Vol. XXXI, Issue 4
Fall 2019
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International members survey 2018 part 1: Practitioner knowledge, training and experience
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Eye Movement Desensitization and Reprocessing (EMDR): Exploring a new avenue for sex offender treatment
Incel inside: Understanding involuntary celibates through dating app experiences
International Perspectives on the Assessment and Treatment of Sexual Offenders
Learning Difficulties and Sexual Vulnerability: A Social Approach
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Heather M. Moulden, Ph.D.
Forensic Program
St. Joseph's Healthcare
Hamilton, Ontario, Canada
E: hmoulden@stjoes.ca
P: (905) 522-1155 ext. 35539
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 different meaning.

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 treatment plan.

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.


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