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Assistant Professor of Clinical Psychiatry, Columbia University Irving Medical Center
Double Board-Certified in Adult Psychiatry & Child/Adolescent Psychiatry
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Quick answer. EMDR is an eight-phase psychotherapy for trauma, recommended for PTSD by the World Health Organization (2013) and placed in the highest tier of the 2023 VA/DoD Clinical Practice Guideline. A meta-analysis of 26 randomized trials found a moderate pooled effect on PTSD symptoms (Hedges's g = -0.662). The eye movements add a modest independent effect (d = 0.41 clinical, 0.74 laboratory). Dropout in randomized trials is 18% for EMDR and 22% for prolonged exposure, with overlapping intervals. EMDR assigns no between-session homework and requires less detailed verbal narration than prolonged exposure. It is applied to episodic memories the patient can describe before treatment begins.

What EMDR Is

Eye Movement Desensitization and Reprocessing is an eight-phase psychotherapy for trauma. The patient holds a specific distressing memory in mind while attending to a repeated bilateral stimulus, most often guided eye movements, sometimes alternating taps or tones. Across repeated sets the memory becomes less vivid and less physiologically activating, and the beliefs attached to it become available for revision. Francine Shapiro observed the effect in 1987 and published the first controlled study in 1989.

The World Health Organization recommends trauma-focused cognitive behavioural therapy and EMDR as the only psychotherapies indicated for PTSD across children, adolescents, and adults (WHO, 2013). The 2023 VA/DoD Clinical Practice Guideline places EMDR in its highest recommendation tier alongside prolonged exposure and cognitive processing therapy, having reviewed each therapy individually rather than as a class.

The guidelines diverge, and the divergence is recent. The 2025 American Psychological Association Clinical Practice Guideline lists EMDR as a second-line treatment, behind cognitive processing therapy, prolonged exposure, and trauma-focused CBT. That position makes the APA an outlier against five other national and international guidelines published in the past decade, and it drew a formal critique in the Journal of EMDR Practice and Research arguing that the panel relied on outdated reviews and lower-quality meta-analytic evidence. Anyone comparing EMDR against CBT should know this disagreement exists rather than meeting one guideline in isolation.

This guide covers what the treatment involves, what the trials show, and where the evidence is thin. For EMDR delivered in Manhattan by the prescribing psychiatrist, see EMDR therapy in NYC. For the broader diagnostic picture, see PTSD and complex PTSD treatment.

The Eight Phases

Skipping phases disqualifies the treatment from being called EMDR under EMDRIA standards. Patients are frequently unaware that phases exist, which makes it difficult to tell a complete course from an improvised one.

PhaseWhat happens
1. History and planningTrauma history, symptom picture, and selection of target memories
2. PreparationStabilization, distress tolerance, and resourcing before any processing begins
3. AssessmentThe target image, the negative belief, the desired positive belief, and baseline ratings
4. DesensitizationSets of bilateral stimulation while the target is held in mind
5. InstallationStrengthening the positive belief against the target
6. Body scanChecking for residual physical activation
7. ClosureReturning to baseline, whether or not the target finished processing
8. ReevaluationChecking what held at the start of the next session

Two measures run throughout. Subjective Units of Distress rates the memory from 0 to 10. Validity of Cognition rates how true the positive belief feels from 1 to 7. Patients who know these scales exist can track their own course, which matters given how many report being unable to tell whether anything is changing.

Phase 2 is the one that gets rushed, and rushing it is the most common way trauma treatment goes wrong. With complex or developmental trauma, preparation can legitimately run months. A long preparation phase reflects the pacing the presentation requires.

What the Trials Show

A meta-analysis of 26 randomized controlled trials found a moderate pooled effect on PTSD symptoms, with Hedges's g of −0.662 (95% CI −0.887 to −0.436). Effects on depression were g = −0.643 (95% CI −0.864 to −0.422), on anxiety g = −0.640 (95% CI −0.890 to −0.390), and on subjective distress g = −0.956 (95% CI −1.388 to −0.525) (Chen and colleagues, PLoS One, 2014). Sessions longer than 60 minutes produced significantly larger reductions in anxiety and depression than shorter sessions.

In a three-arm trial comparing EMDR, fluoxetine, and placebo in 88 adults with PTSD, 75% of EMDR completers reached asymptomatic end-state functioning at six-month follow-up, compared with 0% of the fluoxetine group. Fluoxetine did not separate from placebo at follow-up (van der Kolk and colleagues, Journal of Clinical Psychiatry, 2007). Among patients whose trauma began in childhood, the figure was 33.3%, which illustrates the gap between single-incident and developmental presentations that runs through all of this literature.

In a comparison with prolonged exposure, 7 of 10 EMDR participants achieved a 70% or greater reduction in PTSD symptoms, against 2 of 12 in the prolonged exposure arm, with no dropouts in the EMDR group and 3 of 10 in the comparison group (Ironson and colleagues, Journal of Clinical Psychology, 2002). Sample sizes at this scale support the direction of the finding without settling the comparison.

