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RESEARCH ON EYE MOVEMENT DESENSITIZATON AND
REPROCESSING (EMDR) AS A TREATMENT FOR PTSD
by
Richard J. McNally, PhD
Ten years
ago Shapiro (1989) modified Wolpe's (1958) systematic desensitization
therapy by re-placing progressive muscle relaxation with induced eye
movements as the þreciprocal inhibitorú of distress. Designed originally
as a treatment for traumatic memories, it was called Eye Movement Desensitization
(EMD). Its essence was as follows. After identifying a traumatic target
memory, the therapist would have the client articulate a self-referent
þnegative cognitionú associated with the memory (e.g., þI am shamefulú)
and a þpositive cognitionú (e.g., þI am honorableú) to replace the
negative one. The therapist would then move her fingers back and forth
in front of the client's eyes, instructing the client to track her
fingers visually while concentrating on the distressing memory. After
each set of 10-12 eye movements, the therapist would ask the client
to provide ratings of distress and strength of belief in the positive
cognition. The therapist would repeat this procedure until distress
subsided and belief in the positive cognition increased.
According
to Shapiro (1989), a single 50-minute session of EMD was 100% successful
in abolishing distress associated with a traumatic
memory in survivors of combat, rape, and childhood sexual or emotional
abuse. To explain these impressive results, she hypothesized that
þthe crucial compo-net of the EMD procedure is the repeated eye-movements
while the memory is maintained in awarenessú (Shapiro, 1989, p. 220).
Shortly
thereafter, Shapiro re conceptualized EMD in terms of þaccelerated
information processingú and renamed it Eye Movement Desensitization
and Reprocessing (EMDR). The shift from EMD to EMDR appears more conceptual
than procedural. The treatment, as described in a recent text (Shapiro,
1995), is very similar to the original description (Shapiro, 1989),
and Shapiro (1996) herself refers to her clinical trial as a þcontrolled
study of EMDRú (p. 211). Following Shapiro (1995, pp. 324-336), I use
the term þEMDRú in this article to denote both EMD and EMDR studies.
Interest
sparked by Shapiro's (1989) report has resulted in many studies testing
the efficacy of EMDR for trauma-exposed people. There have
been three kinds of randomized, controlled trials: comparisons against
a wait-list, comparisons against other treatments, and dismantling
studies that test the active ingredients of EMDR.
EMDR versus
Wait-list Control Conditions. Wilson et al. (1995, 1997) reported
significantly better results for trauma-exposed patients
treated with EMDR than for those randomized to a wait-list. Although
sufficiently distressed to seek therapy, nearly two-thirds of Wilson
et al.'s patients fell short of qualifying for a diagnosis of PTSD
when they entered the study. Rothbaum (1997), however, reported similarly
favorable results for rape survivors, all of whom met criteria for
PTSD. She found EMDR markedly more effective than a wait-list.
Comparing
an intervention against no treatment is common in psychotherapy research,
especially for new approaches. This design controls for certain
threats to internal validity (e.g., þspontaneousú remission associated
with the mere passage of time). However, studies testing a treatment
versus a wait-list cannot exclude the possibility that whatever benefits
achieved are merely the consequence of nonspecific (þplaceboú) factors
common to all psychotherapies. Consistent with this possibility, response
to EMDR is strongly related to suggestibility in patients with PTSD
(r = .86; Forbes et al., 1994). EMDR versus Other Treatments. Some
randomized trials have involved comparisons between EMDR and other
treatments. An advantage to this approach is that two (or more) treatments
are directly compared on patients drawn from the same pool. Inferences
about relative efficacy of different treatments are stronger than if
comparisons are made across trials that involve different therapists,
different sites, and potentially different kinds of patients (e.g.,
that vary in chronicity, comorbidity). Comparison of a
treatment against another intervention controls (at least
partly) for nonspecific effects common to any psychosocial intervention.
This design provides a stricter test of a
treatment than one incorporating only a wait-list control
condition.
