# State of the Science: Eye Movement Desensitization and Reprocessing (EMDR) Therapy - URL: https://alisanburak.com/en/bilimin-son-durumu-goz-gareketleriyle-duyarsizlastirma-ve-yeniden-isleme-emdr-terapisi - Language: en - Last updated: 2026-08-15 - Page title: State of the Science: Eye Movement Desensitization and Reprocessing (EMDR) Therapy | Assoc. Prof. Dr. Alişan Burak Yaşar > State of the science: Eye Movement Desensitization and Reprocessing (EMDR) therapy https://onlinelibrary.wiley.com/doi/full/10.1002/jts.23012 State of the This page was translated automatically from Turkish. [Read the original](https://alisanburak.com/bilimin-son-durumu-goz-gareketleriyle-duyarsizlastirma-ve-yeniden-isleme-emdr-terapisi) [← Back to blog](https://alisanburak.com/en/blog) # State of the Science: Eye Movement Desensitization and Reprocessing (EMDR) Therapy March 17, 2024Recent ArticlesWritings and Talks **State of the science: Eye Movement Desensitization and Reprocessing (EMDR) therapy** https://onlinelibrary.wiley.com/doi/full/10.1002/jts.23012 **State of the Science: Eye Movement Desensitization and Reprocessing (EMDR) Therapy** Authors: Ad de Jongh, Carlijn de Roos, Sharif El-Leithy Published in: Wiley DOI: 10.1002/jts.23012 Date accepted: December 8, 2023 Correspondence: Ad de Jongh, PSYTREC, Professor Bronkhorstlaan 2, 3723 MB Bilthoven, the Netherlands E-mail: a.d.jongh@acta.nl , addejonghx@outlook.com **This article was translated into Turkish by Specialist Psychologist Gizem Pozam.** **Abstract** Eye movement desensitization and reprocessing (EMDR) therapy is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD), supported by more than 30 published randomized controlled trials (RCTs) demonstrating its efficacy in both adults and children. Most international clinical practice guidelines recommend EMDR therapy as a first-line treatment for PTSD. This article describes the current state of the evidence on EMDR therapy. We begin with a brief description of EMDR therapy and its theoretical framework. We then summarize the scientific support for its efficacy, effectiveness, and safety, and discuss its applicability across cultures and in different populations. We conclude with recommendations for advancing the research base and applications of EMDR therapy. **Introduction** Eye movement desensitization and reprocessing (EMDR) therapy is one of a handful of psychological treatments for posttraumatic stress disorder (PTSD) with substantial empirical support. Accordingly, most international clinical practice guidelines for PTSD recommend EMDR as a first-line treatment, including those published by the World Health Organization (WHO;2013), the National Institute for Health and Clinical Excellence (NICE;2018), the International Society for Traumatic Stress Studies (ISTSS;2018), and the U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD;2023). EMDR was developed by Francine Shapiro, a psychologist based in the United States, who described its core procedure in 1989 under the name "eye movement desensitization" (EMD; Shapiro,1989a). That same year, Shapiro published the first controlled study of the procedure in the Journal of Traumatic Stress (1989b). For this study, she treated 22 clients with persistent traumatic memories of childhood sexual abuse, physical and sexual assaults, emotional abuse, and Vietnam War experiences using a single EMD session, and found dramatic improvements that were maintained at the 3-month follow-up (Shapiro,1989b). In subsequent years, she elaborated and refined the EMD procedure into EMDR, adding resource development, assessment phases, reprocessing of cognitions, and closure to the protocol. As practiced today, EMDR has evolved into a comprehensive, manualized treatment approach, with adaptations flexibly incorporated into the protocol for various types of psychopathology and barriers to treatment (Valiente-Gomez et al.,2017), as well as for specific populations such as children, adolescents (e.g., de Roos et al.,2017), and individuals with intellectual disabilities (e.g., Mevissen et al.,2020). Several features distinguish EMDR from most other psychological treatments for PTSD. For example, although it can be applied flexibly within the context of a strong therapeutic alliance, EMDR is also highly protocolized: the treatment procedure is taught in exactly the same way worldwide, enhancing the ability to disseminate the treatment and test its efficacy through scientific research. Like other trauma-focused therapies, EMDR involves revisiting traumatic memories and their associated meanings, emotions, and