The search for research into self-administered EMDR therapy

Although there are already many self-help tools for EMDR therapy available via books and technology, with evidence that members of the public are already using these tools, the only published trial of any self-help EMDR therapy is an open trial of an internet-delivered guided self-help programme. That trial suggested that the iEMDR programme may be safe and efficacious; however, significant methodological flaws preclude firm conclusions from being drawn, including the small sample size, high attrition rate and absence of a control group. Furthermore, participants in that trial had weekly contact with a clinical psychologist so were not left to do their therapy completely unsupervised: therefore, conclusions cannot be made about the safety of unsupervised self-help EMDR therapy. A larger study evaluating the efficacy and potential adverse effects of the iEMDR therapy programme is required, using a randomised controlled trial (RCT) design. Changes to the programme may also be required, as the protocol used in the open trial was only moderately tolerated by the participants who completed post-treatment assessments. For example, past studies have indicated that including more social interactive elements such as an accompanying virtual human avatar throughout treatment may be beneficial;^{Reference Rehm, Foenander, Wallace, Abbott, Kyrios and Thomas36} this might improve tolerability of the intervention.

Although there are numerous mobile phone applications offering tools for self-administered EMDR therapy, no article was found on EMDR therapy delivered via mobile phone applications during the systematic literature search. Therefore, the efficacy and risks of EMDR self-administration using mobile phones is currently unknown. This lack of peer-reviewed literature is a key gap, particularly given the unknown effectiveness of EMDR when it is conducted using a screen as small as a mobile phone's (where the left and right dot positions may be less than an inch apart on screen, which we speculate could affect treatment outcomes).

The evidence for other self-help psychotherapies

The growing issue of poorly regulated and unregulated health websites and applications is highlighted above. On the other hand, however, there may be benefits to the use of internet, computerised and mobile applications for delivering psychological therapies in the form of self-help or guided self-help programmes. There is already some evidence in the peer-reviewed literature that internet-delivered psychological therapies can bypass some of the barriers to accessing treatment mentioned above, while being safe and cost-effective for a range of different mood, anxiety and substance-misuse disorders.^{Reference Kumar, Sattar, Bseiso, Khan and Rutkofsky37} For example, internet-guided self-help therapies for anxiety disorders that include exposures to anxiety-inducing stimuli, such as FearFighter for the treatment of phobias and panic, have been shown to be safe and effective.^{Reference Schneider, Mataix-Cols, Marks and Bachofen38} In addition, a cluster RCT of a self-help programme for trauma-exposed refugees in Uganda, guided only by briefly trained lay facilitators, demonstrated good feasibility and safety profiles for the intervention and indicated its effectiveness for reducing psychological distress in a population otherwise unlikely to receive formal psychological support.^{Reference Tol, Leku, Lakin, Carswell and Augustinavicius39}

A meta-analysis of internet-based psychological therapies for PTSD (mostly using cognitive–behavioural models) demonstrated an emerging evidence base supporting e-Mental Health to treat symptoms of PTSD.^{Reference Simblett, Birch, Matcham, Yaguez and Morris16} There have also been initially promising results of research into the quality and effectiveness of medical mobile applications in the treatment of mental health disorders, such as ‘PTSD Coach’, a mobile application comprising self-help techniques including relaxation for PTSD treatment that has already been downloaded by over 100 000 users across 74 countries worldwide.⁴⁰ A recent meta-analysis of six studies into these applications for PTSD treatment (of which five used PTSD Coach) found modest pre-post effect sizes for reduction in PTSD and depressive symptoms, although analysis of the two RCTs suggested the intervention was not superior to a waiting-list control.^{Reference Goreis, Felnhofer, Kafka, Probst and Kothgassner41}

Although many self-help treatments have been shown to be effective, sustaining patient engagement may be problematic, and therapy completion rates as low as 20% have been reported for online CBT.^{Reference Christensen, Griffiths, Mackinnon and Brittliffe42} However, as the costs of self-help therapies are comparatively low, a large number of people may be treated at low cost, so the potential gain in care can still be substantial despite high drop-out rates. The limited existing literature suggests that online therapy does not discourage or affect the efficacy of future personalised therapy,^{Reference McDonald, Eccles, Fallahkhair and Critchley43} although further research into this is needed.

