Researchers measure whether therapists follow the Eye Movement Desensitization and Reprocessing (EMDR) protocol by evaluating something called treatment fidelity. This means checking whether the therapy was delivered according to the established procedures used in EMDR research.
Researchers commonly use recorded therapy sessions, structured checklists, and ratings from trained reviewers to assess how closely therapists follow the protocol. These methods help determine whether participants in a study received the treatment that researchers intended to investigate.
Measuring protocol fidelity is important because a study's results are easier to interpret when researchers can confirm how consistently the treatment was delivered.
What Does It Mean to Follow the EMDR Protocol?
EMDR uses a structured eight-phase treatment approach that guides how memories and associated experiences are identified, processed, and reviewed.
The eight phases are history-taking and treatment planning, preparation, assessment, desensitization, installation, body scan, closure, and reevaluation.
EMDR also uses a three-pronged approach that considers relevant past experiences, present-day triggers, and future situations.
In research, following the EMDR protocol means using the procedures relevant to the treatment being provided. Researchers examine whether important steps were completed appropriately and whether the treatment remained consistent with the study's defined approach.
This does not mean every EMDR session must look exactly alike. Different sessions may focus on different phases, and therapists may adapt the pace or timing to the person's needs while remaining within the protocol.
How Do Researchers Measure EMDR Treatment Fidelity?
Researchers use several methods to evaluate whether therapists follow the EMDR protocol. The most direct methods involve observing treatment sessions and comparing what happened with a structured set of criteria.
1. Recording Therapy Sessions
Video recordings allow trained reviewers to examine what therapists actually do during EMDR sessions.
Reviewers can observe how the therapist introduces an exercise, guides the processing of a memory, uses bilateral stimulation, and moves through relevant procedural steps.
Recordings also allow reviewers to revisit parts of a session when a rating requires closer examination.
Researchers may review every recorded session or select a sample. When sampling is used, sessions may be chosen randomly and across different therapists or treatment stages.
2. Using Structured Fidelity Checklists
A fidelity checklist identifies specific procedures that researchers expect to see during treatment.
Instead of relying on a general impression of whether a session looked like EMDR, reviewers evaluate individual actions against predetermined criteria.
For example, a checklist may examine whether the therapist:
Completed the assessment steps relevant to the target memory.
Used bilateral stimulation as part of the specified processing procedure.
Followed the appropriate sequence of processing and reassessment.
Addressed closure and reevaluation when relevant.
Applied the treatment plan consistently with the study protocol.
The exact checklist depends on the research design and the version of EMDR being evaluated.
3. Having Trained Reviewers Rate Sessions
Researchers may ask trained EMDR reviewers or other appropriately trained evaluators to examine session recordings.
These reviewers compare the therapist's actions with the requirements of the treatment protocol and assign ratings for individual components.
Using independent reviewers can provide a more objective assessment than relying only on the therapist's description of the session.
4. Reviewing Session Notes and Treatment Records
Researchers may also examine forms completed by therapists after sessions.
These records can identify which phases were addressed, which memories or situations were targeted, and whether any changes were made to the planned procedure.
Session notes are useful supporting information, although they do not provide the same direct observation as a recording.
Together, these methods provide a more complete picture of how consistently EMDR was delivered.
What Is the EMDR Fidelity Rating Scale?
One established instrument is the EMDR Fidelity Rating Scale (EFRS), developed to evaluate adherence to EMDR's standard eight-phase treatment approach and three-pronged protocol.
The scale was developed for research and has been revised over time. Version 2.1, published in January 2023, provides detailed instructions for evaluating treatment sessions.
The EFRS includes five areas of assessment:
Introductory phases: Evaluates relevant history-taking, treatment planning, and preparation procedures.
Resource Development and Installation: Evaluates adherence when this specific resource-building procedure is used.
Adverse Life Experiences Processing: Evaluates the procedures involved in assessing and processing distressing memories.
Future Template: Evaluates how the therapist applies procedures for preparing for relevant future situations.
Three-Pronged Protocol: Evaluates whether treatment planning and delivery appropriately address relevant past experiences, present concerns, and future goals.
