COVID-19 SONRASI RUH SAĞLIĞI İHTİYACININ KARŞILANMASI: YENİ BİR SEÇENEK OLARAK UZAKTAN EMDR TERAPİ ÇALIŞMALARININ SİSTEMATİK İNCELEMESİ (ADDRESSING MENTAL HEALTH NEED AFTER COVID-19: A SYSTEMATIC REVIEW OF REMOTE EMDR THERAPY STUDIES AS AN EMERGING OPTION)

COVID-19 SONRASI RUH SAĞLIĞI İHTİYACININ KARŞILANMASI: YENİ BİR SEÇENEK OLARAK UZAKTAN EMDR TERAPİ ÇALIŞMALARININ SİSTEMATİK İNCELEMESİ (ADDRESSING MENTAL HEALTH NEED AFTER COVID-19: A SYSTEMATIC REVIEW OF REMOTE EMDR THERAPY STUDIES AS AN EMERGING OPTION)

Safa Kemal Kaptan [1,2], Zehra Merve Kaya [3,4], Ayşe Akan [1,5]

1-Assistant Professor, Department of Psychology, Boğaziçi University, Istanbul, Türkiye, 2-Honorary Fellow of the Institute of Teaching and Learning at the University of Manchester, Manchester, United Kingdom, 3-Visiting Scholar, Department of Psychology, Boğaziçi University, Istanbul, Türkiye, 4-Licensed Clinical Psychologist, Chicago, State of Illinois, IL, United States, 5-Registered Clinical Psychologist, Health and Care Professions Council (HCPC), London, United Kingdom

Translated by: Specialist Psychologist Gizem Pozam

Introduction

The COVID-19 pandemic has intensified mental health problems such as post-traumatic stress, anxiety, and depression, particularly among vulnerable groups. Remote mental health services, including Eye Movement Desensitization and Reprocessing (EMDR) therapy, have gained attention, but their effectiveness requires further research. Therapists are increasingly comfortable with online EMDR therapy, but the literature on its effectiveness is limited and requires additional investigation.

Method

A systematic review examined the effectiveness of online EMDR therapy, adhering to PRISMA guidelines and including English-language studies with or without control groups. Databases such as PsychINFO, EMBASE, MEDLINE, and Web of Science were searched from 1989 to September 2023. In addition, the Francine Shapiro Library and EMDR Uygulama ve Araştırma Dergisi (Journal of EMDR Practice and Research) were hand-searched. To ensure comprehensive coverage, ongoing studies were searched for in the UK Clinical Trials Gateway and ISRCTN Registry. Search terms included 'EMDR' and variations of 'remote', 'online', or 'web-based'. Two reviewers conducted a phased selection process, and data extraction focused on sample details, study design, and EMDR protocol characteristics. Risk of bias was assessed using the RoB-2 and ROBINS-1 tools, and a narrative synthesis approach summarized the findings, highlighting trends and variations.

Study characteristics

Participants

Total number of participants across 16 studies: 1,231 individuals. Sample sizes varied, including adolescents and adults. Nine studies focused specifically on healthcare workers. Different studies used live individual or group sessions, as well as self-administered computerized sessions.

Interventions

Treatment durations ranged from one to nine sessions, each lasting 60 to 134 minutes. Seven different protocols were tested, including R-TEP, G-TEP, IGTP, the Standard EMDR Protocol, STEP, Blind 2 Therapist, and URG-EMDR. Seven articles tested the Recent Traumatic Episode Protocol (R-TEP), while three tested the standard EMDR protocol.

Comparator/Design

The studies included randomized controlled trials and single-arm pre-post designs. Most used a single-arm design with pre- and post-treatment assessments. Follow-up periods ranged from 1 to 9 months.

Outcomes

Primary focus: changes in PTSD scores. Secondary outcomes: depression, anxiety, and Subjective Units of Disturbance (SUD). Assessment tools included the PTSD Checklist, Impact of Event Scale, Depression Anxiety Stress Scales, and Hospital Anxiety and Depression Scale. Additional measures: burnout, self-efficacy, post-traumatic growth, and mental illness-related shame.