bodily sensations. Unlike trauma-focused cognitive behavioral therapy, EMDR does not involve directly challenging beliefs, prolonged exposure, or homework assignments (Shapiro,2018). Another striking difference is that relatively few verbal instructions are required during the application of the protocol, and the therapist makes no explicit effort to encourage the client to verbalize traumatic memories. The most distinctive component of EMDR is that the client is typically asked to visually track the therapist's hand as it moves from side to side while simultaneously holding traumatic memories in mind. Based on her initial observations and the clinical outcomes of using the EMD technique, Shapiro came to believe that performing lateral eye movements initiated a processing mechanism in the client that reduced the emotional distress associated with the memories. To initiate eye movements, EMDR therapists typically use their own hand and ask the client to focus their attention on it. They then move their hand back and forth approximately 30 cm in front of the client's face, facilitating a series (i.e., a set) of approximately 25 saccadic eye movements. This form of bilateral stimulation remains the best known in EMDR, and its efficacy has been extensively investigated. Initially, critics argued that EMDR showed no efficacy beyond nonspecific treatment effects and that there was insufficient evidence that eye movements, which were central enough to be part of EMDR's name, contributed significantly to the treatment's efficacy (e.g., Herbert et al.,2000). Evidence for the differential effectiveness of EMDR with and without eye movements emerged approximately 20 years after the publication of the initial findings from both laboratory and field studies (Günter & Bodner, 2008; Lee & Cuijpers, 2013; van den Hout & Engelhard, 2012). Many scientists in neurobiology and experimental psychopathology have since developed theories to explain the distinctive effects of EMDR (e.g., Baek et al., 2019; Günter and Bodner, 2008; van den Hout and Engelhard, 2012; de Voogd et al., 2018; de Voogd and Phelps, 2020). The aim of this article is to provide an overview of the state of the science on EMDR for the treatment of PTSD. After describing the treatment paradigm and procedure, we discuss the conceptual and theoretical foundations of EMDR, including research on its most likely mechanisms of action. We also summarize the existing evidence base for applying EMDR across cultures and in minority communities. Finally, we offer recommendations for future research and developments in the field of EMDR in relation to PTSD. **THE STANDARD EMDR PROTOCOL** Research has demonstrated a direct relationship between correct application of the "standard EMDR protocol" and therapeutic outcomes; strict adherence to the protocol is therefore considered crucial to ensuring the integrity and empirical efficacy of EMDR (Maxfield and Hyer, 2002). This protocol consists of eight fixed procedural steps (i.e., phases) involving a set of standard questions and formulations. The relevant steps are listed in Table 1. The aim of the EMDR procedure can be defined as reaching an endpoint at which distress associated with the target memory is minimized and the credibility of a desired positive, self-referential belief associated with that memory is maximized. Within the EMDR framework, the therapist is viewed as a facilitator who helps the client optimally activate traumatic memories while guiding them to focus on various components of a memory as they simultaneously follow the therapist's movements with their eyes. After gathering information about the client's symptoms and history, establishing a diagnosis, and developing a case conceptualization identifying which memories are considered important targets for treating the client's PTSD symptoms (Phase 1), the client is prepared for trauma processing (Phase 2). This involves establishing a therapeutic alliance, providing appropriate psychoeducation, and addressing the client's existing coping skills. Before desensitization begins (i.e., assessment; Phase 3), the therapist activates the memory by asking the client to bring to mind the most disturbing aspects of the first traumatic memory on which the treatment session will focus (i.e., the target image). The therapist assesses the associated dysfunctional self-referential belief (i.e., negative cognition; NC), an alternative desired belief (i.e., positive cognition; PC), the associated core emotions and bodily sensations, and the subjective level of distress associated with the target