EMDR vs Prolonged Exposure Therapy: What Have Studies Found?
Eye Movement Desensitization and Reprocessing (EMDR) and Prolonged Exposure (PE) therapy are two well-established trauma-focused treatments for Post-Traumatic Stress Disorder (PTSD). Both have been tested in randomized controlled trials, and both are recommended in major treatment guidelines.
Because the treatments approach traumatic memories in different ways, researchers have also compared them directly. Do those studies show that EMDR works better than Prolonged Exposure, or vice versa?
Overall, direct comparison studies have found substantial improvement with both treatments and have not established a consistent overall advantage for either one.
Some smaller studies have reported differences in areas such as how quickly symptoms improved, treatment dropout, or how much time participants spent directly engaging with traumatic memories.
Those findings are useful, but they need to be interpreted alongside larger trials and the broader evidence base.
What Is Prolonged Exposure Therapy?
Prolonged Exposure is a specific form of trauma-focused Cognitive Behavioral Therapy (CBT).
The treatment is based partly on the idea that avoiding trauma-related memories, feelings, situations, and reminders can help maintain PTSD symptoms. PE uses a structured process that helps a person gradually approach what has been avoided.
Two common components are:
Imaginal exposure, in which a person deliberately recalls and describes the traumatic experience during a treatment session.
In vivo exposure, in which a person gradually approaches safe situations, places, activities, or reminders that have been avoided because of their connection with the trauma.
The American Psychological Association describes PE as helping people gradually approach trauma-related memories, feelings, and situations that they have been avoiding. It is generally provided over about three months, often in eight to 15 sessions. (American Psychological Association)
The UK National Institute for Health and Care Excellence (NICE) includes Prolonged Exposure among the trauma-focused CBT interventions it recommends for adults with PTSD.
How Is EMDR Different?
EMDR also directly addresses distressing memories, but the treatment process is different.
During EMDR, a person brings aspects of a troubling memory to mind while engaging in bilateral stimulation, most commonly side-to-side eye movements. Treatment follows a structured series of phases that includes identifying target memories and working with associated thoughts, emotions, physical sensations, and more adaptive beliefs.
EMDR generally does not require prolonged verbal descriptions of the traumatic experience. The American Psychological Association describes it as differing from several other trauma-focused treatments because it does not rely on extended exposure to the distressing memory, detailed descriptions of the trauma, challenging beliefs, or homework as core elements. (American Psychological Association)
NICE also recommends EMDR for adults with PTSD in specified circumstances and describes a typical course as approximately eight to 12 sessions, although treatment can be longer when clinically indicated.
So while both approaches work directly with traumatic memories, what happens during treatment is noticeably different.
What Have Direct EMDR vs Prolonged Exposure Studies Found?
There are fewer studies directly comparing EMDR and Prolonged Exposure than there are studies examining either treatment separately. Still, several randomized trials provide useful evidence.
A 2005 Study of Women With PTSD Following Rape
One of the better-known direct comparisons included 74 adult women with PTSD following rape.
Participants were assigned to Prolonged Exposure, EMDR, or a waiting-list control condition. Researchers examined PTSD symptoms as well as depression, anxiety, and dissociation.
Both active treatments produced significantly greater improvement than the waiting-list condition.
Most importantly for the EMDR-versus-PE question, the researchers found no significant difference between EMDR and Prolonged Exposure in changes from the beginning of treatment to the end of treatment or at the six-month follow-up. (PubMed)
That study therefore supported both treatments rather than demonstrating that one consistently worked better.
What Did an Earlier Community Study Find?
A smaller study published in 2002 compared EMDR and Prolonged Exposure in a community clinic serving people who had experienced rape and other crimes.
The analysis included 22 participants who completed at least one active treatment session.
Both treatments significantly reduced PTSD and depression symptoms, and the improvements were maintained at the three-month follow-up.
However, the researchers also reported some differences.
After three active treatment sessions, 7 of 10 people receiving EMDR had achieved a 70% reduction in PTSD symptoms, compared with 2 of 12 receiving Prolonged Exposure. The study also reported fewer treatment dropouts among those assigned to EMDR. (PubMed)
Those results suggest that there may have been differences in treatment speed and retention in this particular study.
But the small sample is important. Results from 22 participants cannot establish that EMDR will generally work faster or have lower dropout rates than Prolonged Exposure across larger and more varied populations.