Individual sessions

Several studies examined individual sessions of EMDR therapy and demonstrated its potential effectiveness. In particular, the Standard EMDR Protocol was evaluated in England and Ireland, showing reductions in mental health difficulties without a significant correlation with therapist training or accreditation level. Similar findings were observed in a study conducted in Germany, highlighting the effectiveness of online EMDR and noting that eye movements led to greater reductions than tapping. In addition, single-session protocols such as VB2Tr and URG-EMDR showed significant reductions in symptoms among participants. Further research into the R-TEP protocol and its variations showed significant reductions in PTSD symptoms across diverse populations, including healthcare workers and trauma-exposed individuals, through both online and face-to-face delivery methods. Collectively, these findings suggest the potential of EMDR therapy to address various mental health problems.

Group sessions

Several studies investigated the feasibility and effectiveness of online group EMDR interventions. In one RCT, frontline mental health and emergency workers received four online EMDR G-TEP sessions, demonstrating significant treatment effects for PTSD and moral injury. Two studies conducted in Italy evaluated IGTP as an online treatment option for healthcare workers during the COVID-19 pandemic, revealing significant improvements in PTSD symptoms and the quality of emotional experience. In addition, a study involving adolescents and young adults delivered R-TEP through three group sessions, showing significant reductions in post-traumatic symptoms and significant positive changes in post-traumatic growth scores. These findings suggest the potential of online group EMDR interventions to reduce PTSD symptoms and promote emotional well-being across different populations.

Self-administered computerized sessions

Two studies investigated self-administered EMDR sessions to ensure accessibility. The first study used a standard EMDR protocol with an artificial intelligence chatbot that adjusted bilateral stimulation according to responsiveness, showing potential for reducing PTSD and anxiety symptoms. The second study, conducted during the COVID-19 pandemic, implemented the Self-Care Traumatic Episode Protocol (STEP), derived from the EMDR group treatment G-TEP. This therapy, which involved a single 90-minute computerized session guided by a registered therapist, resulted in significant decreases in depression, anxiety, and stress levels, as well as increased self-efficacy among participants.

Advantages of Online EMDR Therapy:

• Offers an alternative for reducing trauma symptoms, particularly useful in settings where professionals are in short supply.


• Is cost-effective, requiring fewer sessions than CBT.


• Completion in a single session offers time efficiency and cost-effectiveness, particularly for immediate interventions following work-related incidents.


• Offers flexibility, adaptability, and cost savings by eliminating travel expenses, enhancing linguistic and cultural versatility, and bypassing the stigma associated with seeking mental health support.


• Integration into comprehensive treatment packages improves accessibility and leads to significant reductions in PTSD severity, as demonstrated in studies combining EMDR with other techniques.

Challenges of online EMDR therapy:

• Reliance on access to technology and software may exclude people with limited resources.


• Privacy and confidentiality concerns in the online context, along with the need for smart devices, limit applicability for vulnerable groups.


• Suitability for addressing severe mental health problems may be limited.


• The partial absence of nonverbal cues may restrict the therapeutic experience.


• Managing emotional distress and dysregulation remotely raises safety concerns.


• Debate over the impact of therapist experience and session duration on outcomes.


• Technological difficulties and distractions during online sessions may compromise effectiveness.

Recommendations for future research:

• Evaluate cost-effectiveness compared with other interventions.


• Identify factors influencing outcomes, such as the number of sessions, therapist characteristics, and traumatic experiences.


• Incorporate qualitative techniques to understand the reasons for dropouts and withdrawals.


• Address the lack of studies targeting children and adolescents in the context of online EMDR and highlight the need for more focused research.

Limitations:

• The lack of control groups, small sample sizes, and reliance on self-report measures were noted as limitations of the included studies.


• Despite the effectiveness of face-to-face EMDR for various populations and conditions, the effectiveness of remote EMDR remains uncertain due to limited research.


• Although retrospective registration of the study protocol on INPLASY is acknowledged as a potential limitation, efforts were made to ensure transparency and quality through the involvement of multiple reviewers in article selection.