What the Eye Movements Contribute

The mechanism is genuinely contested, and the contested part is narrow. What is disputed is whether the bilateral stimulation adds anything beyond the exposure and reprocessing core.

A meta-analysis of 26 studies, 15 clinical and 11 laboratory, found an additive effect for the eye movements themselves, with Cohen's d of 0.41 in clinical studies and 0.74 in laboratory studies (Lee and Cuijpers, Journal of Behavior Therapy and Experimental Psychiatry, 2013). Those are real effects of modest size.

Four mechanisms have been proposed. The working memory account holds that tracking a moving target while holding a memory competes for limited resources, which reduces the vividness and emotional charge of the recollection (Andrade, Kavanagh and Baddeley, 1997). The orienting response account attributes the effect to a reflexive shift of attention that dampens arousal. Two further accounts draw analogies to REM sleep and to slow-wave sleep consolidation.

Mechanistic uncertainty is a normal condition in psychiatry and does not undercut outcome data. The mechanism of lithium remains incompletely specified. What matters clinically is that the outcome evidence is replicated and that the treatment is recommended by bodies that reviewed it independently.

How EMDR Compares With Other Trauma Therapies

All three guideline-recommended trauma-focused therapies work. They differ in what they ask of the patient, which is usually the deciding factor.

EMDRProlonged ExposureCognitive Processing Therapy
Detailed verbal narration of the traumaSubstantially lessCentralWritten account
Between-session homeworkNoneExposure assignmentsWorksheets
Typical protocol lengthVaries widely by trauma type8 to 15 sessions12 sessions
Dropout in RCTs18% (95% CI 12–24)22% (95% CI 16–28)Pooled across trauma-focused: higher than non-trauma-focused

Across 116 randomized trials, pooled dropout from psychological therapies for PTSD was 16% (95% CI 14 to 18). For EMDR the rate was 18% (95% CI 12 to 24) across 21 trials, and for prolonged exposure 22% (95% CI 16 to 28) across 22 trials (Lewis and colleagues, European Journal of Psychotraumatology, 2020). Those confidence intervals overlap substantially, and the difference between the two treatments should be read as small. Trauma-focused therapies as a group showed significantly greater dropout than therapies without a trauma focus.

The absence of homework is the practical difference patients notice most. For someone whose schedule or symptom burden makes between-session assignments unworkable, that feature carries real weight. A fuller comparison is at EMDR versus CBT.

How Long Treatment Takes

Published protocols vary enormously, and any single number offered as the answer should be treated with suspicion. Trials have used 12 ninety-minute sessions over six weeks, four to six weekly sessions, nine weekly sessions of about an hour, and in one refugee-camp intervention, two sessions across three days.

For single-incident adult trauma, a course of weekly 60 to 90 minute sessions over roughly three months is a reasonable planning assumption. Complex and developmental trauma runs considerably longer, and the preparation phase alone can account for months of it. Patients comparing their own pace against a figure they read somewhere is a reliable source of unnecessary discouragement.

Who EMDR Helps

The evidence is strongest for discrete-event PTSD following assault, accident, disaster, combat, or medical trauma. Results in complex and developmental trauma are good and more variable, and they depend heavily on adequate stabilization first.

Beyond PTSD, a 2024 meta-analysis of 25 randomized trials in 1,042 participants found a moderate effect on depression, with Hedges's g of 0.75 (Abdulla and colleagues, Frontiers in Psychiatry, 2024). A meta-analysis of 17 randomized trials in 647 patients found g = −0.71 for anxiety and g = −0.62 for panic (Faretta and Dal Farra, Journal of Affective Disorders, 2019). The evidence for grief, phobias, performance anxiety, and chronic pain is earlier-stage and should be described as promising and incomplete.

Stabilization comes first where there is active psychosis, severe dissociation, untreated substance dependence, or an ongoing unsafe living situation. These are sequencing decisions rather than permanent exclusions, and patients are frequently told otherwise. A patient turned away from EMDR because of a borderline personality disorder diagnosis, or because they cannot produce vivid visual memories, has usually been given a rule that the evidence does not support.

What EMDR Is Not Applied To

EMDR is applied to episodic memories the patient can describe before treatment begins. It is not a memory-retrieval procedure and should not be entered as one (Callus, Gallina and Fernandez, Frontiers in Psychology, 2024).

This matters because a substantial number of patients seek EMDR hoping to recover a missing childhood or to confirm an abuse they suspect but cannot remember. Under suggestive conditions adults can develop apparent memories of events that did not occur, and the risk scenario is well described: a patient with no prior suspicion, a clinician who proposes that the symptoms indicate hidden abuse, imagery or hypnosis used to retrieve it, and the product treated as established fact. A clinician who proposes a specific abuse scenario the patient never described is working outside the protocol.