memory. This is indicated using the Likert-type Subjective Units of Disturbance Scale (SUDS), ranging from 0 (no disturbance) to 10 (extreme disturbance). Processing of the target memory then begins with a dual-attention task, typically rapid bilateral eye movements guided by the therapist's hand (i.e., desensitization; Phase 4). After each set of eye movements, the therapist explores what arises spontaneously for the client, as the EMDR procedure elicits a flow of thoughts, images, emotions, and somatic sensations typically referred to as associations. The therapist then proceeds on the basis of this response, encouraging the client to "focus on that" and continue processing by following the therapist's fingers with their eyes. Typically, throughout the EMDR process, traumatic memories gradually become "neutral" (i.e., lose their emotional charge), so that by the end of treatment the client should be able to recall the traumatic memory without experiencing any emotional distress (i.e., a SUDS score of 0). In the next step of the standard EMDR protocol (i.e., installation; Phase 5), the client is asked to rate the believability of the positive cognition on the Validity of Cognition (VoC) scale, ranging from 1 (completely false) to 7 (completely true). The client is then asked to recall the memory and repeat the positive cognition in their mind while simultaneously performing eye movements. These steps are repeated until the VoC is maximized. An EMDR treatment session usually ends with a "body scan" (Phase 6), followed by agreement about follow-up and whether the client feels well enough to end the session (i.e., closure; Phase 7). The final phase of the standard EMDR protocol (i.e., reevaluation; Phase 8) takes place at the next meeting, when the therapist begins the session by reviewing the previous one and assessing progress in terms of the effectiveness of what has been achieved so far. For a full description of the treatment protocol, see Shapiro (2018). A therapy session using EMDR in adults typically lasts 60–90 minutes and can be delivered in an individual or group format. Although randomized controlled trials are few in number and of low methodological quality, emerging evidence suggests that group EMDR protocols can significantly reduce PTSD symptoms (Kaptan et al.,2021). Although EMDR is generally delivered in weekly sessions, intensive formats with daily or twice-daily sessions have also been found to be effective (Bongaerts et al.,2017). Individuals have been shown to no longer meet the diagnostic criteria for PTSD after as few as five treatment sessions following a single traumatic event (e.g., Nijdam et al.,2012); longer protocols of eight to 12 sessions are common in routine clinical practice and for PTSD resulting from multiple traumatic events. **CONCEPTUAL AND THEORETICAL FOUNDATIONS OF EMDR** Francine Shapiro (2018) developed the adaptive information processing (AIP) model as the theoretical foundation of EMDR therapy. This model proposes that highly distressing events can disrupt the brain's emotional balance, causing memories, together with their associated cognitions, emotions, and physiological responses, to be consolidated in a "frozen" state within isolated memory networks that can be readily activated by a wide range of stimuli in everyday life. In addition, the AIP model assumes that every individual has an innate information processing system that allows adaptive learning from new experiences. Under the influence of eye movements, such as those observed during rapid eye movement (REM) sleep (Stickgold, 2002), stored traumatic experiences are believed to be released into working memory for processing. In this sense, Shapiro's AIP model proposes that EMDR facilitates the formation of new connections within the individual's neural network, linking dysfunctionally stored information to other existing networks of functional information and beliefs. The result of this process is the transformation of a traumatic memory into a more adaptive and functional form, leading to cognitive restructuring of the traumatic experience and its associated meanings, followed by a reduction in trauma-related symptoms. Thus, the AIP model primarily illustrates, at a metaphorical level, how the brain integrates and processes dysfunctional information. Numerous studies support the core principles of the AIP model concerning the association between desensitization of pathogenic memories and PTSD symptoms (Hase et al., 2017). The first scientific research supporting the AIP model and the role of eye movements in EMDR was the