The IREM study: Imagery rescripting v EMDR for PTSD from childhood trauma

Maybe the most exciting psychotherapy study published this year is brought to us by a team of authors led by Katrina Boterhoven de Haan that includes Arnoud Arntz, whose psychotherapy research CV is as enviable as it is unparalleled (if you are not familiar with his work, go read everything he’s ever written) and Australia’s Chris Lee, an incredible scientist-practitioner overachiever and tour-de-force of Australian clinical psychology. They have just published the results of the IREM trial: a randomized controlled trial comparing Eye Movement Desensitization Reprocessing Therapy (EMDR) with Imagery Rescripting (ImRS) for childhood trauma.

What is EMDR?
EMDR is a structured, sequential therapy which entails 8 phases (Shapiro, 2007): 1) History taking – which includes identification of disturbing childhood and recent memories, and negative beliefs; 2) Preparation – ensuring the client understands the rationale and has enough coping strategies to be willing to undertake the trauma-focused exercises; 3) Assessment – organising the material to be used in therapy into units involving an image, associated negative cognition and belief rating, positive alternative cognition and belief rating, emotion and intensity rating, and physical sensations; 4) Desensitization phase – during which the client divides their attention between the traumatic memory components (image, negative belief and sensation) and a source of neutral bilateral stimulation (usually watching the therapist’s finger move, which induces eye movements, but other sources can be used such as audio or the client may be directed to tap their fingers); 5) Installation – where the client holds both the traumatic image and the positive belief in mind, while also attending to bilateral stimulation; 6) Body scan – where the client attends to the traumatic image and associated physical sensations while also attending to bilateral stimulation; 7) Closure – ensuring the client is stable before leaving the session; 8) Reevaluation – at the beginning of the next session, the therapist assesses whether gains from the previous session have been maintained and assesses for new intervention targets for the present session.

Undoubtedly, the most distinctive feature of EMDR is its use of bilateral stimulation throughout therapy. It’s fair to say no one really knows for sure why this is helpful, but after years of it being seen as an unnecessary gimmick added to a proven treatment (exposure), most scientists no longer doubt that the stimulation contributes to its efficacy. Theoretical explanations include that: a) bilateral stimulation increases working memory burden, which in turn leads to visual memory degradation during the reconsolidation phase after its activation; b) bilateral stimulation increases interhemispheric connectivity, allowing better integration between propositional, explicit knowledge and implicit, episodic memory, which would otherwise remain dissociated; c) bilateral stimulation promotes better integration of emotional and cognitive components of a memory via stimulating a-amino-3-hydroxy-5-methyl-4-isoxazole (AMPA) receptors in the hippocampus [yeah, I don’t know what that means either]; d) that the combination of sympathetic arousal in response to the trauma memory followed by bilateral stimulation induces a relaxation response to the memory; and e) new hypotheses continue to be formed (Calancie et al., 2018). Notwithstanding the potential power of bilateral stimulation, it is worth noting the degree of structure, focus and organisation of the trauma-related material in EMDR matches or exceeds that in other trauma-focused protocols. EMDR also entails an interesting mix of assessment of specific traumatic events (that is virtually identical to cognitive and behaviour therapy protocols), with an emphasis on “leaving the brain alone” once it has been stimulated. The therapist relies on feedback from the client’s felt sense to direct how to stimulate the brain next (which seems quite less therapist-directed than many cognitive behavioural therapies). I really should shut up about it now. I’ve never been trained in EMDR. I read half of the original book a long time ago and attended a seminar once. It seems quite mysterious to me.

What is Imagery Rescripting (ImRS)?
ImRS has become my favourite way to work with traumatic imagery. After years of haranguing people about the superior evidence base of prolonged exposure, while trying to adhere perfectly to the published protocols and getting regular disappointing, upsetting results, no matter how well I blocked clients’ avoidance, I decided there had to be a better way. And there is. The basic procedure of ImRS entails requiring clients to imagine their traumatic memory in three phases. First, the client experiences the event from their ‘past-self’ perspective (which for a childhood experience, would be their childhood perspective; I know, “slow down, Mat, I can’t keep up”). Critically, it is isn’t necessary for clients to maintain prolonged reliving of the most distressing imagery and emotion associated with it. It is enough to activate the contextual information about the event and the associated emotions and thoughts. In the second phase, the scene is watched by the client as their present-day self (adult perspective). When people have enough strengths, they often notice new and corrective information simply through this perspective shift. If they can think of a way to change the scene by intervening - for example, to stand between their child self and another bullying figure and send that bully away - they are encouraged to imagine doing so. If the client struggles to initiate protecting the past self, the therapist can intervene by asking the client to imagine the therapist or another helper figure protecting the past-self. In the third phase, the client is asked to experience the scene once more from their past-self perspective, focusing on the emotions, thoughts and sensations associated with feeling safe, protected supported – having their needs met in whatever way necessary. Over therapy, therapist and client work somewhat like movie producers, reviewing their scenes and trying new ones out, until (metaphorically speaking) the client is writing most of the script, playing the hero (the helper figure) themselves, and feeling safe and comforted in the third phase.

