Ruwan M Jayatunge M.D.
Abstract: This paper discusses the use of EMDR (Eye Movement Desensitization and Reprocessing) in addictions providing two case studies. Addictions have become a major public health problem impacting millions of individuals and their families. Although the etiology of addiction is multi-factorial clinical evidence shows that frequently the addictions are associated with concurrent mental health problem such as PTSD, or depression. Treating these concurrent conditions would help to reduce the negative impact of addictions. EMDR has been proven effective in the treatment of PTSD and Depression. Therefore EMDR can be used as one of the effective supportive therapies in addictions. Recent researches too support the effectiveness of using EMDR in the treatment of addictions. Further research is warranted to understand the total therapeutic impact of EMDR in treating addictions.
Key Words: EMDR, Addictions, PTSD, Depression, Addiction Memory
EMDR (Eye Movement Desensitization and Reprocessing) is a clinically-proven evidence-based psychotherapeutic method that was developed in 1987 by Francine Shapiro. According to Shapiro (2002) EMDR is an integrative psychotherapy approach. EMDR offers a structured, client-centered model that integrates key elements of intrapsychic, behavioral, cognitive, body-oriented, and interactional approaches (Shapiro, Vogelmann-Sine, & Sine, 1994). Shapiro and colleagues (2007) further elucidate that EMDR contains with a theoretical model that emphasizes the brain’s information processing system and memories of disturbing experiences as the basis of pathology. The eight-phase treatment comprehensively addresses the experiences that contribute to clinical conditions and those that are needed to bring the client to a robust state of psychological health.
EMDR has been initially used to treat posttraumatic stress disorder (PTSD). A large body of research has found that EMDR is one of the efficacious psychotherapeutic methods to treat PTSD. The American Psychiatric Association has recognized EMDR as one of the effective and potential methods to treat PTSD (APA, 2004). Silver & Rogers (2005) and Bisson & Andrew (2007) reported positive outcome using EMDR to treat PTSD. The recent research has also revealed that EMDR is effective in treating people with Addiction Disorders.
Addiction Disorders and EMDR
Addiction is defined by the World Health Organization as repeated use of a psychoactive substance or substances, to the extent that the user is: periodically or chronically intoxicated, shows a compulsion to take the preferred substance(s), has great difficulty in voluntarily ceasing or modifying substance use, exhibits determination to obtain psychoactive substances by almost any means, and tolerance is prominent and a withdrawal syndrome frequently occurs when substance use is interrupted (WHO).
The disease model of addiction describes an addiction as a disease with biological, neurological, genetic, and environmental sources of origin (McLellan et al., 2000). Addiction has serious social economic, and health consequences. Addictive behaviors are major causes of chronic disease, premature death, and high health care costs (Prochaska, 2004). Substance use and dependence cause a significant burden to individuals and societies throughout the world. The World Health Report 2002 indicated that 8.9% of the total burden of disease comes from the use of psychoactive substances. The report showed that tobacco accounted for 4.1%, alcohol 4%, and illicit drugs 0.8% of the burden of disease in 2000 (WHO, 2004).
An important characteristic of addiction is its stubborn persistence (McLellan et al., 2000). It has recurrent cycles of relapse and remission. Although addiction usually (but not always) begins with a conscious decision to use a drug, changes that occur in the brain at some point can turn drug use and then abuse into a chronic, relapsing illness Wasilow-Mueller et al., 2001). According to Hyman (2005) the goals of the addicted person become narrowed to obtaining, using, and recovering from drugs, despite failure in life roles, medical illness, risk of incarceration, and other problems. There is a large and growing body of evidence about the neurobiologic basis for addiction behaviours, the role of genetic, environmental and epidemiologic factors. This evidence demonstrates that substance use is not a simple matter of choice (Stanbrook , 2012).
Although addiction behaviors are multifaceted EMDR can be used to treat addictions. EMDR has been successful with addiction disorders. Hase and colleagues (2008) provide evidence to support the successful application of EMDR in addictions. Marich (2009) illustrates EMDR in the addiction continuing care process with a case study. In this case study of a cross-addicted female was able to achieve 18 months of sobriety and important changes in functional life domains following EMDR.