Jensen (1994) found no difference between the effects of
EMDR and those of treatment-as-usual in combat veterans with PTSD, whereas
Marcus et al. (1997) found that
EMDR was more effective than treatment-as-usual (e.g.,
either psychodynamic, cognitive, or behavioral) for trauma
patients in an HMO setting. Although treatments contrasted with EMDR
possessed ecological validity, they
were unstandardized, rendering it difficult to tell whether
they were delivered appropriately.
Vaughan et al. (1994) found no differences among the
effects of EMDR, applied relaxation, and "image habituation training" in
cases of civilian PTSD, although all treatments were better than a wait-list.
Another study indicated superiority of EMDR over Rogerian active listening
therapy in young women with histories of physical and
sexual abuse (Scheck et al., 1998), and still another indicated greater
efficacy of EMDR relative to relaxation training and biofeedback in veterans
with combat-related PTSD
(Carlson et al., 1998).
Three out of five studies indicated superiority of EMDR
relative to a contrast treatment. At the very least, studies
showing greater effects of EMDR over Rogerian active
listening, relaxation, and so forth strongly imply that
EMDR contains an active ingredient not shared by these
interventions (e.g., graduated, structured imaginal exposure). These
studies are best interpreted as controlling for nonspecific, "placebo" factors
common to any psychotherapy rather than as comparisons of EMDR to an
established intervention. That is, there is no convincing evidence that
relaxation or Rogerian therapy, for example, are effective treatments
for PTSD.
Only one controlled trial has directly compared EMDR
with a reasonably well-established treatment for PTSD. In
this study, Devilly and Spence (in press) randomized
civilian PTSD patients to either EMDR or to a cognitivebehavioral intervention
inspired by Foa's work (see Foa & Rothbaum, 1998). The results revealed
that both EMDR and CBT significantly reduced symptoms in civilian PTSD,
but CBT was significantly more effective and better tolerated than EMDR.
At follow-up, patients treated with CBT continued to improve, whereas
those treated with EMDR
had begun to relapse. Dismantling Studies. The hallmark characteristic
of EMDR is induced eye movement; this feature distinguishes it
from other imaginal desensitization approaches. Because
Shapiro (1989) conjectured that eye movement was responsible for EMDR's
apparently powerful effects, researchers have compared EMDR to EMDR without
eye movements (e.g., patients focused their eyes without
moving them or the therapist tapped the patient's fingers;
Boudewyns & Hyer, 1996; Devilly et al., 1998; Gosselin &
Matthews, 1995; Pitman et al., 1996; Renfrey & Spates,
1994; Wilson et al., 1996). In all but one of the aforementioned dismantling
studies, the effects of EMDR did not differ from the effects of EMDR
minus eye movements;
unfortunately, the study suggesting positive effects of eye
movements (Wilson et al., 1996) has been criticized for
statistical and methodological problems (Lohr et al., 1998).
Taken together, these studies fail to support the hypothesis that eye
movement is "the crucial component"
(Shapiro, 1989, p. 220) in EMDR.
Two interpretations of these "dismantling" studies prevail. According
to one view, what is effective in EMDR (imaginal exposure) is not new,
and what is new (eye
movements) is not effective (McNally, in press-a). Consistent with this
interpretation, a meta-analysis revealed that EMDR produced effects similar
to those produced by
conventional behavioral and cognitive-behavior therapy
(CBT) treatments for PTSD (Van Etten & Taylor, 1998).
According to the other view, studies involving comparisons with EMDR
to other control manipulations (e.g., finger tapping) have merely compared
two versions of
EMDR because all "dual stimulation" procedures are
deemed fungible with eye movements (Shapiro, 1994).
Moreover, Shapiro (1995, p. 95) has also classified "forced
fixation" (of the eyes, presumably) as another acceptable
variant of EMDR.
