Is EMDR an exposure therapy?
A standard treatment for anxiety disorders involves exposing clients to anxiety eliciting stimuli. It has sometimes been assumed that EMDR uses exposure in this traditional manner and that this accounts for EMDR’s effectiveness. Some reviewers have stated, “Had EMDR been put forth simply as another variant of extant treatments, we suspect that much of the controversy over its efficacy and mechanisms of action could have been avoided” (Lohr, Lilienfeld, Tolin, & Herbert, 1999, p. 201). However, such a perspective ignores important elements of the EMDR procedure that are antithetical to exposure theories; in other words, the theories predict that if these EMDR elements were used in exposure therapy, a diminished outcome would result (Rogers & Silver, 2002). These elements include frequent brief exposures, interrupted exposure, and free association. (1) Exposure theorists Foa and McNally (1996) write: "Because habituation is a gradual process, it is assumed that exposure must be prolonged to be effective. Prolonged exposure produces better outcome than does brief exposure, regardless of diagnosis” (p. 334). EMDR however uses extremely brief repeated exposures (i.e., 20-50 seconds). (2) Other theorists (Marks et al., 1998) state that exposure should be continual and uninterrupted: "Continuous stimulation in neurons and immune and endocrine cells tends to dampen responses, and intermittent stimulation tends to increase them” (p 324). EMDR, on the other hand, interrupts the internal attention repeatedly to ask “What do you get now?” (3) Exposure therapy is structured to inhibit avoidance (Lyons & Keane, 1989), and specifically prohibits the patient from reducing “his anxiety by changing the scene or moving it ahead quickly in time to skim over the most traumatic point” (p. 146) in order to achieve extinction of the anxiety. However, free association to whatever enters the person’s consciousness is an integral part of the EMDR process. Differences such as these have prompted exposure researchers to state: "In strict exposure therapy the use of many of ['a host of EMDR-essential treatment components'] is considered contrary to theory. Previous information also found that therapists and patients prefer this procedure over the more direct exposure procedure" (Boudewyn and Hyer, 1996, p.192) A one session direct process analysis of the two therapies found significant differences in practices and subjective response (Rogers et al., 1999).
Clearly theories explicating exposure therapy fail to explain the treatment effects of EMDR, with its brief, interrupted exposures, and its elicitation of free association. In addition there appears to be a difference in treatment process. During exposure therapy clients generally experience long periods of high anxiety (Foa & McNally, 1996), while EMDR clients generally experience rapid reductions in SUD levels early in the session (Rogers et al., 1999). This difference suggests the possibility that EMDR’s use of repeated short focused attention may invoke a different mechanism of action that that of exposure therapy with its continual long exposure.