Psychological Trauma and Addictions
Addictions and psychological trauma are highly correlated. The comorbidity between addiction and psychological trauma has been discussed by numerous researchers. According to Jacobsen, Southwick, and Kosten (2001) 22%–43% of people living with PTSD have a lifetime prevalence rate of substance use disorders. Based on an Australian national survey Mills and colleagues (2006) were of the view that alcohol was the most common substance of misuse by the survivors with PTSD who had a comorbid substance use disorder. PTSD was most prevalent among those using opioids (Ahmed, 2007).
Individuals living with severe psychological trauma often use alcohol and other substances as a negative stress coping method and to displace traumatic memories. This could lead to a vicious cycle. Avoidance of trauma reminders and associated distress may be achieved by the use of drugs and alcohol, alternatively a substance abusing lifestyle might predispose such individuals to experience traumatic events (Reynolds et al., 2005).
In addition unresolved trauma plays crucial role in addictions. The impact of unresolved psychological trauma could be callous and overwhelming. The ramifications of unresolved trauma can be endured for decades. According to Shapiro and Laliotis (2010) these disturbing memories are the cause of psychopathology.
It is essential to address deep rooted psychological trauma and unresolved mental conflicts associated with addictions. Addressing unresolved intrapsychic trauma associated with childhood abuse may increase the efficacy of treatment outcomes and reduce relapse rates among individuals with alcohol addiction (Windle et al., 1995). EMDR can be successfully used to treat psychological trauma (including unresolved mental conflicts and grief) improving functionality of the individual.
Depression and Addictions
Depression is a common mental disorder. Depression and substance abuse frequently occur together. A substance-abusing patient who exhibits symptoms of a mood disorder may be suffering from acute intoxication or withdrawal, substance-induced mood disorder, preexisting affective disorder, or a combination of these conditions (Quello et al., 2005). Depression comorbid with alcohol or substance abuse requires stabilization of the mood and decrease in drug use or cravings. Treating patients’ co-occurring mood disorders may reduce their substance craving and taking and enhance their overall outcomes (Quello et al., 2005).
EMDR has also been proven effective in treating depression. Bae & Park (2008) report that potential application of eye movement desensitization and reprocessing (EMDR) for treatment of depressive disorder. Jayatunge (2008) indicates that the Sri Lankan combatants who were diagnosed with depressive disorder with alcohol abuse achieved successful treatment outcome following EMDR.
EMDR as a Potential Method to Treat Addiction Disorders
Individuals with substance use disorders are heterogeneous with regard to a number of clinically important features and domains of functioning. Consequently, a multimodal approach to treatment is typically required (APA, 2006). Medication and psychological therapies are widely used in treating Addiction Disorders.
Among the psychological interventions EMDR remain as one of the effective therapies. A relatively small but growing body of literature indicates that EMDR may be an effective adjunctive treatment for substance abuse (Abel & O’Brien, 2010). Zweben and Yeary (2006) reported on the potential uses of EMDR in addictions treatment. When combined with traditional addictions treatment approaches, EMDR can enhance client stability, prevent relapse, and promote recovery (O’Brien, & Abel, 2011).
Clinical reports highlight that EMDR is an important addition to the treatment of substance abuse. The application of EMDR apparently stimulates an inherent physiological processing system that allows dysfunctional information to be adaptively resolved, resulting in increased insight and more functional behavior. In addition EMDR is used to incorporate new coping skills and assist in learning more adaptive behaviors. (Shapiro et al., 1994).
Hase and colleagues (2008) reported a randomized controlled study which investigated the effects of eye movement desensitization and reprocessing (EMDR) in the treatment of alcohol dependency. As they report: thirty-four patients with chronic alcohol dependency were randomly assigned to one of two treatment conditions: treatment as usual (TAU) or TAU plus two sessions of EMDR (TAU+EMDR). The craving for alcohol was measured by the Obsessive–Compulsive Drinking Scale (OCDS) pre-, post-, and 1 month after treatment. The TAU+EMDR group showed a significant reduction in craving posttreatment and 1 month after treatment, whereas TAU did not. Their results indicated that EMDR might be a useful approach for the treatment of addiction memory and associated symptoms of craving.
