarna Stop ik. Een mislukte stoppen-met- rokenbehandeling. In: H.
Hornsveld & S. Berendsen (Red.). Casusboek EMDR. 25 voorbeelden uit de
praktijk. (pp. 329-339). Houten: Bohn Stafleu van Loghum.
Hornsveld, H. K., & Markus, W.
(2014). Protocol EMDR en verslaving. Retrieved
Karatzias, T., Brown, M., Taggart, L., Truesdale, M.,
Sirisena, C., Walley, R., ... & Paterson, D. (2019). A mixed‐methods, randomized controlled feasibility trial of Eye
Movement Desensitization and Reprocessing (EMDR) plus Standard Care (SC) versus
SC alone for DSM‐5 Posttraumatic Stress
Disorder (PTSD) in adults with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities. https://doi.org/10.1111/jar.12570
Kraanen, F. L., & Emmelkamp, P. M.
(2011). Substance misuse and substance use
disorders in sex offenders: A review. Clinical
Psychology Review, 31(3), 478-489.
Levenson, J. S., Willis, G. M., & Prescott, D. S. (2016).
Adverse childhood experiences in the lives of male sex offenders: Implications
for trauma-informed care. Sexual Abuse, 28(4), 340-359.
Lobregt-van Buuren, E., Sizoo, B.,
Mevissen, L., & de Jongh, A. (2019). Eye
Movement Desensitization and Reprocessing (EMDR) Therapy as a Feasible and
Potential Effective Treatment for Adults with Autism Spectrum Disorder (ASD)
and a History of Adverse Events. Journal of autism and
developmental disorders, 49(1), 151-164.
Markus, W., De Kruijk, C., De
Weert-Van Oene, G., Becker, E., & De Jong, C. (2019). Treatment of Alcohol Use
Disorder with Adjunctive Addiction
Focused Eye Movement Desensitization and Reprocessing Therapy: A Feasibility
Study. Journal of EMDR Practice and Research,
Miller, R. (2010). The feeling-state theory of
impulse-control disorders and the impulse-control disorder protocol. Traumatology,
16(3), 2-10. Doi: 10.1177/1534765610365912
Miller, R. (2012). Treatment of behavioral addictions
utilizing the feeling-state addiction protocol: A multiple baseline study. Journal
of EMDR Practice and Research, 6(4), 159-169.
Misiak, B., Krefft, M., Bielawski, T., Moustafa, A. A.,
Sąsiadek, M. M., & Frydecka, D. (2017). Toward a unified theory of
childhood trauma and psychosis: a comprehensive review of epidemiological,
clinical, neuropsychological and biological findings. Neuroscience & Biobehavioral Reviews, 75, 393-406.
National Collaborating Centre for Mental Health (2005). Post-traumatic
stress disorder: The management of PTSD in adults and children in primary and
secondary care. London: National Institute for Clinical Excellence.
Popky, A. J. (2005). DeTUR, an urge reduction protocol for
addictions and dysfunctional behaviors. In R. Shapiro (Ed.), EMDR solutions:
Pathways to healing (pp. 167-188). New York: W.W. Norton & Company.
Ricci, R. J., & Clayton, C. A. (2008). Trauma
resolution treatment as an adjunct to standard treatment for child molesters: A
qualitative study. Journal of EMDR Practice and Research, 2(1), 41–50.
Doi: 10.1891/1933- 322.214.171.124
Ricci, R. J., Clayton, C. A., & Shapiro, F. (2006).
Some effects of EMDR on previously abused child molesters: Theoretical reviews
and preliminary findings. The Journal of Forensic Psychiatry &
Psychology, 17(4), 538–562. Doi:10.1080/14789940601070431
Shapiro, F. (1991). Eye movement desensitization and
reprocessing procedure: From EMD to EMDR: A new treatment model for anxiety and
related traumata. Behavior therapist, 14(5), 133-135.
Shapiro, F. (2001). Eye movement desensitization and
reprocessing: Basic principles, protocols, and procedures. New York:
Singer, B., & Toates, F. M. (1987). Sexual motivation. Journal of Sex Research, 23(4), 481-501.
Smid, W. J., & Wever, E. C. (2018). Mixed emotions: an
incentive motivational model of sexual deviance. Sexual Abuse, 1079063218775972.
Valiente-Gómez, A., Moreno-Alcázar, A., Treen, D., Cedrón,
C., Colom, F., Perez, V., & Amann, B. L. (2017). EMDR beyond PTSD: A
systematic literature review. Frontiers
in psychology, 8, 1668.
Van den Hout, M. A., Engelhard, M. I.,
Beetsma, D., Slofstra, C., Hornsveld, H., Houtveen, J., & Leer, A. (2011a).EMDR and
mindfulness: Eye movements and attentional breathing tax working memory and
reduce vividness and emotionality of aversive ideation. Journal of Behavior Therapy and Experimental Psychiatry, 42, 423-431.
Van den Hout, M. A., Engelhard, M. I.,
Rijkeboer, M. M., Koekebakker, J., Hornsveld, H., Leer, … Akse, N. (2011b). EMDR:
Eye movements superior to beeps in taxing working memory and reducing vividness
of recollections. Behaviour Research and
Therapy, 49, 92-98.
Whitehouse, J. (2019). What do
clients say about their experiences of EMDR in the research literature? A
systematic review and thematic synthesis of qualitative research papers. European Journal of Trauma &