experimental research by Christman and colleagues (2003, 2006), who tested the interhemispheric interaction hypothesis. The authors found that inducing horizontal eye movements increased the accessibility of episodic memories for both laboratory and everyday events. A subsequent study by Parker and Dagnall (2007) showed that this increase in accessibility was stronger for horizontal eye movements than for either vertical eye movements or fixation on a particular point in the room. The authors suggest that this finding results from enhanced interaction between the brain's two hemispheres and reflects adaptive information processing; however, direct measurements using electroencephalography (i.e., EEG) data cast doubt on enhanced interhemispheric interaction as a neurobiological mechanism underlying EMDR (Samara et al.,2011). Another theory that potentially offers a better explanation for the effects of EMDR is derived from Baddeley's (2012) working memory model. According to this model, although working memory can perform multiple tasks simultaneously across different domains (e.g., verbal, visuospatial, problem-solving), each domain has a limited capacity. Performing a demanding task therefore potentially interferes with the performance of another task if it takes place within a similar working memory domain. Thus, when the visuospatial working memory store is "filled" by recalling a traumatic memory while a demanding or taxing visuospatial task is performed simultaneously (e.g., accurately tracking the therapist's rapidly moving fingers with one's eyes), working memory has difficulty retaining and processing all this information at once. Consequently, competition for working memory resources reduces the intensity of recall of the traumatic memory. Later, when the memory trace is reconsolidated into long-term memory, it is stored in a degraded, less emotional, and less vivid form. Several predictions derived from working memory taxation theory have been tested in experimental studies. In these studies, participants were asked to perform attention-demanding tasks while recalling negative memories, to recall the memory alone, or to do nothing. After engaging in a demanding task while holding an emotionally charged memory in mind, these memories became significantly less emotionally charged and less vivid than the memories of participants in the control conditions (de Jongh et al., 2013; Günter and Bodner, 2008; Kemps and Tiggemann, 2007; Maxfield, 2008; van den Hout et al., 2010). Although these studies showed that eye movements, particularly following a therapist's fingers, are highly demanding tasks, the effects of several other working memory taxation tasks have also been tested, including listening to clicking sounds through headphones (de Jongh et al.,2013; van den Hout et al.,2011), listening to spoken text (Günter & Bodner,2008), copying a complex figure (Günter & Bodner,2008), playing the computer game Tetris, mental arithmetic (Engelhard et al.,2010; van den Hout et al.,2010), and counting aloud (Kemps & Tiggemann,2007). It is important to note that not all working memory tasks have similar effects on memories. For example, eye movements have been found to be significantly more effective than listening to clicking sounds through headphones in reducing the emotionality and vividness of memories (de Jongh et al., 2013; van den Hout et al., 2011, van den Hout and Engelhard, 2012). Conversely, although matching the modality of the taxation task to the recalled memory appears to have a greater effect, unmatched tasks also appear effective, potentially by taxing the central executive function of working memory (Matthijssen et al., 2019). Overall, there appears to be a linear relationship between the degree of working memory taxation (e.g., the speed of eye movements) and reductions in the emotional intensity and vividness of emotionally charged mental representations (Little and van Schie, 2019; van Veen et al., 2015). Although most experimental studies have involved nonclinical participants, these studies have been conducted and replicated by different research groups, providing strong scientific support for the memory effects observed in both healthy participants and PTSD samples (Wadji et al., 2022). A novel version of EMDR drawing on scientific research into working memory theory and the effects of working memory-taxing tasks on traumatic memories has been termed "EMDR 2.0" (Matthijssen et al., 2021). This version is based on the assumption that EMDR is more effective and efficient when the client is well motivated to bring the