Breaking the Addiction Cycle via EMDR
The etiology of addiction is multi-factorial and complex. Addiction or dependency may be viewed as a subset of brain and behavior disorders (Wasilow-Mueller & Erickson, 2001).Negative childhood experiences, onset of psychological trauma, depression inducing life events play a role in the development of addictions. In such events EMDR can be used as a robust psychotherapeutic intervention.
The mechanism of EMDR has become a central topic. According to Solomon and Shapiro (2008) the Adaptive Information Processing model proposes that the mechanism of action in EMDR is the assimilation of adaptive information found in other memory networks linking into the network holding the previously isolated disturbing event”. Based on this assumption Schubert and Lee (2009) suggest that EMDR transmutes the dysfunctionally stored memory by integrating it with preexisting memory networks.
Describing the neurobiological mechanism of action of EMDR Stickgold (2002) hypotheses that repetitive redirecting of attention in EMDR induces a neurobiological state, similar to that of REM sleep, which is optimally configured to support the cortical integration of traumatic memories into general semantic networks. They further suggest that this integration can then lead to a reduction in the strength of hippocampally mediated episodic memories of the traumatic event as well as the memories’ associated, amygdala-dependent, negative affect.
Addiction memory plays a decisive role in addictions. The human brain is an open learning system, which reveals its own neuronal connectivity through the experience of the perceived environment with its own state; the personal addiction memory is interpreted as an individual acquired software disturbance in relation to selectively integrating “feedback loops” and “comparator systems” of neuronal information processing (Boening, 2001). Addiction memory has an effect on relapse occurrence and maintenance of learned addictive behavior.
It is essential to work on addiction memory in order to break the addiction cycle. Hase and colleagues (2008) discuss the successful application of EMDR to reprocess the addiction memory in chronically dependent patients.
The standard EMDR protocol for treating addictions involves reprocessing the earlier (traumatic) memories that set the basis for the dysfunction (including contributing elements to the development of addiction), the present triggers that activate disturbance, and the development of future templates for more adaptive behavior, which is essentially a form of relapse prevention for this population. Strategies for addressing specific targets related to the addiction are a valuable addition (Shapiro et al., 1994: Hase et al., 2008).
Behavior modification (reprocessing) is an important aspect of EMDR (Rafferty, 2005). EMDR works on conscious and unconscious craving reducing occurrence of relapses.
1) Captain KHZ86 was an officer of the Sri Lanka Army who participated in a number of military operations. In 1992 he went on a rescue mission and accidently walked into an ambush. In this unexpected situation he lost 23 of his men in front of his eyes. Many were killed by the enemy gunfire and mortar attacks. After this incident Captain KHZ86 felt that he was personally responsible for the deaths of his men. He was troubled by survival guilt and ruminations. In order to avoid guilt, intrusions and night disturbances he started indulging in alcohol. He became numbed and withdrawn. He silently suffered abusing alcohol in large quantities. Following his drinking behavior he was diagnosed with harmful use of alcohol and referred for psychological therapy.
Captain KHZ86 underwent the full therapeutic protocol of EMDR with 8 sessions. His image was dead soldiers lying on the battle field with a negative cognition: I am responsible for their deaths. His SUD (subjective units of distress) was recorded the peak of 10. With the reprocessing therapy his disturbed feelings and intrusive memories disappeared. At the end of 8 sessions his SUD reduced up to zero with a newly established positive cognition: Their deaths were caused by the enemy and I did my utmost to save them even risking my life.
He was able to come to terms with his past trauma. The survival guilt that drastically affected him for a long time diminished gradually. He was able to sleep without experiencing depressogenic combat related mental images. He detached from the negative coping method and started to spend time without abusing alcohol. Hence Captain KHZ86 was able to fight back his addition. After sometime Captain KHZ86 got an honorable discharge from the military and now married and working in a multinational company. He has been sober for more than two years.