This is why individual studies are most useful when they are considered as part of the larger research picture.
What Did a Larger Randomized Trial Find?
A considerably larger randomized clinical trial compared EMDR and Prolonged Exposure with a waiting-list condition in 155 people who had both PTSD and a chronic psychotic disorder.
Participants assigned to active treatment received eight weekly 90-minute sessions of either PE or EMDR.
Both treatments produced greater reductions in PTSD symptoms than the waiting-list condition. The researchers found that both EMDR and Prolonged Exposure were effective, without evidence that one treatment had a clear overall advantage over the other on the main PTSD outcomes. (PubMed)
Follow-up research found that improvements associated with the trauma-focused treatments were maintained up to 12 months. (PubMed)
The population in this trial was different from that in many earlier PTSD studies, so its findings should not simply be generalized to everyone. But it adds to the evidence that meaningful PTSD improvement can occur with either treatment.
Have Researchers Compared Treatment Efficiency?
Yes. A 2020 randomized trial looked not only at symptom improvement but also at how efficiently the two treatments processed traumatic memories.
Twenty people with PTSD were randomly assigned to EMDR or Prolonged Exposure and received up to twelve 90-minute sessions over six weeks.
Both groups improved on PTSD symptoms as well as measures of depression, anxiety, and stress.
The researchers also measured factors such as:
total time spent engaging with traumatic memories;
the number of memories processed;
how many sessions were required for the primary target memory to reach very low levels of reported distress; and
distress levels after the first treatment session.
On these particular measures, EMDR was more efficient. Participants receiving EMDR spent less total time engaged with traumatic memories when homework was included, required fewer sessions for the primary target memory to reach very low distress, and processed more traumatic memories during treatment. (ScienceDirect)
However, this was a 20-person study. It provides interesting evidence about possible differences in how treatment proceeds, but it is much too small to establish that EMDR is always faster or more efficient than Prolonged Exposure.
For a broader examination of treatment length, see How Quickly Does EMDR Work in Research Studies?
What Do the Studies Tell Us About Symptom Improvement?
One of the most consistent findings across direct comparisons is that both treatments can substantially reduce PTSD symptoms.
The 2005 trial involving women who had experienced rape found significant improvement with both treatments and no significant difference between them through six-month follow-up. (PubMed)
The larger 2015 randomized trial also found significant PTSD improvement with both EMDR and PE compared with the waiting-list group. (PubMed)
The smaller community study found meaningful improvement with both treatments, although it identified possible differences in how quickly some participants improved. (PubMed)
Taken together, these studies do not support a simple conclusion that one treatment works while the other does not. Both have demonstrated substantial benefits in controlled research.
Do People Drop Out of One Treatment More Often?
The evidence from direct EMDR-versus-PE studies is not consistent enough to establish a clear rule.
The small 2002 community study reported fewer dropouts among participants assigned to EMDR. (PubMed)
But findings from one small trial do not tell us what will happen across all treatment settings and populations.
Dropout is also affected by many factors besides the treatment itself, including the population being studied, how treatment is delivered, the length of sessions, practical barriers to attendance, and how researchers define treatment completion.
Because dropout deserves more detailed treatment than a single comparison can provide, it is examined separately in Do People Drop Out of EMDR Less Often? What Treatment Studies Tell Us.
What Do Major Clinical Guidelines Say?
Clinical guidelines provide another way to interpret the research because guideline panels evaluate a broader body of evidence rather than relying on individual head-to-head trials.
US Department of Veterans Affairs and Department of Defense
The US Department of Veterans Affairs and Department of Defense (VA/DoD) 2023 clinical practice guideline recommends three individual, manualized trauma-focused psychotherapies for PTSD: Cognitive Processing Therapy, EMDR, and Prolonged Exposure. (Health Quality)
The guideline does not treat EMDR or PE as an unsupported alternative to the other. Both are among its specifically recommended trauma-focused psychotherapies.
National Institute for Health and Care Excellence
The National Institute for Health and Care Excellence (NICE) recommends trauma-focused CBT interventions for adults with PTSD, including Prolonged Exposure. It also recommends EMDR for adults in specified circumstances.
NICE describes both treatments as structured interventions that are typically delivered over approximately eight to 12 sessions, while recognizing that more sessions may sometimes be appropriate.
