PROCESSUS STRATEGIQUES : DES ELEMENTS CLES POUR COMPRENDRE L'APRES FUSION : LE CAS SANOFI AVENTIS Philippe REBIERE Professeur Associé (ICN Business School) Université Nancy 2 CEREFIGE Cahier de Recherche n°2010-02 Université Nancy 2 13 rue Maréchal Ney Téléphone : 03 54 50 35 80
Layoutcognitions and associated bodily sensations. Simultaneously they are directed to move their eyes from side EMDR – more than just
to side, or employ some other form ofbilateral stimulation (BLS). The effect isto desensitise the client to the distressing a therapy for PTSD?
memory but, more importantly, toreprocess the memory so that the Robin Logie considers a therapy whose mechanism remains unexplained associated cognitions become more 25 years after it was developed A standardised eight-stage protocol is employed that starts with comprehensive Now recognised by the National
history taking and formulation. This is Institute for Health and Clinical
It has been more than a decade since The Psychologist published an article followed by a preparation phase in which Excellence (NICE) and the World
about eye movement desensitisation the client is provided with the necessary Health Organization as a treatment
and reprocessing (EMDR). F. Shapiro and resources to manage the processing of their of choice for post-traumatic stress
Maxfield's (2002) article provoked a lively distressing memories. The ‘assessment' disorder, it appears that eye
debate on these pages (e.g. Joseph, 2002), phase involves ascertaining the client's movement desensitisation and
and I hope this article will do the same.
target memory, negative cognition, desired reprocessing (EMDR) has ‘come
However, the arguments will probably be positive cognition, bodily sensations and of age' as a psychological therapy
different ones because EMDR has now ratings for level of distress and level of on a par with cognitive behavioural
firmly taken its place as an established belief in their positive cognition. This is therapy or psychodynamic
treatment for post-traumatic stress followed by the actual processing of the psychotherapy. However we still do
disorder (PTSD), particularly since 2005 memory using BLS. After this the positive not know how it works. And should
when it was recognised by the National cognition is ‘installed' and the therapist it really be used for the treatment
Institute for Health and Clinical checks for residual bodily sensations of other disorders as varied as
Excellence (NICE) as one of the before a final debriefing. treatments of choice for PTSD (NICE, disorder and psychosis?
The landscape has changed, and more and more EMDR practitioners no longer After the discovery of the reprocessing What is the history of eye movement reserve this powerful approach for PTSD function of EMDR, a model was desensitisation and reprocessing? but offer EMDR as a comprehensive developed to make sense of what is How does EMDR work and is bilateral therapy to their clients, wherever there is occurring in EMDR. Adaptive information stimulation (BLS) important? evidence of traumatic memories or other processing (AIP: F. Shapiro, 2007) adverse life events. My aim in this article proposes a model of how new experiences Is it just a very effective technique for is to outline some of the evidence that has are integrated into already existing PTSD or is it now a fully fledged led the EMDR community to reframe the memory networks. Normally memories psychological therapy? therapy in this way. are processed and assimilated using the What status has EMDR now reached as individual's past experience and an effective therapy for psychological understanding of themselves and the What is EMDR?
world they live in. However, if the EMDR was developed by American experience is traumatic, the information clinical psychologist Francine Shapiro in processing system stores the memory in Shapiro, F. (2001). Eye movement the 1980s (F. Shapiro, 1989). The therapy a ‘frozen' form without adequately desensitization and reprocessing: Basic involves the identification of unprocessed processing it to an adaptive resolution.
principles, protocols and procedures traumatic or other distressing experiences Traumatic memories fail to become (2nd edn). New York: Guilford Press.
that are continuing to drive an integrated into the individual's life Francine Shapiro Library: individual's psychological disturbance.
experience and self-concept. For example, http://emdr.nku.edu EMDR Association UK and Ireland: The client is asked to recall the worst in PTSD, the first disorder for which the aspect of the memory together with the effectiveness of EMDR was clearly accompanying currently held negative demonstrated, individuals continue to re- Beck, A. (1976). Cognitive therapy and Verhaltenstherapie, 20, 175–181. life events and obsessive-compulsive the effects of prolonged exposure, emotional disorders. New York: Brown, S. & Shapiro, F. (2006). EMDR in disorder Behaviour Research and EMDR and waiting list on patients International Universities Press.
