EMDR Therapy Quarterly

This paper is about four trends that have begun, and will continue, to shape our lives, our economy and the environment in which we learn and practise EMDR, and organise our EMDR communities. The purpose of this paper is to provoke a long needed public discussion about the future of this form of therapy both in the UK and in the wider world. The four trends are:

• the growing crisis in mental health across large parts of the world; 
• the growth of the digital economy and innovation that will particularly affect the fields of health and education;
• the steady demise of the DSM diagnostic system;
• the development of AI (artificial intelligence).

These trends reinforce each other to offer huge challenges to providers of mental health therapy including EMDR, but also opportunities if they can be grasped. When our environment changes we need to adapt to survive and thrive. In this paper I will offer some suggestions as to how we can meet the challenges ahead; but my main hope is that these will generate a proper debate about the future rather than just an argument about my suggestions.

The four trends

1. The growing crisis in mental health across large parts of the world, made worse by Covid-19

In the developed rich world, even before COVID-19, the one quality-of-life indicator that is said to be declining is mental health. Mental wellbeing depends on a sense of meaning and purpose and a feeling that we are part of something larger than ourselves, useful to and needed by others. It is our attachments that give us meaning and purpose [1].

Unfortunately, our modern developed economies help undermine a sense of wellbeing for millions of people. This is because it is tilted in favour of those blessed with strong cognitive abilities (those working with their ‘head’) and who are highly valued and so enjoy the esteem of others and earn higher incomes. In contrast, those who work with their ‘hands’, however skilfully, and those whose abilities are in caring (the ‘heart’), generally are less valued and are less well paid.

In Britain and the USA, in particular, this was reinforced by the enormous expansion in higher level education since the 1950s when less than 5 percent of young people in the UK went to university (in the USA it was somewhat higher). From the 1970s on, the twin goals of all rich countries have been to raise the overall educational level of the population and to select the most able to go into an expanding higher education system. Tony Blair’s famous mantra, ‘education, education, education’, evolved into a plan to send 50 percent of young people into academic education [2].

Of course, there have been very significant benefits from this development, but there have been real downsides too, which are likely to get worse and contribute to the crisis in mental health. As Goodhart points out, high educational achievement, which both in the UK and the USA, means some form of postgraduate qualification, is now a central source of status and human esteem. Secondly, when only some 15 percent of your class in school or town go to University it doesn’t lead to a ‘left behind’ problem with those who don’t; when 50 percent go to University, it does [3]. Third, because of the huge output of university graduates, it’s now estimated that between 30 and 50 percent are employed in non-graduate employment five years after graduating, and still carrying very large debts [4]. These three factors are all likely to contribute to the crisis in mental health.

In the rest of the world, regional and local wars, terrorism and conflict – and now COVID-19 – has and continues to create a vast and ever larger population of severely traumatised people. It’s estimated that one in five people live in countries affected by violent civil conflict and some 60 million people worldwide have been displaced because of conflict, violence and human rights abuse. Add in the one-third of women in the world who have suffered sexual and/or physical abuse and the quarter of a billion people affected by natural disasters, and Rolf Carriere estimates there could be 500 million people in the world with PTSD [5]. Moreover we know now that trauma can be transmitted to future generations not only because of cultural transmitted beliefs but also through biology. Many millions of these suffering people have little or no access to formal mental health provision.

In the meantime we have the pandemic, affecting rich, poor and troubled countries.  It is highly likely that the effects of the pandemic will be with us all for several years, and causing havoc with peoples’ mental health. The Times reports the Pandemic has increased inequality. Overall, one-third of Britons who say they cannot afford an unexpected expense now report moderate to severe symptoms of depression [6]. The Economist reports that lockdowns have significantly damaged mental health in the USA: more than 10 percent of Americans have given serious consideration to suicide [7]. The effects on mental health in many other parts of the world, especially in poor countries and in already traumatised populations, can only be worse.

Clearly, we face as a nation and as a world a long-term increasing demand for mental health services, including the provision of EMDR. The pressure to minimise session numbers and toward manualised therapies like CBT will continue, if not intensify, as a means of managing costs.

2. COVID-19 will accelerate the growth of the digital economy and innovation.  Healthcare and education are two areas ripe for disruption, which will include the rise of cross-border providers in these fields [8]

Personally, this author prefers to work person to person as an EMDR therapist (much less so when working as a supervisor), but I have been forced to work online with some of my clients and have found it effective, relatively straightforward and less anxiety-provoking with regard to my own health (I fall into the ‘vulnerable’ category for COVID-19). I have been surprised at the complexity of cases that I have successfully worked with online, including severe childhood abuse and ego state work. On the other hand, I did have one ‘scare’ when a client unexpectedly dissociated and experienced severe somatic symptoms. Being 100 miles away and unable to intervene as I would normally was chastening – sometimes it’s only when things go wrong that we recognise the power of EMDR. The conclusion I have come to is there are cases that are better treated person-to-person, especially where there are potential safety issues.