Conclusion:

In summary, while acknowledging their limitations, the studies reviewed suggest that online EMDR holds promise for alleviating PTSD symptoms and addressing other mental health problems. However, methodological challenges call for more robust studies with larger samples, validated measures, and follow-up assessments. Future comparative studies could investigate the impact of different delivery methods on treatment outcomes and provide insight into the role of group interaction in treatment effectiveness beyond treatment content alone.

 

 

 

 

ADDRESSING MENTAL HEALTH NEED AFTER COVID-19: A SYSTEMATIC REVIEW OF REMOTE EMDR THERAPY STUDIES AS AN EMERGING OPTION

 

Safa Kemal Kaptan [1,2], Zehra Merve Kaya [3,4], Ayşe Akan [1,5]

 

1-Assistant Professor, Department of Psychology, Bogazici University, İstanbul, Türkiye, 2-Honorary Fellow of the lnstitute of Teaching and Learning at the University of Manchester, Manchester, United Kingdom, 3-Visiting Scholar, Department of Psychology, Bogaziçi University, istanbul, Türkiye, 4-Licensed Clinical Psychologist, Chícago, State of Illinois, IL, United States, 5-Registered Clinical Psychologist, Health and Care Professions Council (HCPC), London, United Kingdom

 

 

 

Introduction

The COVID-19 pandemic has intensified mental health issues, notably post-traumatic stress, anxiety, and depression, particularly among vulnerable groups. Kemote mental health services, including Eye Movement Desensitization and Reprocessing (EMDR) therapy, have gained traction, but their effectiveness warrants further research. Therapists are increasingly comfortable with online EMDR therapy, yet the literature on its efficacy remains limited, necessitating additional investigation.

 

Method

A systematic review examined the efficacy of online EMDR therapy, adhering to PRISMA guidelines and including English studies with or without control groups. Databases including PsychINFO, EMBASE, MEDLINE and Web of Science were searched from 1989 to September 2023. Additionally, the Francine Shapiro Library and the Journal of EMDR Practice and Research were hand-searched. To ensure inclusivity, ongoing studies were searched from the UK Clinical Trials Gateway and The ISRCTN Registry. Search terms encompassed ‘EMDR’ and variations of ‘remote’, ‘online’, or ‘web-based’. Two reviewers conducted a phased selection process, with data extraction focusing on sample details, study design, and EMDR protocol specifics. The risk of bias was assessed using RoB-2 and ROBINS-1 tools, and a narrative synthesis approach summarized the findings, emphasizing trends and variations.

 

Study characteristics

Participants

Total participants across 16 studies: 1,231 individuals. Sample sizes varied, including adolescents and adults. Nine studies focused specifically on healthcare workers. Different studies used individual or group live sessions, as well as self-administered computerized sessions.

 

Interventions

Treatment durations ranged from one to nine sessions, lasting 60 to 134 minutes each. Seven different protocols were tested, including R-TEP, G-TEP, IGTP, Standard EMDR protocol, STEP, Blind 2 Therapist, and URG-EMDR. Seven articles tested the Recent Traumatic Episode (R-TEP) protocol, while three tested the standard EMDR protocol.

 

Comparator/Design

Studies included randomized controlled trials and single-arm pre-post designs. The majority used one-arm design with pre-and post-treatment assessments. Follow-up durations ranges form 1 to 9 months.

 

Outcomes

Primary focus: alteration of PTSD scores. Secondary outcomes: depression, anxiety, and Subjective Units of Disturbance (SUD). Assessment tools included PTSD Checklist, Impact of Event Scale, Depression, Stress and Anxiety Scale, and Hospital Anxiety and Depression Scale, among others. Additional measures: burnout, self-efficacy, post-traumatic growth, mental illness-related shame.

 

 

Individual sessions

Several studies examined individual sessions of EMDR therapy, demonstrating its potential efficacy Notably, the Standard EMDR Protocol was assessed in the UK and Ireland, showing reductions in mental health difficulties without significant correlation to therapist training or accreditation level. Similar findings were observed in a German study, emphasizing the effectiveness of online EMDR, with eye movements leading to greater reductions than tapping. Additionally, single-session protocols such as VB2Tr and URG-EMDR showed substantial decreases in symptoms among participants. Further investigations into the R-TEP protocol and its variations indicated significant reduction in PTSD symptoms across diverse populations, including healthcare workers and trauma-exposed individuals, both through online and face-to-face delivery methods. These findings collectively suggest the potential of EMDR therapy in addressing various mental health challenges.