the treatment of borderline Therapy, 45, 2581–2592. with a current diagnosis of psychosis Bisson, J., Ehlers, A., Matthews, R. et al.
personality disorder. Clinical Case Davidson, P. & Parker, K. (2001). Eye and co morbid PTSD. Treating Trauma (2007). Psychological treatments for Studies, 5, 403–420. movement desensitization and in Psychosis, 14, 151. chronic post-traumatic stress Callcott, P., Standart, S. & Turkington, D.
reprocessing (EMDR): A meta- De Jongh, A., Ernst, R., Marques, L. & disorder. British Journal of Psychiatry, (2004). Trauma within psychosis.
analysis. Journal of Consulting and Hornsveld, H. (2013). The impact of 190, 97–104. Behavioural and Cognitive Clinical Psychology, 69, 305–316. eye movements and tones on Böhm, K. & Voderholzer, U. (2010). Use Psychotherapy, 32, 239–244. De Bont, P., Van den Berg, D., Van der disturbing memories of patients with of EMDR in the treatment of Cromer, K., Schmidt, N. & Murphy, D.
Vleugel, B. et al. (2013). A multi-site PTSD and other mental disorders.
(2006). An investigation of traumatic single blind clinical study to compare Journal of Behavior Therapy and vol 27 no 7
thought to alter the original memory,extinction processes appear to create a new memory that competes with the oldone. Also, whereas traditional cognitivetherapies identify an irrational self-beliefand then deliberately challenge,restructure and reframe the belief into anadaptive self-belief, in EMDR there are nospecific attempts to change or reframe theclient's currently held belief. It is foundthat the belief spontaneously shifts duringsubsequent processing, although it issometimes necessary to employ a‘cognitive interweave' when processingbecomes stuck. Another possible mechanism may relate to mindfulness. During thedesensitisation phase of EMDR, clients are instructed to ‘let whatever happens,happen' and to ‘just notice' what is comingup (Shapiro, 2001) which is consistentwith principles of mindfulness (Siegel,2007). Perceived mastery may be anotherimportant element contributing to EMDR'sefficacy. Whereas exposure techniquesrequire focused attention on the incidentin order to prevent avoidance, EMDRtherapy employs only short periods ofattention to the traumatic memory.
Moreover the client is assisted in movingamong the various associations that ariseinternally during the sets of eye movements, which often leads to an The client is asked to recall the worst aspect of the memory together with the
increase in the sense of mastery in being accompanying currently held negative cognitions and associated bodily sensations.
able to go back and forth between Simultaneously they are directed to move their eyes from side to side.
experiencing the event and the ‘here andnow'. This experience of mastery andefficacy may therefore become encoded as experience the trauma (‘as if it's have accommodated to the new adaptive information available to link into happening now'). They are avoidant information. Although the event and memory networks holding dysfunctionally of anything connected to the trauma what has been learned can be verbalised, stored information (Oren & Solomon, and tend to be hyper-aroused. the inappropriate emotions and physical Through ‘dual attention' (recalling sensations have been discarded and can the trauma whilst keeping ‘one foot in no longer be felt. the present' assisted by BLS), EMDR Oren and Solomon (2012) show How does EMDR work?
appears to allow the brain to access the how this may be consistent with recent A crucial and frequently posed question is dysfunctionally stored experience and neurobiological theories of reconsolidation whether BLS is necessary for EMDR to be stimulate the innate processing system, of memory. They suggest that the effective and, if so, what physiological or allowing it to transform the information mechanism involved in EMDR may differ neurological changes are occurring during to an adaptive resolution. When fully from that in exposure therapies, where processed, the necessary information is extinction is proposed to be a major Some early studies compared using assimilated and the memory structures mechanism. While reconsolidation is EMDR with and without the use of BLS Experimental Psychiatry, 44, 447–483. Preliminary evidence for the efficacy Gunter, R. & Bodner, G. (2009). EMDR De Jongh, A., ten Broeke, E. & Meijer, S.
