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Articles
A Review of Mobile Applications for Facilitating EMDR
Treatment of Complex Trauma and Its Comorbidities
Sylvia A. Marotta-Walters
Kshipra Jain
Jeffrey DiNardo
Paramjit Kaur
Shobila Kaligounder
George Washington University, Washington, DC
With the continued advancement in technology, there is a rise in the development and utilization of
mobile health applications (mHealth apps) that claim to be using eye movement desensitization and
reprocessing (EMDR) theory and techniques to facilitate the therapeutic process. However, there are
concerns regarding the quality of these apps and the safety of clients who may be using them, partic-
ularly for those who may present with complex posttraumatic conditions and associated comorbidities.
Hence, this study evaluates current EMDR apps to determine their purpose, potential benefits, and
risks when used by clients and/or clinicians. Twelve apps were found to be eligible for evaluation and
are rated on applicability, validity, accuracy, and usefulness. Currently, our review concludes that none
of the EMDR apps are recommended for use by a client. Only 6 of the 12 apps would be recommended
for use by a trained clinician as a tool to aid with EMDR treatment, provided the clinician were able
to offer a safe environment that could adapt to the selected technology. Risks of using EMDR apps
include safety concerns with unregulated use, particularly for clients with complex posttraumatic stress
disorder (PTSD) and comorbid conditions, such as dysregulated emotions or cognitions, and concerns
regarding cyber security and data privacy. Clinical implications for the use of technology and mHealth
apps are discussed, and recommendations for the development of an ideal EMDR app for the future
are provided.
Keywords: EMDR; complex trauma; PTSD; mobile health (mHealth) applications; technology
ye movement desensitization and repro- Overview of EMDR
Ecessing (EMDR) therapy (Shapiro, 2001) is an The Adaptive Information Processing (AIP) model
evidence-based approach to the treatment of (Shapiro, 2002) underlying EMDR views symptoms of
posttraumatic stress disorder (PTSD) and its complex disorders as manifestations of unprocessed traumatic
variants. Recognized in many international PTSD memories (Shapiro, 2001). Chen, Zhang, Hu, and
treatment guidelines, such as those of the World Liang (2015) meta-analysis found significant reductions
Health Organization (2013), EMDR uses a standard in trauma symptoms when using EMDR treatment for
procedure and addresses past, present, and future PTSD. Various designs of studies, such as systematic
aspects of distressing memories. Originally devel- reviews and effectiveness studies, have been conducted
oped for PTSD, EMDR treatment is now also used for on motor vehicle accidents (Boccia, Piccardi, Cordel-
many other presenting problems, such as depression lieri, Guariglia, & Giannini, 2015), survivors of natural
and anxiety (Shapiro, 2014).
2 Journal of EMDR Practice and Research, Volume 12, Number 1, 2018
© 2018 EMDR International Association http:// dx. doi. org/ 10. 1891/ 1933- 3196. 12. 1.2
EMDR_Vol012-001_A1.indd 2 1/18/2018 8:45:53 PM
disasters (Natha & Daiches, 2014), and victims of sexual EMDR and Technology
violence (Regehr, Alaggia, Dennis, Pitts, & Saini, 2013). EMDR therapy has been associated with technology
EMDR therapy is guided by a protocol outlining from its earliest descriptions as a behavioral technique
eight phases of treatment as found in Shapiro (2001). (Shapiro, 1989). Our use of the word “technology”
These phases are described in chronological order, in this context means the use of scientific knowledge
though there is no specified length of time for each translated to practical solutions. In this sense, Shap-
phase and the phases can be recursive and nonlinear. iro’s use of her hand to supplement existing verbal
The first phase focuses on obtaining a complete client therapies was a technological innovation to thera-
history and the client and clinician work together to pies that had historically been verbal. Over the years,
identify disturbing memories to be processed. The various devices were created to assist with bilateral
second phase, preparation, involves preparing a saccadic eye movements and other forms of sensory
client for the processing phases of treatment. The dual attention mechanisms, such as taps and sounds.
third phase, assessment, identifies the perceptual, In today’s society, the most recent of such devices
cognitive, emotional and somatic components of involves the use of mobile applications on smart
the memory which will be targeted in that session. phones.