The scale allows researchers to examine individual sessions and, where appropriate, combine results across a course of treatment.
How are fidelity scores calculated?
For most individual items, the EFRS uses a four-point rating system:
| Score | Meaning |
|---|---|
| 0 | No adherence |
| 1 | Some adherence, but inadequate |
| 2 | Acceptable adherence |
| 3 | Very good adherence |
The scale uses a score of 2.0 as the threshold for acceptable overall fidelity. Its three-pronged protocol section uses yes-or-no ratings rather than the four-point system.
The accompanying scoring workbook can calculate fidelity scores for individual sessions, therapists, and research studies.
An important detail is that not every phase is rated during every session. Reviewers assess the procedures that are applicable to the session being examined.
For example, if processing has not reached the point where installation or a body scan would normally occur, those components may not be applicable to that session's rating.
This distinction helps researchers assess adherence without treating appropriate differences between sessions as automatic protocol violations.
How Do Researchers Check Whether Fidelity Ratings Are Reliable?
A fidelity rating is more useful when different trained reviewers can evaluate the same session and reach similar conclusions.
Researchers examine this through interrater reliability, which refers to the level of agreement between people independently rating the same material.
For example, two reviewers may watch the same recorded EMDR session and complete the same fidelity checklist. Researchers then compare their scores to determine how consistently the instrument was applied.
A 2019 study by Cooper and colleagues, published in the Journal of EMDR Practice and Research, examined the reliability of a modified EMDR fidelity checklist.
The researchers first refined and tested the checklist using five recorded sessions. They then evaluated another 15 sessions and examined how consistently the two reviewers scored different treatment components.
The results showed strong agreement for most sections. The researchers also identified items that needed refinement to improve agreement in the desensitization section.
The study provided evidence that a structured checklist could reliably measure several aspects of EMDR treatment fidelity, while identifying areas requiring further validation.
This type of research is important because a fidelity instrument needs to measure protocol adherence consistently, not simply produce a numerical score.
What Does Protocol Fidelity Measurement Look Like in an EMDR Study?
A published randomized controlled trial by Covers and colleagues in 2021 provides an example of how researchers assess treatment fidelity.
The study investigated early EMDR therapy following sexual assault. The therapists had completed accredited EMDR training and received additional instruction in the study's treatment protocol.
Researchers recorded the treatment sessions and used an EMDR-specific treatment integrity checklist to evaluate adherence.
Of the 48 recorded sessions, 25% were assessed by two independent reviewers.
The researchers reported 97% treatment fidelity, with no inconsistencies between the two reviewers' assessments.
This finding indicated that the therapists in the reviewed sessions followed the study's specified EMDR procedures closely.
Importantly, this percentage describes adherence to the treatment protocol in that particular study. It does not represent the effectiveness of EMDR across studies or predict how much an individual participant will improve.
Other EMDR studies use different checklists, scoring systems, and recording samples. For this reason, fidelity percentages from separate studies are not always directly comparable.
Why Is Measuring Protocol Fidelity Important in EMDR Research?
Treatment fidelity helps researchers interpret whether the results of a study reflect the intervention that was intended to be tested.
It helps confirm what treatment was delivered.
When a study describes participants as receiving EMDR, fidelity assessments provide evidence about whether the relevant procedures were actually used.
This makes the description of the treatment more informative than relying on the treatment name alone.
It supports comparisons between research studies.
Two studies may both investigate EMDR but differ in how consistently therapists follow the protocol.
Knowing how fidelity was assessed helps researchers understand whether differences in treatment delivery may have contributed to differences in study results.
It helps identify variation between therapists.
Research studies sometimes involve several therapists working with different participants.
Fidelity assessments can help identify whether treatment procedures were applied consistently across therapists or whether meaningful differences occurred.
It improves transparency.
When researchers explain their recording methods, assessment tools, reviewer training, and fidelity scores, readers can better evaluate how the study was conducted.
Does High Protocol Fidelity Mean EMDR Was Effective?
Not necessarily. Treatment fidelity and treatment effectiveness measure different things.