of EMDR in treating generalized works… but how? Journal of EMDR Jaberghaderi, N., Greenwald, R., Rubin, (2010). Two method approach: A case anxiety disorder. Journal of EMDR Practice and Research, 3, 161–168. A. et al (2004). A comparison of CBT conceptualization model in the Practice and Research, 2, 26–40. Herbert, J., Lilienfeld, S., Lohr, J. et al.
and EMDR for sexually abused context of EMDR. Journal of EMDR Grey, E. (2011). A pilot study of (2000). Science and pseudoscience in Iranian girls. Clinical Psychology and Practice and Research, 4, 12–21. concentrated EMDR. Journal of EMDR the development of EMDR. Clinical Psychotherapy, 11, 358–368. De Jongh, A., ten Broeke, E. & Renssen, Practice and Research, 5, 14–24. Psychology Review, 20, 945–971. Joseph, S. (2002). Emperor's new M. (1999). Treatment of specific Greyber, L., Dulmus, C. & Cristalli, M.
Hofmann, A. (2012). EMDR and chronic clothes? The Psychologist, 15, phobias with EMDR. Journal of (2012). EMDR, PTSD, and trauma.
depression. Paper presented at the Anxiety Disorders, 13, 69–85. Child and Adolescent Social Work EMDR Association UK & Ireland Kowal, J.A. (2005). QEEG analysis of Gauvreau, P. & Bouchard, S. (2008).
Journal 29, 409–425. National Workshop and AGM, treating PTSD and bulimia nervosa read discuss contribute at www.thepsychologist.org.uk
and a meta-analyses of 13 studies However, Gunter and Bodner (2009) vividness and/or emotionality of negative (Davidson & Parker, 2001) concluded that found that although vertical eye memories (De Jongh et al., 2013).
BLS made no difference to its effectiveness.
movements do not enhance hemispheric Although specific hypotheses relating However, Lee and Cuijpers (2013) pointed communication, they did decrease memory the orienting response, hemispheric out some methodological problems with emotionality as effectively as horizontal communication and working memory lend this study and carried out a new review themselves to testable predictions (Gunter of the literature relating to two groups of Thirdly, the ‘working memory' account & Bodner, 2009), it may be that to search studies. The first group comprised 15 suggests that eye movements and visual for one overarching account of how EMDR clinical trials and compared the effects of imagery both draw on limited-capacity works may obscure the possibility that EMDR with and without eye movements.
visuospatial and central executive working multiple mechanisms are at work.
The effect size for the additive effect of eye memory resources. The competition Researchers may therefore need to consider movements in EMDR the interrelationships treatment studies was moderate and significant. proposed treatment The second group comprised mechanisms in order 11 laboratory trials that investigated the effects of eye movements while thinking of a distressing memory versus the same procedure without the eye movements in a non- astute reader will therapy context. For this realise that these group the effect size was large and significant with the strongest effect size difference being for vividness measures.
model which has the So if it is correct that BLS strongest empirical is necessary, what is the evidence) tend to mechanism involved? Firstly the rapid eye movement (REM) hypothesis (Stickgold, 2002) proposes that eye movements in EMDR produce a brain state similar to that reprocessing function produced during REM sleep. It is known that REM sleep espoused in F.
serves a number of adaptive Shapiro's AIP model functions, including memory described above. It is consolidation. Observing the The rapid eye movement (REM) hypothesis proposes that eye
my opinion that, for parallels between REM sleep movements in EMDR produce a brain state similar to that produced
example, proponents of and EMDR, Stickgold proposed during REM sleep
the working memory that EMDR reduces trauma- model do not usually take related symptoms by altering the theory as far as they emotionally charged autobiographical memories into created by dual tasks will impair imagery, My own understanding is that the a more generalised semantic form.
such that images become less emotional distancing effect caused by the degradation A second hypothesis draws upon and vivid. It has been established that of working memory enables the client to research suggesting that retrieval of horizontal eye movements tend to tax ‘stand back' from the trauma and thereby episodic memories is enhanced by working memory (e.g. Van den Hout et al., re-evaluate the trauma and their 2011). In support of the working memory understanding of it because they can re- communication – Propper and Christman account, analogue studies have found that experience the trauma whilst not feeling (2008) reviewed evidence to support this.