EMDR is also not hypnosis. There is no induction, no altered state, no suggestion, and no trance. The patient remains alert and can stop at any point.

What Happens Between Sessions

EMDR assigns no homework, and processing continues anyway. Fatigue, tearfulness, irritability, disrupted sleep, and vivid dreams in the days after a processing session are common enough to be worth anticipating out loud.

In trauma-focused protocols where this has been measured, temporary worsening affected 28.6% of patients receiving cognitive processing therapy, 20.0% receiving prolonged exposure, and 14.7% receiving a cognitive-only variant (Larsen and colleagues, Behaviour Research and Therapy, 2016). The worsening was unrelated to whether patients completed treatment, and patients who experienced it still achieved clinically significant improvement. Notably, they finished with somewhat higher symptom scores than patients who did not worsen, which means the intensity of a reaction carries no information about the quality of the processing. The full picture is at what happens after an EMDR session.

EMDR Delivered by the Treating Psychiatrist

Most EMDR in New York is delivered by therapists who do not prescribe. That arrangement works, and it introduces a coordination gap at two specific points.

The first is differential diagnosis. Hypervigilance and concentration difficulty resemble ADHD, dissociation is misread as inattention, and trauma-related mood instability is misdiagnosed as bipolar disorder. Complex PTSD is frequently misdiagnosed as borderline personality disorder, which changes how a patient is treated by every clinician who reads the chart afterward.

The second is medication. Sleep, substance use, and emerging suicidality are most usefully monitored in the interval between processing sessions, which is precisely where a split arrangement has the least visibility. Patients who develop suicidal thinking during trauma work frequently withhold it out of fear the EMDR will be stopped. The correct response is to adjust the sequencing, and a clinician managing both sides can do that in one conversation.

Dr. Sultan provides EMDR as the treating psychiatrist at the Chelsea office in Manhattan and by telehealth in New York, Virginia, Montana, and Florida. Consultations can be arranged through Integrative Psych.

Related Reading

Detailed answers to the questions patients ask most often during treatment:

Frequently Asked Questions

Does EMDR actually work, or is it pseudoscience?

It works. EMDR is recommended for PTSD by the World Health Organization (2013) and sits in the highest tier of the 2023 VA/DoD Clinical Practice Guideline. A meta-analysis of 26 randomized trials found a moderate pooled effect on PTSD symptoms, g = −0.662. What remains contested is the mechanism, specifically what the eye movements add beyond exposure and reprocessing.

How many EMDR sessions will I need?

Published protocols range from two sessions to twelve or more, and the number depends on trauma type. For single-incident adult trauma, weekly 60 to 90 minute sessions over roughly three months is a reasonable planning assumption. Complex and developmental trauma takes considerably longer.

Why did the APA rank EMDR as second-line in 2025?

The 2025 American Psychological Association Clinical Practice Guideline placed cognitive processing therapy, prolonged exposure, and trauma-focused CBT ahead of EMDR. The panel raised concerns in four areas: durability of long-term gains, adverse effects, outcomes for comorbid conditions such as depression, and cross-cultural acceptability. The position is contested. It differs from five other national and international guidelines published in the past decade, including the 2023 VA/DoD guideline, which places EMDR in its highest tier, and a critique in the Journal of EMDR Practice and Research argues the panel relied on outdated reviews and gave limited transparency into how it reached its EMDR decision.

Is EMDR better than CBT for PTSD?

Head-to-head trials show comparable efficacy, and the 2023 VA/DoD guideline recommends EMDR, prolonged exposure, and cognitive processing therapy at the same tier. The choice usually turns on fit: EMDR requires less detailed verbal narration and assigns no between-session homework.

Can EMDR make things worse?

Temporary worsening affected 14.7% to 28.6% of patients across measured trauma-focused protocols, resolved on its own, and did not predict dropping out. Sustained worsening usually indicates that processing began before adequate stabilization, which is a pacing problem and is correctable.

Can I do EMDR if I have no clear memories?

Yes. Vivid visual memory is not a requirement, and neither is the ability to locate emotion in the body. Patients with aphantasia, alexithymia, or autism are sometimes told they are unsuitable for EMDR, and that judgment is usually a mismatch between the standard instructions and the patient rather than a genuine contraindication.

Does EMDR work over telehealth?

Yes, with adaptation. Bilateral stimulation can be delivered through self-administered tactile stimulation or on-screen cues. Remote delivery has become standard practice, and it makes EMDR available to patients in states where the treating psychiatrist holds licensure.

Will EMDR recover memories I have forgotten?

EMDR is applied to episodic memories a patient can describe before treatment starts. It is not a memory-retrieval procedure. Patients hoping to recover a missing childhood should raise that goal before beginning, because it changes the treatment conversation.

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