Phases four through seven, which heavily benefit The purpose of this study is to evaluate current
from the foundational work in earlier phases, tend mobile health applications (mHealth apps) that are
to happen interactively. Phase four, desensitization, based on EMDR techniques, or claim to be performing
starts with the client holding the target memory in EMDR treatment. In particular, this study has been
mind along with the negative cognition and then designed to evaluate the safety concerns of using
allowing the process to play out in a mindful manner. mHealth apps for EMDR, especially as these pertain
Phase five then shifts to reprocessing as there is an to their unregulated use for clients with complex
installation of a positive cognition to replace the trauma histories, emotional dysregulation, substance
formerly distressing negative cognition. Phase six, use problems, and/or who exhibit dissociative symp-
the body scan, serves as a check to make sure the toms as part of their PTSD presentation. Therefore,
distressing material has dissipated. Phases seven and this study aims to analyze the purpose, risks, and
eight are closure and reevaluation. These phases benefits of using these apps, with a particular focus on
are presented here because mobile technology and
applications may interact in varying ways depending accessibility, applicability, efficacy, validity, and useful-
on the phase in which they are used or may speak to ness for clinicians who treat complex trauma and its
certain needs within phases as opposed to a global variants with EMDR.
EMDR treatment approach.
During the trauma processing phases of EMDR EMDR Treatment of Complex Trauma and
therapy, clients focus on aspects of a disturbing Its Comorbidities
memory, while simultaneously engaging in hori-
zontal eye movements or experiencing other bilateral As EMDR therapy’s efficacy for PTSD was estab-
stimulations (BLSs), such as tones or taps. The posited lished (e.g., World Health Organization, 2013), it
process underlying the use of BLS is that trauma began to be tested with more treatment-resistant
processing is facilitated when a client holds dual disorders, such as PTSD with comorbid psychosis
attention on traumatic material and on sensory-based (de Bont et al., 2016), comorbid bipolar I and II disor-
BLS. This dual attention effectively titrates the level of ders (Novo et al., 2014), and comorbid substance use
disturbance and keeps the client within the window disorder (Kullack & Laugharne, 2016). Case reports
of tolerance. Over the years, the original introduction using EMDR for complex presenting problems
of BLS as a mechanism of change was integrated into such as borderline personality disorder (Mosquera,
today’s AIP model with emphasis on dual attention Leeds, & Gonzalez, 2014) and narcissistic personality
to facilitate resolution of disturbing material. A large disorder (Mosquera & Knipe, 2015) also show the
body of research conducted in laboratory settings has utility of EMDR for complicated features involving
studied the effects of having participants think of a emotional dysregulation and trauma-related attach-
memory while engaging in simultaneous eye move- ment disturbances. Earlier cautions about limiting
ments guided by a moving dot on a computer screen. the use of EMDR to simple PTSD have been,
Participants report significant decreases in memo- thereby, relaxed with the accumulating evidence that
ry-related emotion and memory vividness, and no supports the use of EMDR for more complicated
adverse reactions (van den Hout & Engelhard, 2012). clinical issues.
Journal of EMDR Practice and Research, Volume 12, Number 1, 2018 3
Review of Mobile Apps for EMDR
EMDR_Vol012-001_A1.indd 3 1/18/2018 8:45:53 PM
Some recent research suggests that no extended of symptom management, the clinical utility of
preparation is needed for clients with complex these apps to trauma processing and/or symptom
trauma and its variants, such as complex PTSD management warrants evaluation.
with comorbidities (Bongaerts, Van Minnen, de
Jongh, Minnen, & Jongh, 2017), where the poten- mHealth Apps
tial for dysregulated emotions, cognitions, and
relationships could be high. Other research found Smart phone developers tout the benefits of mobile
that higher levels of dissociation predicted poorer health (mHealth) apps as providing increased accessi-
response in EMDR treatment (Bae, Kim, & Park, bility and efficiency to therapeutic treatment (Boulos,
2016). Various adaptations to EMDR procedures Brewer, Karimkhani, Buller, & Dellavalle, 2014).