other taxing tasks during recall also reduce overwhelmed by it. However the literature using EMDR. Journal of Neurotherapy, of EMDR Practice and Research, 8, National Institute for Health and Clinical 9, 114–115. Meyer, V. (1966). Modification of Excellence. (2005). Post traumatic Lee, C.W. & Cuijpers, P. (2013). A meta- Marr, J. (2012). EMDR treatment of expectations in cases with stress disorder (PTSD). London: analysis of the contribution of eye obsessional rituals. Behavior movements in processing emotional Preliminary research. Journal of Research and Therapy, 4, 273–280. Nazari, H., Momeni, N., Jariani, M. & memories. Journal of Behavior EMDR Practice and Research, 6, 2–15. Nanni, V., Uher, R. & Danese, A. (2012).
Tarrahi, M. (2011). Comparison of Therapy and Experimental Psychiatry, Maxfield, L., Melnyk, W. & Gordon Childhood maltreatment predicts EMDR with citalopram in treatment 44, 231–239. Hayman, C. (2008). A working unfavorable course of illness and of OCD. International Journal of Logie, R. & De Jongh, A. (2014). The memory explanation for the effects treatment outcome in depression: A Psychiatry in Clinical Practice, 15, of eye movements in EMDR. Journal meta-analysis. American Journal of Confronting the catastrophe. Journal of EMDR Practice and Research, 2, Psychiatry, 169, 141–151. Oren, E. & Solomon, R. (2012). EMDR vol 27 no 7
on the working memory hypothesis though the research evidence for EMDR seems to be rather sketchy about this with, with children is still tentative, the World It is well established that dysfunctional perhaps, the exception of Maxfield et al.
Health Organization has recommended or core beliefs (Beck, 1976) can be traced (2008), who hypothesise that ‘links are EMDR as one of the treatments of choice to early experiences, and it is generally forged between the associated material and for PTSD for children along with adults accepted amongst EMDR practitioners the original memory, thus transforming the (World Health Organization, 2013). that the technique can be extremely way that the traumatic memory is stored in effective in treating depression (R.
memory networks' (p.259). Shapiro, 2009). Rather than working on Some critics have reasonably Beyond PTSD
the core beliefs themselves, the EMDR disparaged the proponents of EMDR It is becoming increasingly evident therapist assists the client to ‘identify the for implementing a treatment before its that trauma and other negative life evidence' for these beliefs and find the mechanism of action has been discovered experiences are causal factors in many earliest ‘touchstone' memory to use as (e.g. Herbert et al., 2000). However, the psychological disorders. For example, a target for the EMDR processing (De healing professions have a long history of depression has been linked to adverse Jongh et al., 2010). For example, the implementing efficacious treatments before experiences in childhood such as ‘touchstone event' that relates to the their mechanisms of action are maltreatment (Nanni et al., 2012). client's current belief that they are understood. For example, aspirin was The AIP model would therefore suggest ‘worthless' might be a childhood memory used effectively for over 70 years before that EMDR may be effective for any of being expected to take responsibility its mechanism was discovered (Vane & for others in the family, Botting, 2003). One might therefore argue disorder that can perhaps a parent with alcohol that EMDR should be no exception. be traced to trauma problems. They might remember a specific occasion movements tend to tax when their mother said, ‘you Post-traumatic stress disorder
are stupid and will never For a therapy that is directly related to original pioneering amount to anything'. The unresolved trauma, PTSD was an obvious touchstone memory would starting place for the application of then form the focus for EMDR EMDR. Most of the early work and protocols have been developed for its from which currently negative cognitions, research into EMDR focused on PTSD, use in a wide variety of disorders. For emotions and somatic responses are and F. Shapiro's seminal first published example, there are published RCTs paper (F. Shapiro, 1989) demonstrated showing the effectiveness of EMDR with Whilst there have been published case its efficacy with PTSD. Since that time survivors of sexual abuse (e.g. Jaberghaderi studies on the treatment of depression as a considerable body of research evidence et al., 2004). In another RCT, EMDR a primary diagnosis with EMDR (e.g. Grey, has been generated and a meta-analysis resulted in large and significant reductions 2011), there have been no RCTs published of 38 randomised controlled trials (RCTs) of memory-related distress and problem in English to date that address this established that EMDR and trauma behaviours in boys with conduct problems question (Wood & Ricketts, 2013).