Access to technology worldwide is increasing rapidly, including in LMICs. In a 2015 survey of 21 emerging and developing countries, a median of 54% reported using the internet and 37% reported owning a smartphone (Pew Research Centre, 2016),⁴⁴ and there is a growing body of evidence that treatments using mobile and internet technologies can be feasible and efficacious in LMICs, while increasing the availability and accessibility of mental health services.^{Reference Ruzek and Yeager23,Reference Hall, Fottrell, Wilkinson and Byass45}

Potential risks and controversies around self-administered EMDR therapy

A session of EMDR therapy can lead to a short-term increase in distress for patients,^{46,Reference Shapiro47} which Francine Shapiro, the founder of EMDR therapy, warned could lead to a transient increase in suicidality in some patients.^{Reference Shapiro47} She explained that this may be due to the resurfacing of dissociated information, emotions and physical sensations. Therefore, according to the treatment protocol, therapists first assess their patients’ suitability and readiness for EMDR therapy prior to commencing the active processing of memories, particularly by evaluating their abilities to successfully utilise self-control and relaxation techniques and to maintain their own safety.^{Reference Shapiro47} Shapiro further cautioned that EMDR processing may even be ‘very disturbing’^{Reference Shapiro47} (p. 89) and that ‘the lack of adequate screening, preparation, or implementation of EMDR can have literally fatal consequences’^{Reference Shapiro47} (p. 303). The EMDR UK and Ireland Association also advised that ‘according to American Psychological Association ethical guidelines, all prescribed therapies should be done according to the standardised procedures that have been examined by research’.⁴⁶

However, it appears that these warnings may have been drawn solely from anecdotal evidence; it has been argued that previous research studies have not assessed or reported upon the adverse effects of EMDR therapy with enough rigor to be able to make a conclusion about the risk of harm.^{Reference Jonas, Cusack and Forneris48} In particular, there is inadequate evidence in the published literature to either prove or disprove that computerised, mobile or self-help EMDR therapy can be harmful. Shapiro co-authored one article in 2000 in which EMDR therapists were described as ‘escorts rather than active agents during therapy’,^{Reference Zabukovec, Lazrove and Shapiro49} (p. 190) a notion that that brings into question whether digital ‘escorts’ could be substituted for individual therapists.

Opinions differ among the authors of the self-help literature on the potential safety of self-administered EMDR therapy. EMDR therapists – and, indeed, Shapiro herself – have begun to publish self-help books using techniques derived from EMDR therapy with the aim of reducing readers’ symptoms of PTSD, anxiety or insomnia, among other conditions.^{Reference Parnell50,Reference Shapiro51} For example, Shapiro's self-help book recommends the unsupervised use of several aspects of the preparation phase of EMDR therapy, including affect scan, identifying unprocessed memories and negative cognitions, and breathing techniques.^{Reference Shapiro51} However, Shapiro cautions that the memory processing itself should not be done without following all the EMDR therapy procedures with a trained therapist, and that professional help should be sought if symptoms are severe or persistent. On the other hand, self-help books are also available to the public that recommend that all eight stages of EMDR therapy in their entirety can be safely tried by members of the public unsupervised.^{52,Reference Long and Bannert53} Concerningly, the author of one of these books states that they are not themselves trained in EMDR therapy,⁵² and the authors of the other book declare, without citing scientific evidence, that self-help EMDR is as safe as ‘grandma gently moving backwards and forwards in her rocking chair’^{Reference Long and Bannert53} (p. 1).

Further to the paucity of research and the lack of consensus among EMDR therapists about the efficacy and safety of self-administered EMDR, it is concerning that poor-quality and unregulated mobile apps and internet programmes, as well as self-help books, are so easily available to the public. The mean quality of nine applications advertising themselves as tools for self-help EMDR therapy for PTSD was recently rated as 2.91 using the Mobile Application Rating Scale German Version (MARS-G), indicating ‘poor’ quality.^{Reference Sander, Schorndanner and Terhorst54} To our knowledge, the quality of internet websites providing these tools has yet to be rated.

Strengths and limitations

This was the first commentary or review article that has explored the risks and benefits of self-help, computerised, internet or mobile EMDR therapy, and how these could potentially improve accessibility to EMDR therapy for treatment of PTSD in low- and high- income countries. A strength of this study is the thorough systematic search that was conducted for peer-reviewed articles on the topic, using several search engines. However, the main limitation was the lack of available primary research published on the topic, which limited the analysis and the conclusions that could be drawn. In addition, other than the search of the EMDR Library, it did not include any further search of the grey literature.