) Mr. BXXF14L- a Sri Lankan Tamil expatriate experienced stressful life events before migrating to North America. He had to flee his hometown when the militants tried to forcibly recruit him. He came to Colombo and worked in a company for a short period. He lived in Colombo without proper documents and in a random search he was caught by the Police. Mr. BXXF14L was detained and questioned for a period of one week. Following these distressing events and foreshortened future he decided to migrate. He came to Canada and claimed refugee status.
While living in Canada Mr. BXXF14L gradually became depressed. He sadly missed his hometown, friends and family. Practically every day after work he started drinking alcohol and tried to forget grief-stricken memories. He frequently smoked cannabis. He became more and more depressed and reluctant to seek psychiatric help due to social stigma. Sometimes he engaged in self harm such as head banging and punching walls out of anger.
Mr. BXXF14L was referred for EMDR by a close relative. Although Mr. BXXF14L was ambivalent in the first few sessions later became an active participant. He willfully followed the EMDR treatment protocol. After six sessions of EMDR, Mr. BXXF14L became less agitated and reduced alcohol abuse considerably. His depressive feelings became less prominent. His sleep improved and he stopped smoking cannabis. Eventually he cut down his drinking volume for more than 80 %. Now for the last seven months he drinks only in social occasions and alcohol consumption does not exceed more than 2 cans of beer.
Addictions have negative consequences in private and social life. It has become one of the public health concerns. Psychological trauma and stressful life events often trigger addiction behaviors. A large number of individuals with addiction disorders are affected by PTSD, Depression and sometimes unresolved psychological conflicts. Often these core conditions hinder the individual’s functionality and sustain addictive behaviors. These individuals would be benefitted by EMDR. Numerous researches indicate positive clinical outcome in addictions following EMDR. EMDR is safe, cost effective and seems to have no side effects. Therefore EMDR is one of the efficacious psychotherapeutic interventions to treat addictions.
Abel, N. J., & O’Brien, J. M. (2010). EMDR treatment of comorbid PTSD and alcohol dependence: A case example. Journal of EMDR Practice and Research, 4(2), 50-59. doi:10.1891/1933-3220.127.116.11.
Ahmed, A. S. (2007). Post-traumatic stress disorder, resilience and vulnerability. Advances in Psychiatric Treatment, 13, 369-375. doi: 10.1192/apt.bp.106.003236.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC.
American Psychiatric Association (2006). Practice Guideline for the Treatment of Patients with Substance Use Disorders, Second Edition. Retrieved on 5th March 2014 from http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243188&PDFSource=6
Bae, H., Kim, D. & Park, Y.C. (2008). Eye movement desensitization and reprocessing for adolescent depression. Psychiatry Investigation, 5(1), 60-65.
Bisson, J., Andrew, M. (2007).Psychological treatment of post-traumatic stress disorder (PTSD).Cochrane Database Syst Rev. 18;(3):CD003388.
Boening,J.A. (2001).Neurobiology of an addiction memoryJ Neural Transm. 108(6):755-65.
Hase, M., Schallmayer, S., & Sack, M. (2008). EMDR reprocessing of the addiction memory: Pretreatment, posttreatment and 1-month follow-up. Journal of EMDR Practice and Research, 2(3), 170–179.
Hyman, S. E. (2005). Addiction: A disease of learning and memory. American Journal of Psychiatry, 162, 1414—22.
Jacobsen, L., Southwick, S., & Kosten, T. (2001). Substance use disorders in patients with post-traumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158, 1184–1190.
Jayatunge, R. M (2008) . EMDR Sri Lanka experience: (Psychological trauma management through EMDR in Sri Lanka , Sarasavi Publishers Colombo.
Marich, J. (2009). EMDR in the addiction continuing care process: Case study of a cross-addicted female’s treatment and recovery. Journal of EMDR Practice and Research, 3(2), 98–106.