EMDR clinicians have also argued that researchers who
have reported unimpressive results for EMDR have either
been inadequately trained or have not confirmed that they
performed the EMDR protocol with sufficient fidelity
(Greenwald, 1996). But therapists had been trained in
sanctioned EMDR workshops in 15 out of 16 studies, as
documented in one recent review (Lohr et al., 1998), and
there is no convincing evidence that fidelity to protocol
predicts outcome in EMDR treatment (e.g., Pitman et al.,
1996; Rosen, in press). Indeed, if eye movements are
therapeutically inert, it should not matter how one induces them (McNally,
in press-a). As a number of psychologists have emphasized (e.g., Rosen & Lohr
, 1997; Rosen et al., 1998), the burden of proof rests on EMDR
advocates to demonstrate that eye movements actually
have therapeutic effects; assuming that eye movements
are active (until proven otherwise) is tantamount to requesting that
critics prove the null hypothesis. EMDR as a Treatment for
Other Anxiety Disorders. EMDR has been tested as a treatment for
anxiety disorders other than PTSD. Controlled studies have shown that
EMDR is
less effective than established behavioral treatments for
phobic disorders (Muris et al., 1997, 1998), and its effect on
panic disorder appears modest (Feske & Goldstein, 1997)
relative to established cognitive-behavioral methods
(McNally, 1994, pp. 139-164). Feske and Goldstein (1997)
found that EMDR was no more effective than a condition
involving eye fixation at three months posttreatment,
although both conditions were more effective than a waitlist control.
They concluded "that EMDR should not be the
first-line treatment for this severe anxiety disorder" (Feske & Goldstein, 1997, p. 1034). Finally, EMDR clinicians
affirm its utility in the treatment of other problems (e.g.,
delusions, learning disabilities, couples therapy, AIDS,
cancer, paranoid schizophrenia, eating disorders; see
Singer & Lalich, 1996, p. 187, for a convenient summary),
but controlled studies are lacking. Summary. Although the marketing of EMDR has provoked
many lively debates, the purpose of the present article is merely to
provide a "road map" to the literature
on randomized, controlled trials. Discussion of the sociological, historical, and economic dimensions of EMDR is
available elsewhere (e.g., DeBell & Jones, 1997; Greenwald,
in press; McNally, in press-b; Rosen et al., 1998).
In summary, there are two sharply divergent views
regarding what clinical scientists should do next regarding EMDR. On the one hand, some people believe that
further research on EMDR is needed (e.g., Shapiro, 1995).
According to this view, more controlled trials comparing
EMDR to other effective treatments are warranted. Indeed, EMDR has been compared to an established PTSD
treatment in only one trial (Devilly & Spence, in press). On
the other hand, others believe that further research on
EMDR qua EMDR is unnecessary (e.g., Rosen et al., 1998).
According to this view, EMDR is distinguished from
traditional desensitization treatments by its addition of
induced eye movements to imaginal exposure, and if the
defining element of EMDR is therapeutically inert, then
there is little reason to investigate EMDR qua EMDR.
Finally, there is at least one point on which EMDR
advocates and critics can agree. People should read the
primary literature carefully, and arrive at their own conclusions regarding
the merit of the method.
REFERENCES
FOA, E.B. & ROTHBAUM, B.O. (1998). Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York: Guilford
Press.
MCNALLY, R.J. (1994). Panic disorder: A critical analysis. New
York: Guilford Press.
SINGER, M.T. & LALICH, J. (1996). " Crazy" therapies: What are they? Do they work? San Francisco: Jossey-Bass.
WOLPE, J. (1958). Psychotherapy by reciprocal inhibition.
Stanford: Stanford University Press.
SELECTED ABSTRACTS
BOUDEWYNS, P.A. & HYER, L.A. (1996). Eye movement
desensitization and reprocessing (EMDR) as treatment for posttraumatic stress disorder (PTSD). Clinical Psychology and Psychotherapy, 3, 185-195. EMDR is a new and controversial cognitivebehavioural treatment technique that combines cognitive processing and exposure methodology to treat conditioned emotional responding and other trauma-related symptoms. EMDR is
controversial in part due to initial excessive claims by its originator, Francine Shapiro, and also because of what many believe to
be Shapiro's proprietary emphasis in controlling who may use
the technique with patients. In this paper our aim is to take an
objective look at the process and effectiveness of this technique.
The purpose here is to (1) offer a brief objective review of the
outcome literature to date on EMDR; (2) present a short summary
of results of an `early look' at an ongoing controlled study of this
method that we are presently conducting; (3) speculate on the
merits of this approach based on both scientific and clinical
experience with EMDR and (4) offer a brief description of the
evolved process of EMDR along with a commentary on that
process.