have been proposed. For example, van der Hart, Others note that mHealth apps have the potential to
Nijenhuis, and Solomon (2010) emphasized the provide supportive resources for clients and families
need to work directly with dissociation in trauma (Shen et al., 2015). mHealth apps are focused software
work, particularly with more chronic traumatic applications developed to run on modern mobile
exposures. Other recommendations have included: a devices such as smart phones and tablets, which are
prolonged period of stabilization and resource devel- available to be downloaded from app stores such as
opment (Korn, 2009; van der Hart, Groenendijk, Apple’s App Store, Windows, and Google Play. These
Gonzalez, Mosquera, & Solomon, 2013); situating apps convert mobile devices into smarter devices
EMDR within a phased treatment model (Korn, that can perform specific tasks, and, in turn, have
2009); increasing the number of sessions (Maxfield, transformed the use of technology in everyday life.
2003); and/or focusing on specific maladaptive Increasingly, apps are designed to assist mental health
coping strategies, such as self-harming behaviors practitioners to enhance help-seeking behavior among
(Mosquera & Ross, 2016). Some therapists have the public while opening up new avenues to monitor
warned that the incorrect use of EMDR could progress and/or provide better understanding of
lead to decompensation in clients with histories of mental health conditions.
complex trauma and dissociation (Twombly, 2000). There are several forms of mHealth apps in the
Further, there is some evidence that destabilization current environment. Some have been developed for
during treatment increases premature dropout rates symptom assessment, some for symptom or mood
and affects response to treatment (Schottenbauer, tracking, and some for treatment of various disor-
Glass, Arnkoff, Tendick, & Gray, 2008). ders, such as anxiety or mood disorders. For example,
These treatment parameters are in line with apps that address anxiety can have multiple purposes,
the most recent revision of the Diagnostic and including psychoeducation, clinical or self-assess-
Statistical Manual (DSM-5; American Psychiatric ment, and/or symptom monitoring. Real-time data
Association, 2013), which added the dissociative collection using active strategies like keeping e-dia-
specifier for those individuals with derealization ries, and passive ones such as calculating heart rates
and/or depersonalization in addition to the symp- can assist with effective planning of treatment goals.
toms found in the PTSD clusters of previous DSM More advanced apps can encourage behavioral change
versions (American Psychiatric Association, 2013; through games that help clients manage anxiety,
Lanius, Brand, Vermetten, Frewen, & Spiegel, 2012). or use reminders to help follow through with treat-
The addition of a dissociative specifier of PTSD has ment goals (Van Ameringen, Turna, Khalesi, Pullia, &
great clinical utility, providing greater clarity in the Patterson, 2017).
evaluation of the psychological correlates, course, However, the lack of regulatory guidelines for
and treatment of the disorder (Miller, Wolf, & mHealth apps is concerning. Most of the mHealth
Keane, 2014). Like the conditions mentioned above, apps are developed without health-care providers’
where PTSD is associated with various co-morbid- involvement and with no assurance of security and
ities or with dysregulated emotions or cognitions, privacy of private health information (Boulos et al.,
individuals who experience dissociative symptoms 2014; O'Neill & Brady, 2012). Currently, there are
may have difficulty benefitting from trauma-fo- no federal or state agencies with oversight respon-
cused treatment modalities if the dissociation inter- sibilities for safety and privacy of data collected by
feres with the crucial stage of processing traumatic mHealth apps, which are distributed by app stores
memories (Lanius et al., 2010). Because EMDR- such Apple’s App Store, Windows, and Google
focused mobile applications are marketed as benefi- Play. The Federal Communications Commission
cial to the overall EMDR process or to various forms (FCC), Food and Drug Administration (FDA), and
4 Journal of EMDR Practice and Research, Volume 12, Number 1, 2018
Marotta-Walters et al.