On the other hand I do welcome the development of online working for these reasons:

Many, maybe the majority of clients with straight forward PTSD who would benefit from EMDR, could be treated online.Online working is less resource hungry for the client (no travel costs) and for the institutions such as the UK National Health Service (freeing up space set aside for waiting and therapy rooms) and more convenient for private therapist not having to set aside a therapy room.  Overall, cost of therapy should fall.As online working becomes more and more common, this could help address the wildly different levels of EMDR availability throughout the UK.  Here in Wales, one Health Board has over one hundred trained EMDR therapists working within it, whereas in others you would be pushed to find more than a couple. There are similar disparities across the UK in the provision of private EMDR therapy. The more online working grows in various fields, the more likely will we see improvements in the technology affecting ease of operation, reliability, flexibility and safety. New innovative technology, developed by a Dutch company called Psylaris, aims to reduce the number of sessions needed to achieve a given level of trauma symptom relief [9].

3. The demise of DSM system for mental health diagnosis will gather pace over the next 10 years. What will replace it is an open question, but for EMDR practitioners, the Power Threat, Meaning Framework (PTM) [10] offers a process ideally suited to the therapy.

According to World Psychiatry, the greatest obstacle to scientific progress is, and has been, the DSM system of diagnosis [11]. And in a devastating blow to the DSM system, Thomas R. Insel, M.D., Director of the USA National Institute of Mental Health, made clear the agency would no longer fund research projects that rely exclusively on DSM criteria. Henceforth, the National Institute of Mental Health, which had thrown its weight and funding behind earlier editions of the manual, would be “re-orienting its research away from DSM categories.” The “weakness” of the manual, he explained, “is its lack of validity”.  “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure” [12].

One result of reliance on the DSM has led to what has been called ‘cookbook’ diagnosis and assumptions of ‘chemical imbalance’ for psychiatric disorders. Pharmaceutical companies have exploited this in their marketing and significant overprescribing of psychotropics has resulted. DSM-5 will provide new disorders and broader diagnostic criteria that will likely exacerbate this [13].

The PTM framework, offered as a replacement to the DSM, focuses on ‘What happened to you?’ not ‘What’s wrong with you?’.  Rather than match the client’s symptoms to the DSM manual’s categories, it requires engagement with the client’s story, exploring information that is critical to the practice of EMDR:

• What has happened to you? (How has Power operated in your life?)
• How did it affect you? (What kind of Threat does this pose?)
• What sense did you make of it (What is the Meaning of these situations and experiences to you?)
• What did you have to do to survive? (What kinds of Threat Responses are you using?).

In practice, two other questions are needed:

• What are your strengths? (What access to Power resources do you have?)
• ……..and to integrate all of the above: What is your story?

This framework was supported by Dr Farrell in his recent webinar on Supervision [14].

So we come back to the ‘stories’ we tell about ourselves, which those familiar with narrative therapy know are key to shaping who we are and which, with DSM, it is too easy to simply ignore [15].

4. The rapid development of AI (Artificial Intelligence) is likely to be highly disruptive in health care diagnosis and delivery over the coming years.

AI technologies are categorised by their capacity to mimic human characteristics. Artificial narrow technologies (ANI) is goal oriented, designed to perform singular tasks – e.g. spotting cancer in patient scans. While these machines seem intelligent, they do not mimic or replicate human intelligence, they simply mimic human behaviour. Artificial general intelligence (AGI) is very different. The concept is of a machine that mimics human intelligence and/or behaviour with the ability to learn and apply its intelligence to solve any problem.

To date AGI has not been achieved and may not for some years. But imagine if this could be done, so that robots could perform at least some EMDR therapy, possibly with a human supervisor? Already there are computer algorithms that can provide some forms of therapy to patients.  A paper describes a ‘computer psychologist’ treating two men for social anxiety based on ANI technology (see above). It concluded that: “The quality of the interaction appeared to be similar to person-to-person therapy and that the computer psychologist established an effective therapeutic relationship, and the automated techniques used were sufficiently engaging to prompt users to log on regularly and complete the treatment programme [16].”

Meeting the challenges and grasping the opportunities

In discussing these issues I will address them from a UK perspective focussing on how the EMDR Association can meet the challenges and opportunities ahead in the UK. In doing so I will also address the role of both UK EMDR bodies – the Association and Trauma Aid – in how they might contribute to addressing the worldwide crisis in mental health and the need for EMDR therapy.

