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Research suggests that eye movement desensitization and reprocessing (EMDR) therapy may help reduce cravings in people addicted to drugs and alcohol. We spoke to Dr Wiebren Markus, from the Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), about how this treatment approach works.

Usually used to treat post-traumatic stress disorder (PTSD), EMDR involves the client recalling a traumatic memory while simultaneously moving their eyes side to side. This ‘dual-task paradigm’ is believed to tax the brain’s working memory, which helps reprocess the traumatic memory and reduce its emotional charge, making it less likely to elicit strong levels of distress when it is re-activated.

It’s thought a similar approach may help reduce cravings – a significant driver of substance use – in people with addictions. Dr Wiebren Markus is developing an adapted, addiction-focused EMDR therapy protocol called CARE (craving and addiction reprocessing with EMDR). The idea is that the mental representations that elicit cravings are re-stored in long-term memory during EMDR (a process known as reconsolidation) in such a way that they no longer elicit cravings when activated.

No trauma focus

Unlike traditional EMDR, Dr Markus’ approach doesn’t focus on traumatic memories, even when trauma has played a role in the addiction: “We believe that events that are historically relevant to the onset and escalation of substance use do not primarily maintain it, once an addiction has been established. People who develop an addiction as a reaction to trauma may benefit from trauma treatment, but in many cases, it doesn’t have an ongoing effect on alcohol or drug use.”

Instead, the researchers argue that mental representations generate cravings, and it is these that the client focuses on during treatment. EMDR therapy may work on cravings on three different levels: a low, sensorimotor level; a middle, emotional/contextual level; and a high, cognitive/identity level. Dr Markus clarifies: “Relevant mental representations may contain elements of one or more levels and working on one level may or may not spill over into the other levels.

"At the low level, mental representations are thought to be associated with craving-action loops and the immediate, physiological effects of consuming a substance. So in treatment, the therapist may ask the client to focus on a typical image of injecting a drug, while focusing on its somatosensory aspects, like preparing the substance, handling the syringe, and experiencing the immediate effects of the drug, which then triggers their craving in the here and now.

"At the middle level, future-orientated mental representations are associated with the expected emotional reward or relief of using a substance. This includes feeling-good signals like, 'I deserve a beer' (reward), or feeling shame signals like, 'I really need a drink' (relief). Therapists might guide the client to remember when they felt ashamed, and a craving would then be elicited in the treatment room.

"At the higher cognitive or identity level, mental representations are often autobiographical in nature. These may include memories where maladaptive beliefs (such as 'I need alcohol to enjoy myself,') are strong and self-efficacy beliefs are low, (such as, 'I can’t resist liquor').

"We believe it is important to identify craving and reward-related expectancies in addictions, much like identifying harm expectancies in exposure therapy with PTSD. These expectancies need to be falsified (expectancy violation) during treatment. In EMDR, we can use cognitive interweaves to provide disconfirming information. For example, the therapist might say, ‘You’ve experienced periods of craving without using cannabis, what does that tell you about your ability to tolerate craving?’.” Importantly, the therapist and client should still discuss the addiction history at the start of treatment, as this can provide information that can be used for these interweaves.

Intense cravings

It’s not yet known which types of cravings EMDR could most effectively treat. Dr Markus speculates: “I suspect that substance use disorders that are often associated with intense cravings, such as amphetamines and cocaine use disorder, may benefit more – especially if their use if clearly bound to specific triggers, like a certain mood, stimulus, or context. We know from research that arousal during retrieval is important for a clinical effect. This may be because the trauma memory representation needs to be activated to become malleable and changeable. More arousal means more activation and, in clinical practice, quicker or stronger reduction of the vividness and emotionality of a memory representation. In addictions, intense craving is likely to be associated with more arousal."

Mixed findings

Previous studies on addiction-focused EMDR therapy have been inconclusive and difficult to interpret. "Several addiction-focused EMDR protocols have been developed by clinicians, often without a research background, and tested in different groups, where the substance type, treatment setting, abstinence status at baseline, and clients' trauma history varied. Our approach is now to focus more on the direct antecedents of substance use (such as cue reactivity and preparatory behaviours) and their immediate consequences (such as changes in reinforcement value and physiological sensations), instead of on memories of events linked to the origins of the addiction".

Dr Markus hopes to conduct a randomized controlled trial in the future. In the meantime, he has conducted a small single-case experimental design study of eight inpatients with non-opioid drug use (due to be published later this year). He is also involved in a similar study in patients with gamma hydroxybutyric acid (GHB) addiction that starts in the coming months.

For clinicians who are interested in using the technique with patients, he is working on an English-language version of the CARE protocol. “At this point it will only be available for research purposes since we’re just establishing proof-of-concept. Further studies are needed to provide an evidence base for its use in clinical practice. However, given that there are no evidence-based pharmaceutical options for high cravings in those with non-opioid drug use, it might be worth considering on a case-by-case basis. At a later stage, training may become available, but it will require extensive knowledge of and experience with EMDR and addictions.”

A broader treatment plan

While the potential for EMDR with addictions is clear, Dr Markus describes it as an “add-on intervention”, on the grounds that cravings are only one of the mechanisms that need to be addressed in addiction care. “People also need care for comorbidities like ADHD (to learn or strengthen coping skills) and a motivating perspective that helps them make other choices and rebuild their lives. In addition, not everyone who struggles with addiction experiences cravings or uses substances due to cravings. So while EMDR may be able to aid craving reduction and result in a lower chance of relapse, it should be part of a broader treatment plan. To put things in perspective, the chance of relapse within a year following successful detoxification can be as high as 60-80%, depending on the substance. We only have craving-reducing medication for alcohol and opioids. There is potential to improve outcomes if treatments can be optimized by adding targeted interventions.”

Read the full article

Read the full article in the journal Addictive Behaviors

Citation: Larsen, J. K., Markus, W., Wiers, R. W., & de Jongh, A. (2025). Targeting craving with EMDR therapy: Future directions. Addictive Behaviors, 164, 108288.