World Health Organization
The World Health Organization (WHO) includes both trauma-focused CBT and EMDR among psychological interventions that may be considered for adults with PTSD. Its updated guidance rates the overall quality of evidence for the listed psychological interventions as moderate. (World Health Organization)
These guideline recommendations are consistent with the direct-comparison research: both approaches have substantial evidence supporting their use for PTSD.
Why Is It Difficult to Say Which Treatment Is Better?
Several features of the research make a simple ranking difficult.
First, there are relatively few large trials that directly compare EMDR and Prolonged Exposure.
Second, the studies do not all examine the same populations. Some involve people who experienced sexual assault, others include broader community samples, and others examine more specific clinical groups.
Third, studies measure different things. Overall PTSD symptoms may be the main outcome in one trial, while another may also examine depression, anxiety, treatment dropout, treatment time, or how quickly an individual memory becomes less distressing.
Finally, a statistically significant difference in one outcome does not necessarily mean that one treatment is better overall.
For example, a study could find that one approach requires less time focused directly on traumatic memories while finding similar overall PTSD outcomes. Those are two different findings.
Are EMDR and Prolonged Exposure Essentially the Same Treatment?
No.
Both treatments directly address traumatic memories, but they use different procedures.
Prolonged Exposure deliberately uses repeated and structured engagement with trauma memories and safe trauma-related situations that have been avoided.
EMDR uses a structured protocol in which aspects of traumatic memories are brought to mind while bilateral stimulation is used. Extensive verbal recounting of the traumatic event is generally not required.
Similar outcomes therefore do not mean that the treatments are identical.
A related article, EMDR vs Trauma-Focused CBT: What Does the Research Show?, looks at EMDR alongside the broader family of trauma-focused CBT approaches rather than Prolonged Exposure alone.
What Can We Reasonably Conclude?
The direct research supports several conclusions.
Both EMDR and Prolonged Exposure can substantially reduce PTSD symptoms.
Larger direct comparisons have generally not found a significant overall difference between them.
Some smaller studies have found possible advantages for EMDR in areas such as early symptom reduction, dropout, or time spent directly engaging with traumatic memories. Those findings are worth studying further, but they do not establish that EMDR is universally faster or more effective.
Major clinical guidelines continue to recommend both treatments.
The research therefore supports viewing EMDR and Prolonged Exposure as different, well-supported approaches to PTSD treatment rather than one clearly established winner and one inferior treatment.
Frequently Asked Questions
Is Prolonged Exposure a type of Cognitive Behavioral Therapy?
Yes. Prolonged Exposure is a specific form of trauma-focused Cognitive Behavioral Therapy (CBT). It uses structured exposure to traumatic memories and safe reminders that have been avoided because of their connection with the trauma. (American Psychological Association)
Is EMDR a form of exposure therapy?
EMDR involves bringing aspects of distressing memories to mind, but its protocol is different from Prolonged Exposure. EMDR combines attention to the memory with bilateral stimulation and does not rely on prolonged recounting of the trauma as the central treatment procedure.
Have studies found EMDR more effective than Prolonged Exposure?
Not consistently. Several direct comparisons have found substantial improvement with both treatments and no significant difference in overall PTSD outcomes. Some smaller studies have found differences favoring EMDR on particular measures, but those findings have not established an overall advantage across the research. (PubMed)
Does EMDR work faster than Prolonged Exposure?
Some small studies have reported faster improvement or greater treatment efficiency with EMDR. However, the research is not strong enough to conclude that EMDR will generally work faster for everyone. (PubMed)
Do major guidelines recommend both treatments?
Yes. The US Department of Veterans Affairs and Department of Defense recommends both EMDR and Prolonged Exposure among its individual trauma-focused psychotherapies for PTSD, while the National Institute for Health and Care Excellence also recommends both approaches in specified circumstances. (Health Quality)
Conclusion
Studies comparing Eye Movement Desensitization and Reprocessing with Prolonged Exposure have repeatedly found that both treatments can produce substantial improvement in Post-Traumatic Stress Disorder symptoms.
Some smaller studies have identified differences in treatment speed, dropout, or the amount of time spent directly engaging with traumatic memories. Larger direct comparisons, however, have generally found similar overall PTSD outcomes.
The current research therefore does not establish that either EMDR or Prolonged Exposure is consistently superior. Instead, it supports both as well-established trauma-focused approaches that use different methods to address traumatic memories.