What will the EMDR Association need to do in order to contribute to meeting the mental health crisis in the UK? 

Increasing the number of therapists is an obvious answer, but it leaves several key questions unanswered.

Whom should we be recruiting to become therapists? I believe that we recruit people from a wide range of professions but not necessarily with clinical experience or with clear evidence that they have the ability to establish a positive therapeutic relationship with clients.  Is this wise when research over the past fifty years has demonstrated that one factor more than any other is associated with successful psychotherapeutic treatment – the quality of the relationship between the therapist and the patient? [17] I believe all applicants for training should be asked to provide comments from a supervisor or other competent person about their ability to develop an effective therapeutic relationship with clients, or to be interviewed before they are accepted. In addition, there should there be ongoing evaluation of all trainees on basic training courses to ‘weed out’ those who are unlikely to meet certain criteria, of which one should definitely be about their ability to build a good therapeutic relationship with clients? In addition, all trainees should have undergone some EMDR therapy so that they can experience being on the other side of the equation and can learn how it is to put your trust in a therapist.  The author was fortunate to have had this experience on his first EMDR training.   It had such a profound effect on the issue I brought that I was completely sold on EMDR as a therapy.

What should applicants learn in basic training? In the light of the trends discussed above, I believe training will need to focus on a broader and deeper range of skills including:

• use of online technology,
• use of the PTM framework
• interviewing
• how and when to use basic interventions for times when the standard protocol fails, such as CIPOS, LOUA, LOPA, etc. [18].

Should there be more emphasis on complex PTSD even in basic training? I believe there should be.  Most therapists soon learn that there are few ‘single incident traumas’ to be found in practice. To equip therapists for working with more complex cases requires much more than the straightforward application of the Standard Protocol. 

Should training be much more experiential? I believe it should, giving more opportunities for ‘live’ practice [19]. This seems far more possible now with online training. The author recently went on a course organised by EMDR Focus in which there were live demonstrations of client/therapist interactions and each participant had the opportunity to be the therapist, client and observer.  The interaction were carried out in individual ‘break out’ rooms and participants had access to a facilitator in case of difficulty, or needing advice.  It felt remarkably safe as well as providing an excellent  learning opportunity [20].

Are the rules for gaining access to Continuing Professional Development adequate in view of the changes ahead? Change is needed for several reasons: after COVID-19 and the widespread use of online platforms to facilitate meetings, people may never be willing to travel to and attend conferences, workshops and seminars to the same extent as in the past; secondly, the cost of gaining CPD points can be onerous for therapists seeking re-accreditation; thirdly, the paucity of opportunities to gain CPD points this year must not be allowed to continue.  There are several possible routes for increasing CPD opportunities, which may also lead to a reduction in cost.  I believe the UK Association should:

• In principle be willing to award points to UK therapists who attend training recognised as suitable for CPD points by other EMDR National Associations
• Allow training to be delivered person-to-person, via webinar and online provided all three offer ways of measuring learning and opportunities to ask and receive answers to questions. These two provisions have been identified as reasons why attendance at webinars qualify for CPD points and online does not.  Yet the author has attended two Association sponsored webinars recently where both criteria were missing. Moreover, both criteria can be met with online training, which enjoys other advantages for learners over both other delivery methods, including convenience and cost
• Caution is the enemy of innovation.  Let’s learn from what has happened in the NHS where COVID-19 has pushed the organisation to breaking point and brought forth a wave of innovation [21].

Is the structure of EMDR UK and the way it operates fit for purpose? Like many charities, the Association was created and led by a group of individuals prepared to spend a lot of their time and energy doing something they believed was important and worthwhile.  We should all be grateful for the sacrifices they made, which all EMDR therapists in the UK have benefited from.  However, there comes a time when the functions of the Board (which has a specific duty to think about the future, shape strategy and see that plans are in place), and  the Executive (responsible for running the operation day-to-day and implementing the strategy and plans approved by the Board) are split.  This division has yet to be made in the Association and I believe this is needed urgently in view of the challenges ahead and the opportunities to be grasped. I propose:

• The appointment of a chief Executive and withdrawal of Board members from involvement in the day–to-day running of the operation over as short a time scale as is possible
• The Board should focus its energies and expertise on the future, including technological developments such as Artificial Intelligence, rethinking the training regimes, and overseeing the work of the Executive.  This is a huge task in itself
• A fundamental review of the way training is organised so that Trainers have their own businesses to manage while at the same time serving the interests of the Association.  Unfortunately, the Association and the trainers have competing incentives and interests.  For example, the Association should want to know details of every single person who has attended a training course both to develop an overall database, and to enable it to measure the conversion rate from training to membership and to accreditation.  Trainers, on the other hand, will want their own databases to remain private for competitive reasons among others. While this is understandable it ties the hands of the Association. By my calculation as many as 40 percent  of those who have attended some EMDR training and are practising therapists may not have become members of the Association [22].