The IREM Study
Ok, so now we know what we’re talking about, back to the study. Participants received up to 12 x 90-minute sessions of either ImRS or EMDR, twice a week. Just pause for a moment and consider how often you plan to offer therapy in format of that intensity. Anecdotally, study therapists were impressed that the intensity alone seemed to be more effective than the routine way they would deliver services. The therapy was delivered by psychologists, psychotherapists, psychiatrists and a mental health nurse across Australia, Germany and the Netherlands over a 5-year period. ImRS therapists had to have basic CBT training. EMDR therapists had to have level 1 basic training. Therapists in both conditions had to have 2 days training for the study. They also had to demonstrate competence in the approach with at least 2 pilot cases, where their videos were assessed by site coordinators before commencing in the trial. Again, pause and consider how often therapists in routine practice are required to demonstrate this level of competence before administering a system of therapy with clients. Some minor structural changes were made to each therapy to standardize it for the study. In ImRS, the therapist intervened as the helper figure for the first 6 sessions and the client would intervene as their adult selves in the second 6 sessions. In EMDR, therapists were not allowed to use imagery techniques that resembled ImRS.

The results were impressive. Eight weeks after treatment ended, PTSD symptoms decreased in both groups by a similar, large amount (d ~ 1.7) and 68% participants no longer met PTSD criteria according to the CAPS-5 (Clinician-Administered PTSD Scale for DSM-5). By 1-year follow-up, 81% no longer met diagnostic criteria. Large within-treatment effects of about 1 standard deviation change were also found for depression, shame, post-traumatic cognitions, and anger and disgust in relation to the index trauma. Respectable improvements were also found for remoralisation, guilt, quality of life, and hostility. Only dissociative experiences showed a weak treatment effect. Interestingly, although the results were similar by follow-up, there was some evidence that EMDR achieved its improvements faster: self-reported PTSD symptoms (measured by Impact of Events Schedule); trauma-related shame; anger expression and control; and hostility; guilt, shame, anger and disgust related to the index trauma had all improved more by midway through treatment in EMDR, compared to ImRS. The authors emphasised that it is often assumed that clients with childhood trauma need to be stabilised before treatment can focus on their trauma, yet IREM clients tolerated an almost immediate focus on their trauma and achieved good symptomatic improvement. There was a low dropout rate within treatment of 7-8% in both conditions. There was substantial disability and comorbidity in the study as indicated by 45% being either unemployed or on a disability pension, 59% having sexual assault as their index trauma, an average PTSD duration of 7 years for their index trauma, which on average onset 8 years prior, 81% had previous treatment, including 25% with psychiatric hospital admission, 72% had comorbid mood disorders, 56% comorbid anxiety disorders, and 54% comorbid substance use. The range of benefits from only 6 weeks (and for some EMDR participants, less) of intervention is a truly valuable discovery.

Without taking anything away from these results, there are some contextual factors which I emphasize for the sake of clinicians who will focus on the 81% recovery rate and be unnecessarily self-critical if they can’t reproduce this result. There was something of a selection effect operating before the recovery rate count started. 466 people were screened for eligibility: 59% were excluded and 15% declined. Participants were excluded if they were deemed a suicide risk, comorbid psychotic disorder, bipolar I disorder, alcohol or drug dependence, PTSD from a trauma occurring in the past 6 months, IQ < 80, medication changes or any PTSD-focused therapy in the past 3 months and taking benzodiazepine medication unless willing to taper off and achieve 2 weeks abstinence. This doesn’t reduce the value of the study but it is important clinicians consider these factors when comparing their performance against randomized trials. In my experience, most clinicians in private settings don’t have enough time to assess for these exclusion criteria properly. Who knows the IQ of most of their therapy clients? So, the 81% recovery rate applies to 155 who were randomised after an up to 7 week waiting period (37 dropped out prior), which constituted 33% of those who initially presented to the trial.

I hope readers will share my excitement for these results. First of all, after years of scepticism, I am thankful that all the time, money and energy spent on EMDR training wasn’t a con. And if you’re one of those who has been trained, you should feel excited to have another study affirm your decision to invest in that training. Secondly, if you’re thinking of getting EMDR training, these results suggest it is worth it. Faster relief from trauma symptoms for your clients is an exciting benefit. Thirdly, as a psychotherapy research fan, it is exciting to see that all of the effort to explore and refine specific approaches to therapy does have pay-offs. Faster recovery should not be reduced to mere therapy equivalence. Fourthly though, the results suggest that if ImRS is the tortoise in the race, it will eventually reach the hare of EMDR which is great news for those of us who haven’t invested the time, money and energy to be trained in EMDR, and whose work context maybe wouldn’t justify that investment given the balance of presenting problems. Mostly though it is exciting to think that after the trauma that clients have been through in the first place, there are some slightly kinder options than prolonged exposure that seem to achieve excellent results in a relatively brief time.

For the original article, go to:
https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/imagery-rescripting-and-eye-movement-desensitisation-and-reprocessing-as-treatment-for-adults-with-posttraumatic-stress-disorder-from-childhood-trauma-randomised-clinical-trial/A97132EE142BA88DA207E8CCB0044475

REFERENCES

Boterhoven de Haan, K.L., Lee, C.W., Fassbinder, E., van Es, S.M., Menninga, S., et al., (2020). Imagery rescripting and eye movement desensitization and reprocessing as treatment for adults with post-traumatic stress disorder from childhood trauma: randomised clinical trial. British Journal of Psychiatry, 217, 609-615.

Calancie, O.G., Khalid-Khan, S., Booij, L., & Munoz, D.P. (2018). Eye movement desensitization and reprocessing as a treatment for PTSD: current neurobiological theories and a new hypothesis. Annals of the New York Academy of Sciences, 1426, 127-145.

Shapiro, F. (2007). EMDR, adaptive information processing, and case conceptualization. Journal of EMDR Research and Practice, 1, 68-87.