EMDR vs. Exposure therapy: Are we trying to fit a square peg into a round hole?
EMDR known as Eye Movement Desensitization and Reprocessing, is recognized as an evidence based psychotherapy for the treatment of PTSD. It involves someone thinking of a traumatic memory while simultaneously experiencing bilateral stimulation (typically eye movements). A description on the American Psychological Association’s website explains that “while clients briefly focus on the trauma memory and simultaneously experience bilateral stimulation (BLS), the vividness and emotion of the memory are reduced.” Exposure therapy involves systematically confronting feared memories, emotions, or situations without avoidance or escape, allowing new learning to occur about safety, tolerability, and emotional survivability. Prolonged exposure therapy is considered a first line evidence based psychotherapy to treat PTSD and has a few more decades of substantial research supporting it’s efficacy compared to EMDR.
EMDR has exploded in popularity and hype over the past couple of decades - but is it worth all the hullabaloo? What does the research say when it comes to what actually works in EMDR? Is moving your eyes back and forth causally contributing to a decrease in PTSD symptoms? If it isn’t, why are we still advocating for it’s clinical utility?
Dismantling Studies
In psychotherapy research, dismantling studies are experimental studies designed to figure out which parts of a treatment are actually doing the therapeutic work. A dismantling study asks: If we remove one part, does the treatment still work? If the answer is yes—and outcomes stay about the same—then that removed part may not be an essential “active ingredient.” Importantly, a treatment can be effective without all of its components being necessary. Dismantling research does not ask whether EMDR works; it asks what within EMDR is doing the work.
For example, Eye Movement Desensitization and Reprocessing (EMDR) includes multiple components including recalling traumatic memories, exposure to distressing material, therapist-guided cognitive processing, and bilateral stimulation (eye movements, tapping, tones). A dismantling study might compare full EMDR vs EMDR without eye movements. If both groups improve equally, that suggests the eye movements may not be the critical mechanism of change. If the full EMDR group improves significantly more, that would support eye movements as an active and hence, causal ingredient.
The two most recent dismantling studies are what I’d like to highlight as they help elucidate the causal mechanisms associated with EMDR. The randomized clinical trial by Martin Sack and colleagues (2016) examined whether the eye movement component of EMDR contributes unique therapeutic value beyond trauma exposure itself. In this dismantling design, 139 adults with PTSD were randomly assigned to one of three conditions: trauma exposure with eye movements (standard EMDR-style dual attention), trauma exposure with fixed visual attention, or trauma exposure alone without a structured attentional task. This design allowed researchers to isolate whether bilateral stimulation or divided attention meaningfully enhanced treatment effects. Across all three conditions, PTSD symptoms significantly decreased, indicating that repeated trauma engagement and emotional processing were effective regardless of whether eye movements were included. Although there were some modest short-term differences in subjective distress during memory activation, the addition of eye movements did not produce robust or clinically meaningful superiority in overall PTSD outcomes. The authors concluded that exposure to traumatic memory appears to be the primary therapeutic mechanism, while eye movements may function as a secondary attentional aid rather than an essential ingredient. This finding aligns with the broader exposure therapy literature, which consistently identifies fear activation, habituation, inhibitory learning, and corrective emotional processing as central mechanisms of change across PTSD treatments such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT).
The meta-analysis by Christopher W. Lee and Pim Cuijpers (2013) synthesized 26 studies (15 clinical trials and 11 laboratory experiments) to evaluate whether eye movements contribute incremental benefit in emotional memory processing. Their analysis found a moderate additive effect of eye movements in clinical treatment studies (d = .41) and a larger effect in laboratory analogue studies (d = .74), particularly in reducing the vividness and emotional intensity of distressing memories. Importantly, however, the strongest effects emerged in non-clinical analogue tasks rather than in actual PTSD treatment, raising questions about the generalizability of these effects to trauma therapy. The authors concluded that eye movements may enhance the desensitization process by taxing working memory, thereby reducing the emotional salience of traumatic memories during recall. Within the broader exposure therapy literature, this positions eye movements as a potential augmentation strategy rather than a distinct mechanism of action. In other words, the findings suggest that EMDR may facilitate exposure-based processing somewhat more efficiently for some clients, but the central therapeutic process remains confrontation with avoided traumatic material—consistent with decades of evidence showing that exposure itself is the most robust active ingredient in trauma treatment.
Taken together, the dismantling literature presents an interesting paradox: EMDR appears effective as a treatment for PTSD, yet its signature ingredient—bilateral stimulation—has shown inconsistent evidence as a necessary mechanism of change. This raises an important clinical question: if exposure to traumatic memory is the primary engine of improvement, should EMDR be understood as a distinct treatment model, or as a specialized delivery format of exposure-based therapy?
Effectively: If we substituted the bilateral stimulation for let’s say, ass scratching, would we get the same results in the studies?
Treatment Decisions and Influences
In conversations on social media and within clinical communities, many therapists who practice Eye Movement Desensitization and Reprocessing argue that it may feel more approachable for individuals with Post-traumatic stress disorder, particularly given the intensity often associated with Prolonged Exposure Therapy and other exposure-based treatments. That is a fair consideration. Treatment decisions are influenced by many factors, including patient preference, readiness, perceived tolerability, and therapeutic fit. These variables matter. But if the primary goal is to select the treatment with the strongest and most direct evidence for reducing PTSD symptoms, an important question remains: why not choose exposure-based treatment directly?
This question matters because exposure therapy is often misunderstood as simply “throwing someone into” traumatic material. In reality, effective exposure treatment is collaborative, gradual, and highly individualized. A central part of the work involves psychoeducation, building motivation, increasing willingness, and helping clients develop the capacity to approach distressing memories rather than avoid them. In other words, tolerating and engaging with difficult emotional material is not a barrier to exposure therapy; it is part of the therapeutic process itself. If avoidance is a core maintaining factor in PTSD, then systematically reducing that avoidance remains one of the most empirically supported pathways to recovery.
Is there a conclusion?
I believe it is crucial to continue strengthening Clinical Psychology as a scientific discipline. Doing so helps reduce harm, protect patients, and ensure that we are selecting interventions with the strongest empirical support. Beyond that, it also preserves the identity of the field as one grounded in scientific rigor rather than trend, intuition, or anecdote—especially when treating serious and chronic conditions that significantly impair quality of life and functioning.
If we lose that grounding, the distinction between evidence-based psychological treatment and non-evidence-based wellness practices becomes increasingly blurred. The value of the field depends not only on the existence of effective treatments, but on our commitment to systematically testing what actually works, what does not, and why. Otherwise, what’s the difference between us and the crystal slewing gut health supplementing chiropractor on instagram?
References
Sack, M., Hofmann, A., Weigel, C., Nijdam, M. J., Wöller, W., & Michael, T. (2016). A comparison of dual attention, eye movements, and exposure only during eye movement desensitization and reprocessing for posttraumatic stress disorder: Results from a randomized clinical trial. Psychotherapy and Psychosomatics, 85(6), 357–365. https://doi.org/10.1159/000447671
Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44(2), 231–239. https://doi.org/10.1016/j.jbtep.2012.11.001