traumatic memory into working memory, the traumatic memory is activated more strongly, and the client's working memory is therefore taxed more heavily. Within EMDR 2.0, many different procedures can be used to tax working memory, including extremely rapid, diagonal, vertical, or other complex patterns to be tracked with eye movements; spelling words or sentences forwards and backwards or reciting the alphabet; singing a song; or tapping complex rhythms on the shoulders or legs. The first experimental study of the efficacy of EMDR 2.0 taxation methods found no overall superior effect compared with bilateral eye movements in traditional EMDR. However, the finding that fewer sets were needed with EMDR 2.0 to achieve the same reductions in the emotionality and vividness of target memories supports the procedure's efficiency (Matthijssen et al., 2021). Interestingly, neurobiological research supports working memory theory as applied to EMDR. Taxing working memory has been shown to suppress activity in the amygdala, the brain structure that serves as the brain's "alarm bell" and plays a central role in memory storage and reconsolidation (de Voogd et al., 2018; Pierce & Black, 2023). This effect does not appear to be limited to eye movements; research has shown that any intervention that taxes a client's working memory may have an attenuating and desensitizing effect on emotionally charged memories (de Voogd & Phelps, 2020). There is also evidence of a dose-dependent effect, such that the more heavily working memory is taxed, the stronger the inhibition of the amygdala. **EMPIRICAL SUPPORT FOR EMDR FOR PTSD IN ADULTS** The efficacy of EMDR in adults diagnosed with PTSD has been established in more than 30 published RCTs. To this end, individuals receiving EMDR have been compared with those in waitlist control conditions (Acarturk et al., 2016; Högberg et al., 2007; Jensen, 1994; Marcus et al., 1997; Roth- baum, 1997; van den Berg et al., 2015) or with a wide range of active control conditions, including relaxation training with and without biofeedback (e.g., 2016; Carlson et al., 1998); imagery rescripting (Alliger-Horn et al., 2015; Boterhoven de Haan et al., 2020); the counting method (Johnson and Lubin, 2006); forms of stabilization intervention (ter Heide et al., 2016; van Vliet et al., 2021); and pharmacotherapy such as fluoxetine (van der Kolk et al., 2007) and sertraline (Arnone et al., 2012). Most studies using an active comparison group have compared EMDR with trauma-focused CBT, another first-line treatment for PTSD (e.g., de Jongh, Amann et al., 2019). Overall, the results show large effect sizes for reductions in PTSD symptoms and substantial decreases in the proportion of participants meeting the diagnostic criteria for PTSD after treatment, with remission rates ranging from 36% (Devilly and Spence, 1999) to over 90% (Capezzani et al., 2013; Nijdam et al., 2012). Meta-analytic findings In 2023, Yunitri and colleagues (2023) used network analysis to conduct a comprehensive meta-analysis of the efficacy of various treatments for PTSD. This meta-analysis examined both the short- and long-term effects of PTSD treatment. The researchers assessed 18,897 studies published before March 2021 and ultimately analyzed 98 RCTs involving 5,567 participants, examining outcomes of PTSD interventions immediately after treatment and at 6-month follow-up. The results showed that EMDR and Cognitive Processing Therapy (Resick et al., 2017) had the strongest effects on long-term outcomes, with moderate to large effect sizes and moderate heterogeneity. The authors reported no specific concerns about risk of bias in the EMDR studies. It is important to note that several highly relevant controlled outcome studies have been published in recent years but were not included in the latest meta-analyses (Boterhoven de Haan et al., 2020; van Vliet et al., 2021). One of these studies compared the efficacy of EMDR therapy for childhood trauma with imagery in 155 participants who each received 12 sessions lasting 90 minutes (Boterhoven de Haan et al., 2020). As assessed using a clinician-administered interview, the treatment effects of EMDR between baseline and 1-year follow-up were very large (d = 1.88), and more than 80% of participants no longer met the diagnostic criteria for PTSD at that assessment. However, no differences between the two treatments were observed at posttreatment or 1-year follow-up. In addition to evidence for the efficacy of EMDR as a treatment, there is some evidence for its relative efficiency and cost-effectiveness. Estimates of the