McLellan, A.T., Lewis, D.C., O’Brien, C.P., Kleber, H.D.(2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA .284:1689– 1695
Mills, K. L., Teesson, M., Ross, J., et al (2006) Trauma, PTSD, and substance use disorders: findings from the Australian National Survey of Mental Health and Well-Being. American Journal of Psychiatry, 163, 652–658.
O’Brien, J.M. & Abel, N.J. (2011) EMDR, Addictions, and the Stages of Change: A Road Map for Intervention. Journal of EMDR Practice and Research, 5(3), 121- 130.
Prochaska, J.O. (2004). Population Treatment for Addictions. Current Directions in Psychological Science, 13, pp. 242-246.
Quello, S. B., Brady, K. T., & Sonne, S. C. (2005). Mood disorders and substance use disorder: A complex comorbidity. Science & Practice Perspectives, 3, 13–21.
Rafferty, P. (2005). Eye movement desensitization and reprocessing: An analysis of a controversial evidence based treatment. The New School for Social Research, New York, NY. The New School Psychology Bulletin, 3(2), 83-105.
Reynolds, M., Mezey, G., Chapman, M., Wheele,r M., Drummond, C., Baldacchino, A. (2005)Co-morbid post-traumatic stress disorder in a substance misusing clinical population. Drug Alcohol Depend. 7;77(3):251-8.
Ricci, R. J., Clayton, C. A., Foster, S., Jarero, I., Litt, B., Artigar, L., & Kamin, S. (2009). Special applications of EMDR: Treatment of performance anxiety, sex offenders, couples, families, and traumatized groups. Journal of EMDR Practice and Research, 3(4), 279-288. doi:10.1891/1933-318.104.22.1689.
Schubert, S., Lee, C.W. (2009). Adult PTSD and its treatment with EMDR: A review of controversies, evidence, and theoretical knowledge., Journal of EMDR Practice and Research, 3(3), 117-132.
Shapiro, F., Vogelmann-Sine, S., Sine, L.F.(1994).Eye movement desensitization and reprocessing: treating trauma and substance abuse. J Psychoactive Drugs. 26(4):379-91.
Shapiro, F. (2002).EMDR and the role of the clinician in psychotherapy evaluation: towards a more comprehensive integration of science and practice. J Clin Psychol. 58(12):1453-63.
Shapiro, F., Kaslow, F., & Maxfield, L. (Eds.) (2007). Handbook of EMDR and Family Therapy Processes. Hoboken, NJ: Wiley.
Shapiro, F., Laliotis, D. (2010). “EMDR and the adaptive information processing model: Integrative treatment and case conceptualization”. Clinical Social Work Journal 39 (2): 191–200.
Silver, S.M., Rogers, S., Knipe, J., & Colelli. (2005). EMDR Therapy Following the 9/11 Terrorist Attacks: A Community EMDR Therapy Following the 9/11 Terrorist Attacks: A Community Based Intervention Project in New York City. International Journal of Stress Management, 12, 29-42.
Solomon, R. M., Shapiro, F. (2008). EMDR and the adaptive information processing model. Journal of EMDR Practice and Research, 2, 315–325.
Stanbrook , M.B. (2012).Addiction is a disease: We must change our attitudes toward addicts. CMAJ 184:155.
Wasilow-Mueller, S., & Erickson, C. K. (2001). Drug abuse and dependency: Understanding gender differ-ences in etiology and management. Journal of the American Pharmacology Association, 41 , 78–90.
Windle, M., Windle, R.C., Scheidt, D.M., Miller, G.B.(1995).Physical and sexual abuse and associated mental disorders among alcoholic inpatients.Am J Psychiatry. 152(9):1322-8.
WHO .(2004). Neuroscience of psychoactive substance use and dependence
World Health Organization website. Programmes and Projects, Management of Substance Abuse. Lexicon of alcohol and drug terms published by the World Health Organization.
Zweben, J., & Yeary, J. (2006). EMDR in the treatment of addiction. Journal of Chemical Dependency Treatment, 8(2), 115–127.