EMDR_Vol012-001_A1.indd 4 1/18/2018 8:45:53 PM
the Office of Civil Rights can only regulate mHealth on outcome (Hofmann & Barlow, 2014; Wampold,
apps when the apps interact or exchange personally 2015). Although some EMDR research has shown
identifiable data with Health Insurance Portability that the therapeutic relationship is not important
and Accountability Act (HIPAA) covered entities (Edmond, Sloan, & McCarty, 2004) or necessary
(“FCC Proposed,” 2017). When a developer provides (Bongaerts, Van Minnen, de Jongh, Minnen, &
an app directly to the public, it is outside the scope Jongh, 2017), other research has shown that some
of HIPAA. As such, data collected by these mHealth clients value it highly and attribute a substantial part
apps are not protected by law. of their change process to that relationship (Marich,
2012). In either case, it is important to explore
EMDR and mHealth Apps further whether mHealth Apps for EMDR facilitate
or obstruct the therapeutic relationship as well as
EMDR mHealth apps were developed to provide the process of change itself.
an EMDR-based treatment to the user. The infor-
mation that is provided in the marketing materials Methods
primarily focuses on BLS and the benefits to a clini-
cian of technology-assisted ways of providing such The Research Team
stimulation. The apps give a cursory description The research team consisted of both experienced
of a potential mechanism of BLS using a senso- EMDR-trained clinicians, licensed professional coun-
ry-based stimulus, but do not relate it to the theo- selors with no EMDR background, and doctoral
retical basis for EMDR itself. A clinician can attach students who are unlicensed but have clinical experi-
headphones to his or her phone, and then use the ence. Such a range of experience would help mitigate
app to administer bilateral tones to the client. Other the effects of an unconscious bias towards any form
versions allow the clinician to play the app on a of therapeutic service delivery.
computer, providing the client with both visual and
auditory BLS. While research has shown that eye
movements have intrinsic value to the therapeutic Mobile App Selection Criteria
change process, the complexities of those remain to
be explored (Lee & Cuijpers, 2013). EMDR mobile apps were selected and evaluated by
Although some individuals may enjoy the inde- the research team over a period of 3 months. The
pendent self-administrative experience of mHealth inclusion criteria consisted of mHealth apps that
apps, when clients present with dissociative symp- referenced the terms EMDR, Eye Movement Desen-
toms or any form of dysregulation deficits, higher sitization and Reprocessing, BLS, and eye movements
risks associated with using such apps can be antici- in their titles or descriptions. The research team
pated. Thus, there is grave concern about unstable searched for these apps on both iOS (iPhone, iPad)
and/or dissociative clients accessing disturbing and Android operating systems, and initially discov-
memories without the guidance of a trained clini- ered 17 iOS apps and 8 Android apps.
cian. EMDR therapy is a powerful treatment, and The inclusion criteria were as follows. First, the app
therapists are trained to assist clients who can expe- had to claim that it was utilizing EMDR techniques or
rience intense reactions or who get “stuck” in the theory. For instance, one of the apps stated that it was
disturbing memory. Some clients are overwhelmed inspired by EMDR, but did not claim to utilize any of
with strong emotions, while others dissociate and the techniques or theory, so it was excluded. Second,
require therapeutic assistance for grounding and apps needed to be accessible in order to evaluate them,
restabilizing. Others recall associated memories so they had to be downloadable in the United States, the
and/or have new insights, and clinicians are trained location of the research team. Three of the apps were not
to work with this material and to optimize potential accessible in the United States, and had to be excluded
transformative changes to the targeted memory. It as a result. Third, some apps had multiple versions, for
is possible that many individuals would not achieve example, there were four versions of EyeMove EMDR
this outcome without therapeutic guidance in the Trauma Therapy, so the research team decided to
treatment session. include only the latest and most updated version of each
Additionally, despite having a structured app. Finally, two of the remaining apps were present on
protocol, EMDR therapy remains a highly relational both iOS and Android operating systems; hence, only
process. According to common factors research, the the iOS versions of those apps were included in order to
therapeutic relationship has a significant influence avoid repetition and redundancy.
Journal of EMDR Practice and Research, Volume 12, Number 1, 2018 5
Review of Mobile Apps for EMDR
EMDR_Vol012-001_A1.indd 5 1/18/2018 8:45:53 PM
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