focused cognitive behavioural therapy (Soberman et al., 2002). Unfortunately, the research evidence for are the two most effective treatments for Many other papers have been the effectiveness of EMDR with depression adults with this disorder (Bisson et al., published regarding the efficacy of EMDR is currently limited to evidence that levels for other disorders in non-randomised of depression are reduced when it occurs A review of the efficacy of EMDR for studies including borderline personality cormorbidly with other disorders such as children with PTSD showed EMDR and disorder (Brown & F. Shapiro, 2006), PTSD (e.g. Rothbaum et al., 2005). cognitive behavioural therapy (CBT) to generalised anxiety disorder (Gauvreau & However, an RCT is currently under be superior to all other treatments, and Bouchard, 2008), bulimia nervosa (Kowal, way. The European Depression and EMDR EMDR was found to be slightly more 2005) and phobia (De Jongh et al., 1999), Network RCT involves patients from six effective when compared with CBT as well as for pain management (Ray & European countries with recurrent (Rodenburg et al., 2009). However, a meta- Zbik, 2001).
depression, randomly assigned to analysis by Greyber et al. (2012) identified In order to illustrate the wide range medication alone, EMDR and medication, just five studies using different selection of applications of EMDR, I wish to focus or CBT and medication. The trial hopes to criteria and concluded that the on the use of EMDR with three diverse recruit over 350 participants, but thus far effectiveness of EMDR as compared with disorders, namely depression, obsessive none of this work has been published other treatments was equivocal. Even compulsive disorder (OCD) and psychosis.
(Hofmann, 2012). There is also a single- therapy. Revue européenne de Tollison (Eds.) Practical pain Psychology Review, 29, 599–606. Basic principles, protocols and psychologie appliquée, 62, 197–203. management (3rd edn) (pp.189–208).
Rothbaum, B.O., Astin, M.C. & Marsteller, procedures (2nd edn). New York: Propper, R. & Christman, S. (2008).
F. (2005). Prolonged exposure versus Guilford Press.
Interhemispheric interaction and Read, J., van Os, J., Morrison, A. & Ross, EMDR for PTSD rape victims. Journal Shapiro, F. (2007). EMDR, adaptive saccadic horizontal eye movements.
C. (2005). Childhood trauma, of Traumatic Stress, 18(6), 607–616. information processing, and case Implications for episodic memory, psychosis and schizophrenia. Acta Shapiro, F. (1989). Eye movement conceptualization. Journal of EMDR EMDR, and PTSD. Journal of EMDR Psychiatrica Scandinavica, 112, desensitization. Journal of Behavior Practice and Research, 1, 68–87. Practice and Research, 4, 269–281. Therapy and Experimental Psychiatry, Shapiro, F. & Maxfield, L. (2002). In the Ray, A. & Zbik, A. (2001). Cognitive Rodenburg, R., Benjamin, A., de Roos, et 20, 211–217. blink of an eye. The Psychologist, 15, behavioral therapies and beyond. In al. (2009). Efficacy of EMDR in Shapiro, F. (2001). Eye movement C. Tollison, J. Satterhwaite & J.
children: A meta-analysis. Clinical desensitization and reprocessing: Shapiro, R. (2009). EMDR Solutions II. read discuss contribute at www.thepsychologist.org.uk
case experimental design with that trauma-focused treatments replications in the UK, the Sheffield may be an important addition to EMDR and Depression Investigation the treatment of psychosis (Callcott (SEDI), which aims to ascertain et al., 2004).
whether clients respond to EMDR A study (van den Berg & van der not only with an improvement in Gaag, 2011) showed that EMDR is depressive symptoms but also in social effective and safe in the treatment of functioning. The study will investigate PTSD in clients with a psychotic whether the participants respond in disorder. Treatment of PTSD with the same ways as PTSD clients to EMDR had a positive effect on changes such as memory narrative, auditory verbal hallucinations, heart rate variability and skin delusions, anxiety symptoms, conductance response, and will elicit depression symptoms, and self- information about the patients' esteem. EMDR was utilised with this experience of receiving EMDR for group of patients without adapting depression (Wood & Ricketts, 2013). the treatment protocol or delayingtreatment by preceding it with Obsessive compulsive disorder stabilising interventions. Currently a Whilst the aetiology of OCD is less multicentre RCT is being conducted clearly connected to trauma and life to investigate the safety and efficacy events than in depression, such a of EMDR therapy and prolonged connection often exists. For example, exposure for treating clients with Cromer et al. (2006) found that 54 psychosis and comorbid PTSD (De per cent of individuals with OCD Bont et al., 2013). Although this had experienced at least one research evidence looks promising, traumatic life event.