Treatment fidelity evaluates whether the therapist followed the intended procedures.
Treatment effectiveness evaluates whether participants experienced improvements in the outcomes being studied, such as reduced symptoms or better everyday functioning.
A study may report high treatment fidelity while finding limited differences between treatment groups. Similarly, participants may report improvement even when the study provides little information about protocol adherence.
Researchers therefore examine fidelity and outcomes separately.
High fidelity strengthens confidence that the treatment was delivered as planned. However, it does not automatically demonstrate that the treatment produced a particular result.
What Are the Limitations of EMDR Fidelity Measurements?
Although structured fidelity assessments provide useful information, they have limitations.
Not every session may be reviewed.
Some studies rate only a sample of treatment recordings. The selected sessions may not capture every variation in how the treatment was delivered.
Ratings involve professional judgment.
Even with detailed scoring instructions, reviewers may occasionally interpret an action differently. Training and interrater reliability assessments help researchers evaluate this issue.
Fidelity tools may differ between studies.
Different research teams may use different checklists, scoring scales, or definitions of acceptable adherence. A high score on one instrument may not mean exactly the same thing as a high score on another.
Protocol adherence does not capture every aspect of treatment quality.
A fidelity score primarily describes whether specified procedures were followed. It may not fully reflect other aspects of the therapeutic interaction, such as communication, responsiveness, or the quality of the relationship between therapist and participant.
These limitations do not make fidelity assessments unhelpful. They explain why the methods used to calculate and report fidelity matter.
What Can Readers Look for When Evaluating EMDR Research?
When reading an EMDR study, it can be useful to look beyond whether the authors simply state that therapists were trained or supervised.
A clear research report may explain which fidelity checklist was used, whether sessions were recorded, how recordings were selected, who evaluated them, and whether reviewers reached consistent ratings.
It may also report the overall fidelity results and explain any departures from the planned treatment protocol.
These details help readers distinguish between a study that actively measured treatment adherence and one that primarily relied on therapist training or supervision.
They also make it easier to understand how confidently the study's findings can be connected to the particular EMDR procedures being investigated.
What Is the Main Takeaway?
Researchers measure whether therapists follow the EMDR protocol through treatment fidelity assessments.
These assessments commonly involve recorded sessions, structured checklists, trained reviewers, and numerical adherence ratings. Instruments such as the EMDR Fidelity Rating Scale provide a systematic way to evaluate relevant treatment procedures.
Fidelity measurement does not determine whether EMDR works on its own. Instead, it helps establish whether the treatment studied was delivered as intended.
By measuring both treatment fidelity and participant outcomes, researchers can provide a clearer and more reliable picture of what happened during an EMDR study and what its findings mean.
References
EMDR Research Foundation. (2023). EMDR Fidelity Rating Scale, Version 2.1.
https://www.emdrresearchfoundation.org/emdr-fidelity-rating-scale
Korn, D. L., Maxfield, L., Stickgold, R., & Smyth, N. J. (2023). EMDR Fidelity Rating Scale (EFRS): Manual, Version 2.1. EMDR Research Foundation.
https://www.escuelaemdr.com/wp-content/uploads/2023/12/EFRS-Version-2.1-Part-2-Manual.pdf
Cooper, R. Z., Smith, A. D., Lewis, D., Lee, C. W., & Leeds, A. M. (2019). Developing the interrater reliability of the modified EMDR fidelity checklist. Journal of EMDR Practice and Research, 13(1), 32–50.
https://doi.org/10.1891/1933-3196.13.1.32
Covers, M. L. V., et al. (2021). Early intervention with eye movement desensitization and reprocessing (EMDR) therapy to reduce the severity of post-traumatic stress symptoms in recent rape victims: A randomized controlled trial. European Journal of Psychotraumatology, 12(1), 1943188.
https://doi.org/10.1080/20008198.2021.1943188
De Jongh, A., et al. (2024). State of the science: Eye movement desensitization and reprocessing (EMDR) therapy. Journal of Traumatic Stress, 37(2), 205–216.
https://doi.org/10.1002/jts.23012