 

Group sessions

Several studies explored the feasibility and effectiveness of online group EMDR interventions. In an RCT, frontline mental health and emergency workers underwent four online sessions of EMDR G-TEP, showing significant treatment effects for PTSD and moral injury. Two studies in Italy assessed IGTP as an online treatment option for healthcare workers during the COVID-19 pandemic, revealing significant improvements in PTSD symptoms and emotional experience quality. Additionally, a study involving adolescents and young adults delivered R-TEP through three group sessions, demonstrating  substantial reductions in post-traumatic symptoms and significant positive changes in past-traumatic growth scores. These findings suggest the potential of online group EMDR interventions in reducing PTSD symptoms and promoting emotional well-being across different populations.

 

Self-administered computerised sessions

Two studies have investigated self-administered EMDR sessions to engance accessibility. In the first study, a standard EMDR protocol was utilized with an artificial intelligence chatbot adjusting bilateral stimulation based on responsiveness, showing potential in reducing PTSD and anxiety symptoms. The second study during the COVID-19 pandemic implemented the Self-Care Traumatic Episode Protocol (STEP), derived from EMDR group treatment G-TEP. It involved a single 90 minute computerized session guided by a recorded therapist, resulting in significant decreases in depression, anxiety, and stress levels, along with increased self-efficacy among participants.

 

Advantages of Online EMDR Therapy:

• Provides and alternative for reducing trauma symptoms, especially beneficial in professional-limited environments.


• Cost-effective, requiring fewer sessions compared to CBT.


• Completion within a single session suggests time efficiency and cost-effectiveness, particularly for immediate interventions post-work-related incidents.


• Offers flexibility, adaptability, and cost reduction by eliminating commute cost., enhancing linguistic and cultural versatility, and bypassing stigmas associated with seeking mental helath help.


• Integration into comprehensive treatment packages enhances accessibility, as demonstrasted in studies combining EMDR with other techniques, resulting significant reductions in PTSD severity.

 

Challanges of online EMDR therapy:

• Reliance on technology and software access, potentially excluding those with limited resources.


• Privacy and confidentially concerns in the online context, requiring smart devices, limiting applicability for vulnerable groups.


• Suitability for addressing severe mental health issues may be limited.


• Partial absence of non-verbal cues may restrict the therapeutic experience.


• Management of emotional distress and dysregulation remotely poses safety concerns.


• Debate over the impact of therapists’ experience and session duration on outcomes.


• Technological challenges and distractions during online sessions may compromise effectiveness.

 

 

Recommendations for future research:

• Evaluate cost-effectiveness compared to other interventions.


• Identify factors influencing outcomes, such as session number, therapist characteristics, and trauma experiences.


• Incorporate qualitative techniques to understand reasons for dropouts and withdrawals.


• Adress the lack of studies targeting children and adolescents in the context of online EMDR, suggesting a need for more focused investigations.

 

Limitations:

• Lack of control groups, small sample sizes, and reliance on self-report measures are noted as limitations in the included studies.


• The effectiveness of remote EMDR remains uncertain due to limited research, despite the effectiveness of face-to-face EMDR for various populations and conditions.


• Retrospective registration of the study’s protocol on INPLASY is acknowledged as a potential limitation, although efforts were made to ensure transparency and quality through multiple reviewers’ involvement in article selection.

 

Conclusion:

In summary, while acknowledging its limitations, the trials reviewed suggest that online EMDR holds promise for alleviating PTSD symptoms and addressing other mental health issues. However, methodological challenges necessitate more robust studies with larger samples, validated measures, and follow-up assessments. Future comparative trials could explore the impact of different delivery methods on treatment outcomes, providing insight into the role of group interaction in treatment effectivesness beyond treatment content alone.