there is no doubt that there is still a Individuals with OCD often get need for considerable more research stuck in their own cognitive world, before EMDR can be recommended and one of the advantages of EMDR for the treatment of psychosis. is the way in which it integrates the Individuals with OCD often get stuck in their
negative cognition with the emotion own cognitive world
and felt sense in the body. Unlike with PTSD and depression however, it is This article challenges the notion that usually necessary to combine EMDR with Marr (2012) described how OCD was EMDR is solely a treatment for PTSD. more psycho-education and behavioural successfully treated with EMDR in four It invites debate if this assertion appears approaches such as exposure and response cases where CBT had previously been to readers as questionable. It is my prevention (ERP: Meyer, 1966). Whilst unsuccessful. The first RCT in this area contention that, whilst much more EMDR will always start by processing past indicated that EMDR is more effective research needs to be carried out, the unresolved traumas or events, it is often than medication in the treatment of OCD current successful application of EMDR the case that the individual is still (Nazari et al., 2011).
to a whole range of disorders, together experiencing symptoms after past events with a growing evidence base, shows that have been fully processed, and this occurs it is rapidly achieving the status of a fully particularly in the case of OCD. In such Can EMDR really be effective in the fledged psychotherapy in its own right.
situations, for example, an additional treatment of psychosis? This may seem application of EMDR, ‘Flashforwards', less surprising when one considers that uses the standard protocol to address many individuals with psychosis have Robin Logie is a Chartered
future feared ‘worst case scenarios', often a history of trauma (Varese et al., 2012) Psychologist, EMDR Europe a hallmark of OCD (Logie & De Jongh, and between 50 and 98 per cent of adults Accredited Consultant and with a severe mental illness such as President of the EMDR Böhm and Voderholzer (2010) psychosis had at least one traumatising Association UK and Ireland described three case studies using both experience (Read et al., 2005). In EMDR and ERP in the treatment of OCD.
addition, it has already been established New York: Norton.
neurobiological mechanism of action.
taxing working memory and reducing an evidenced-based treatment for Siegel, D.J. (2007). The mindful brain.
Journal of Clinical Psychology, 58, vividness of recollections. Behaviour depression? Journal of EMDR Practice New York: Norton.
Research and Therapy, 49, 92–98. and Research, 7, 225–235. Soberman, G., Greenwald, R. & Rule, D.
van den Berg, D. & van der Gaag, M.
Vane, J. & Botting, R. (2003). The World Health Organization (2013).
(2002). A controlled study of eye (2011). Treating trauma in psychosis mechanism of action of aspirin.
Guidelines for the management of movement desensitization and with EMDR: A pilot study. Journal of Thrombosis Research, 110, 255–258. conditions specifically related to stress.
reprocessing (EMDR) for boys with Behavior Therapy and Experimental Varese, F., Smeets, F., Drukker, M. et al.
conduct problems. Journal of Psychiatry, 43, 664–671. (2012). Childhood adversities Aggression, Maltreatment, and Van den Hout, M., Engelhard, I., increase the risk of psychosis.
Trauma, 6, 217–236. Rijkeboer, M. et al. (2011). EMDR: Schizophrenia Bulletin, 38, 661–671. Stickgold, R. (2002). EMDR: A putative Eye movements superior to beeps in Wood, E. & Ricketts, T. (2013). Is EMDR vol 27 no 7
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Int. J. Mol. Sci. 2015, 16, 18185-18223; doi:10.3390/ijms160818185 OPEN ACCESS International Journal of Molecular Sciences ISSN 1422-0067 Exploiting the Pleiotropic Antioxidant Effects of Established Drugs in Cardiovascular Disease Sebastian Steven 1,2,†, Thomas Münzel 1,† and Andreas Daiber 1,†,*