costs and benefits of treatment provided by the United Kingdom's National Health Service for individuals diagnosed with PTSD indicated that EMDR was the most cost-effective intervention for adults diagnosed with PTSD among the 11 intervention types evaluated (Mavranezouli et al., 2020). **Efficacy of EMDR in clients with PTSD and comorbid conditions** Because PTSD is highly comorbid with other psychiatric disorders, it is important to examine the efficacy of therapy in clients with comorbid mental health problems. In this regard, EMDR therapy has been shown to produce significant reductions in symptoms of anxiety and depression (Yunitri et al., 2020, 2023), low self-esteem, general psychological symptoms (Griffioen et al., 2017), and characteristic symptoms of borderline personality disorder (Wilhelmus et al., 2023). One of the most important studies in this area is an RCT investigating the efficacy of EMDR for PTSD in 155 participants diagnosed with schizophrenia or other psychotic disorders (van den Berg et al., 2015). After eight sessions of EMDR, 60% of participants no longer met the diagnostic criteria for PTSD; these positive effects were maintained at 12-month follow-up (van den Berg et al., 2018). Interestingly, psychosis did not interfere with treatment, and the frequency of delusions also decreased significantly after treatment, with the severity of these symptoms halved on average at posttreatment (de Bont et al., 2016). Based on these findings, the authors concluded that individuals with psychosis should not be excluded from EMDR. **The status of EMDR in relation to complex PTSD** In 2012, an ISTSS working group published guidelines for treating individuals with early childhood interpersonal trauma and symptoms of complex PTSD (C-PTSD), based on a phase-based treatment model (Cloitre et al., 2012; Herman, 1992). The preference for this model stems from the assumption that people who have experienced numerous and ongoing interpersonal traumatic events, particularly during developmental periods, lack the psychological stability to confront their traumatic memories in therapy and therefore require a stabilization phase in preparation for trauma processing (for a discussion, see de Jongh et al., 2016). Two studies tested the need for such a phased treatment approach by investigating the efficacy of trauma-focused treatment in clients who met the diagnostic criteria for C-PTSD according to the International Statistical Classification of Diseases and Related Health Problems (11th rev.; ICD-11; WHO, 2019; van Vliet et al., 2021; Voorendonk et al., 2020). One study examined whether participants meeting the diagnostic criteria for C-PTSD would benefit from a brief, intensive trauma-focused treatment for severe C-PTSD without a preliminary stabilization phase involving skills training (Voorendonk et al., 2020, 2023). Participants were offered a trauma-focused residential treatment combining exposure, EMDR, psychoeducation, and physical activity, compressed into 8 days. Of the 308 participants diagnosed with PTSD, 66% met the ICD-11 diagnostic criteria for C-PTSD. Remarkably, after 8 days of treatment, 88% of individuals classified as having C-PTSD no longer met the diagnostic criteria. Although these results provided initial support for the notion that trauma-focused therapy is a safe treatment alternative for individuals diagnosed with C-PTSD, it is important to note the study's limitations: the treatment program used an intensive format with several therapeutic components, treatments took place in a residential setting, the study lacked a control condition, and the authors did not examine the long-term effects of treatment. To address these limitations, a follow-up RCT was conducted to examine the efficacy of EMDR with and without a stabilization intervention in 121 adult participants diagnosed with PTSD resulting from early childhood trauma who presented with C-PTSD symptoms. Treatment took place in an outpatient setting, with follow-ups at 3 and 6 months (van Vliet et al., 2021). The authors compared the efficacy of 16 sessions of stand-alone EMDR with the same treatment preceded by eight sessions of a stabilization intervention (i.e., Skills Training in Affective and Interpersonal Regulation; Cloitre et al., 2002). No differences in effects between the two interventions were observed when assessed immediately after treatment or at follow-up. Regardless of treatment condition, the severity and frequency of PTSD symptoms decreased significantly, and no differences were found in dropout rates or other adverse effects. At