How can the UK contribute best to the overwhelming needs for mental health services related to untreated trauma around so much of the poor and underdeveloped world?

Globally, attempts to address this need seems to have led to a confusing patchwork of international, regional and national organisations.  Examples of these organisations include, but are not limited to, the Global Initiative for Stress and Trauma Treatment (GISTT), Trauma Aid Europe, EMDR International in the USA and of course in the UK, Trauma Aid.  Among the various members of this patchwork relatively little collaboration seems to take place in terms of meeting emergencies or fostering the longer term development of local cohorts of EMDR therapists and self-sufficient national Associations. Despite this, some wonderful work has been done by organisations such as Trauma Aid UK, which have been instrumental in creating in Bosnia a group of EMDR therapists and a functioning Association.  In the USA, EMDRIA’s Council of Scholars is examining over a three-year project goals and directions for research, clinical practice, training & credentialing and defining ‘What is EMDR’ [23]. This is highly significant in many ways, not least because there are different standards in training and accreditation between Associations.  Also,  there is the question of who to train in countries where psychiatrists, psychologist and other health professionals are largely absent.

One other factor missing from the world scene is consideration of resourcing and the development of these efforts is a concerted coordinated attempt at a global level to raise funds for these unmet needs. This is becoming more feasible now that trauma is recognised by the general publics as a serious and real condition not limited to members of the armed forces. There are opportunities here that should not be wasted, but many things will have to change to grasp them. This is where the UK EMDR organisations can play an important role. Here are some possible steps on the way:

Envisioning a collective response to the needs for trauma treatment in terms of a global organisation representing all EMDR National Associations and organisations. Its  role would be to:

• Coordinate responses to emergencies 
• Once initial emergency needs are met, see resources are identified and mobilised to ensure a longer term presence is put in place that could develop into a permanent organisation and source of EMDR therapists
• Gather and provide information on emergency and ongoing needs that could be used to raise funds in the rich world
• Set priorities for the development of national or regional cohorts of EMDR therapists and appropriate organisations
• Develop and maintain a database of all key EMDR protocols, interventions and training by language, and arrange for the translation of these as needed
• Help to identify research needs and priorities.

• Persuading Associations and relevant organisations to collaborate to achieve this. (4)  The key is probably first to persuade the USA-based EMDRIA to join this venture and provide leadership as ‘first among many’.  Why the USA and how might this be accomplished?
• History shows that the creation of most of the successful multinational organisations in the past 70 years has required the commitment, and also usually leadership, of the USA. The range of organisations created is extraordinary, ranging from the  United Nations to the International Monetary Fund, the World Bank, NATO and even to the United Bible Societies, a federation of 140 countries and on whose Board  the author served
• The USA has the financial, therapeutic and leadership heft needed for this task of helping create a truly global network of collaborating organisations
• With the next President planning to put America back into a much more multinational posture, now maybe a propitious time to engage the American EMDR Communities in exploring this global project to address trauma needs around the world
• Someone will need to initiate this exploration and why shouldn’t it be from the UK?  A first step would be for representatives from the UK EMDR Association and Trauma Aid to flesh out this idea, fashion it into a persuasive argument and initiate a discussion with other Associations and interested parties.

Final Thoughts

Where do we go from here? What I have outlined, and particularly the changes I believe are needed, would provide an immense challenge to any organisation. Where do we start? First with the Association members. An opportunity to do this would be at the next National Conference, where a day or at least a half a day could be set aside for a discussion of this article to elicit views and ideas for the future.

Secondly, if there is a willingness to engage seriously with this agenda, the first place to start is restructuring the Association to free up the Board to do the heavy thinking and planning. This probably needs to happen anyway to prepare the Association better for the challenges ahead as these will happen whether or not the Association prepares for them in the ways suggested.

This is a time of uncertainty and at such times, rather than trying to control things, the best strategy is to experiment, get feedback and adjust accordingly [24]. And as Tancredi told his uncle Don Fabrizio, in di Lampedusa’s novel about people struggling to adapt to change, “If we want things to stay as they are, things will have to change.” [25]

Richard Worthing-Davies spent over 30 years working in the private and charitable sectors before becoming a Family and Systemic therapist and an EMDR Consultant. He works in private practice. He and his wife Sally, also a therapist, are two of the founders of emdrgateway.com - an online learning platform showing short, bespoke videos demonstrating solutions to common problems that arise in EMDR therapy.