posttreatment, approximately 70% of participants no longer met the diagnostic criteria for PTSD, and of the 29% of participants who had been diagnosed with PTSD, only 3% still met the diagnostic criteria for the disorder. These results support the notion that PTSD can be treated effectively with EMDR without a pretreatment phase in which clients are taught emotion regulation or other coping skills (de Jongh et al., 2016; de Jongh, Bicanic et al., 2019). **CROSS-CULTURAL APPLICATIONS OF EMDR THERAPY** Individuals from ethnic minority groups and marginalized communities tend to be underrepresented in the EMDR literature. Published studies generally report only basic demographic characteristics and do not control for diversity characteristics. Reviews indicate that, at least in studies conducted in the United States, most EMDR research participants are White, middle-class, heterosexual, educated, verbal adults (Madnick & Spokas., 2022). When studies have focused on EMDR treatment in non-White participants, therapy has generally been delivered in a Westernized setting or the cohort sample size has been small (Wippich et al., 2023). Furthermore, most studies include participants with posttraumatic stress symptoms identified through self-report instruments rather than clinician-rated measures, and participants often do not meet the full diagnostic criteria for PTSD. Despite this, EMDR is now widely used to treat posttraumatic stress symptoms in many Asian countries, including China, Japan, Thailand, and Cambodia. The EMDR Humanitarian Assistance Program has established projects in more than 30 countries worldwide, including Afghanistan, Ukraine, Syria, Uganda, Palestine, and Latin American countries, aimed at treating survivors of disasters and war and training local mental health professionals to provide EMDR (Gelbach, 2014). There is also a growing body of clinical practice guidance on culturally adapting EMDR to address the effects of minority stress, including chronic adversity, discrimination, and racial trauma (see Nickerson, 2022). In Western contexts, controlled studies have demonstrated that EMDR can be effective in treating trauma-related conditions across different cultural and ethnic groups. For example, PTSD and depressive symptoms in Syrian and Iraqi refugees receiving treatment in Germany improved significantly after two group EMDR therapy sessions facilitated by Arabic-speaking interpreters (Lehnung et al., 2017). An RCT involving 72 refugee clients diagnosed with PTSD at a specialized treatment center in the Netherlands found that a course of six EMDR sessions was safe and effective in reducing PTSD symptoms among participants. Although most treatment completers achieved clinically significant improvements in clinician-rated PTSD symptoms, only four of the 32 participants in the EMDR group no longer met the diagnostic criteria for PTSD. Notably, the effect size was no better than that of a stabilization intervention and was smaller than the effect sizes of other trauma-focused treatments in comparable clients. The authors suggest that this was because a six-session course was insufficient to process the multiple traumatic memories underlying PTSD symptoms in this population (ter Heide et al., 2016). Promising results have also emerged from studies conducted in non-Western settings, including regions with high rates of trauma, such as conflict and disaster areas. In the largest study to date, 268 adults of low socioeconomic status living in Lebanon, including a small cohort of refugees, were treated with individual EMDR for symptoms resulting from a wide range of traumatic events. EMDR was found to be highly effective in reducing posttraumatic stress, depressive, and anxiety symptoms, and outcomes were maintained at 6-month follow-up, although there was a 22% dropout rate (Wippich et al., 2023). The authors suggest that this may have resulted from the fluidity and social instability of participants' circumstances. EMDR has also shown promise in refugee populations living in contexts of displacement and ongoing threat. For example, 48 Eritrean adolescent refugees with clinically significant PTSD symptoms were treated in an Ethiopian refugee camp using six sessions of group-format EMDR delivered in Tigrinya over 2 days, supported by local refugee workers (Smyth-Dent et al., 2019). Treatment focused on the most distressing memories of the refugee experience, particularly trauma experienced during participants' escape journeys and the loss of contact with family and friends. Depression, anxiety, and PTSD symptoms all improved significantly, and the time-intensive group format showed promise both for scaling up and for working in circumstances where individuals live in unstable conditions and/or are at risk of sudden relocation or further traumatization. Similarly, an RCT conducted in a Syrian refugee camp involving a sample of 47 adult refugees diagnosed with chronic PTSD found PTSD recovery rates of over 60% following two group EMDR sessions delivered over 3 days (Yurtsever et al., 2018). **DISCUSSION** The relatively large number of RCTs and meta-analyses on the efficacy of EMDR, demonstrating large effect sizes in the treatment of PTSD symptoms in both the short and long term, provides robust support for considering EMDR a first-line treatment for PTSD. Beyond PTSD, EMDR has also demonstrated significant effects on symptom clusters including symptoms of C-PTSD, anxiety, depression, and psychosis. Although EMDR appears to be as effective as other first-line treatments in the field, this therapeutic approach may have potential advantages over other treatments, such as prolonged exposure therapy (Foa et al., 2007). Perhaps its most important advantage is that clients are not required to explicitly disclose the full details of a traumatic event but are instead instructed simply to hold the traumatic memory in working memory (i.e., "Just think about it"). Where cultural barriers to trauma disclosure exist (e.g., perceived stigma, the need for self-protection), existing EMDR adaptations, such as conducting the procedure "blind to therapist" (Farrell et al., 2020), mean that clients do not need to verbalize potentially shame-laden details of traumatic memories in order to process them with EMDR therapists using dual-attention tasks. Conversely, there are specific categories of traumatic events for which scientific evidence on EMDR is limited. A working group recently identified a range of promising research areas and targets for the future, concluding that six areas require further research: PTSD in children and adolescents, early EMDR interventions, combat-related PTSD, unipolar depression, chronic pain, and cost-effectiveness studies (Matthijssen et al., 2020). In addition, improvements could be made to the standard EMDR protocol, which has undergone minimal changes since its initial version in 1994; for example, there is room for improvement in Phase 2, the preparation phase in which the client is asked to hold an imaginary safe place in mind. This and other interventions aimed at emotion regulation conflict with studies clearly showing that significantly better treatment effects can be expected when a traumatic memory is well activated and the client's overall level of arousal is increased (Littel et al., 2017; van den Hout et al., 2014). As with the pretreatment stabilization phase (see the earlier section on C-PTSD), these findings provide arguments for removing emotion regulation-focused elements from the standard protocol. Further research efforts are also needed to increase the effectiveness and efficiency of EMDR and the implementation of its protocol (e.g., the importance of maximizing working memory taxation; Matthijssen et al., 2021). Challenges may arise when applying EMDR in different cultural contexts, including language barriers, stigma associated with mental health, and differences in symptom expression. For example, Seponski (2011) investigated the use of EMDR among Cambodian clients and therapists and concluded that, although research findings were generally positive about the treatment's efficacy, there was broad agreement that standard EMDR was not an "easy fit" for this population. Because no study to date has compared the efficacy of standard and adapted EMDR protocols for a specific population, there is currently no empirical basis to guide when and how EMDR should be culturally adapted. More rigorously designed outcome studies focusing on individuals diagnosed with PTSD and using clinician-rated measures across diverse populations would be helpful. In conclusion, EMDR is recognized as an evidence-based intervention for PTSD, given the substantial evidence supporting its efficacy and effectiveness. Although rigorous studies evaluating the beneficial effects of EMDR in specific areas are still needed, the current evidence clearly supports its use as a first-line treatment for PTSD. **AUTHOR NOTE** Ad de Jongh and Carlijn de Roos receive income from published books on eye movement desensitization and reprocessing therapy and from training postdoctoral professionals in this method. 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