CARLSON, J.G., CHEMTOB, C.M., RUSNAK, K., HEDLUND,
N.L., MURAOKA, M.Y. (1998). Eye movement desensitization and reprocessing (EMDR) treatment for combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3-24. Despite
the clinical and social impact of PTSD, there are few controlled studies
investigating its treatment. In this investigation, the effectiveness of two psychotherapeutic interventions for
PTSD were compared using a randomized controlled outcome
group design. 35 combat veterans diagnosed with combat-related PTSD were treated with either (a) 12 sessions of EMDR (n
= 10), (b) 12 sessions of biofeedback-assisted relaxation (n = 13),
or (c) routine clinical care, serving as a control (n = 12). Compared
with the other conditions, significant treatment effects in the
EMDR condition were obtained at posttreatment on a number of
self-report, psychometric, and standardized interview measures.
Relative to the other treatment group, these effects were generally
maintained at 3-month follow-up. Psychophysiological measures reflected an apparent habituation effect from pretreatment
to posttreatment but were not differentially affected by treatment
condition.
DEBELL, C. & JONES, R.D. (1997). As good as it seems?: A
review of EMDR experimental research. Professional Psychol ogy: Research and Practice, 28, 153-163. The article reviews 7 experimental
studies that examined EMDR treatment. The 7 studies varied greatly
in their complexity, their designs, how
treatment effects were measured, and their results. Each study
is detailed and critically examined. A summary of results is
provided as well as suggestions for clinical application and
future research. In addition, questions are raised regarding F.
Shapiro's approach to disseminating information about EMDR.
DEVILLY, G.J. & SPENCE, S.H. (in press). The relative efficacy and treatment distress of EMDR and a cognitive behavioral trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal of Anxiety Disorders. The growing
body of research into treatment efficacy with PTSD has, byand-large,
been limited to evaluating treatment components or
comparing a specific treatment against wait-list controls. This
has led to 2 forms of treatment, EMDR and Cognitive Behavioral
Therapy (CBT), vying for supremacy without a controlled study
actually comparing them. This research compared EMDR and
a CBT variant (Trauma Treatment Protocol, TTP) in the treatment of PTSD, via a controlled, clinical study using therapists
trained in both procedures. It was found that TTP was both
statistically and clinically more effective in reducing pathology
related to PTSD and that this superiority was maintained and, in
fact, became more evident by 3-month follow-up. These results
are discussed in terms of past research and directions for future
research are suggested.
DEVILLY, G.J., SPENCE, S.H., & RAPEE, R.M. (1998). Statistical and reliable change with eye movement desensitizat and reprocessing: Treating trauma within a veteran popula tion. Behavior Therapy, 29, 435-455. Fifty-one war veterans with
PTSD symptomatology were randomly allocated to 1 of 3 conditions: 2 sessions of EMDR, an equivalent procedure without
EMDR, or a standard psychiatric support control condition.
There was an overall significant main effect of time from preto
posttreatment, with a reduction in symptomatology for all
groups. However, no statistically significant differences were
found between the groups. Participants in the 2 treatment conditions were more likely to display reliable improvement in
trauma symptomatology than subjects in the control group. By
6-month follow-up, reductions in symptomatology had dissipated and there were no statistical or reliable differences between the 2 treatment groups. Overall, the results indicated that,
with this war veteran population, improvement rates were less
than has been reported in the past. Also, where improvements
were found, eye movements were not likely to be the mechanism
of change. Rather, the results imply that other nonspecific or
therapeutic processes may account for any beneficial effects of
EMDR.
JENSEN, J.A. (1994). An investigation of eye
movement desensitization and reprocessing (EMD/R) as
a treatment for
posttraumatic stress disorder (PTSD) symptoms of Vietnam
combat veterans. Behavior Therapy, 25, 311-325. EMDR was investigated
with 25 Vietnam combat veterans with PTSD, randomly assigned to EMDR
or a control condition. First, PTSD was assessed and subjects were assisted in developing a PTSD-related
treatment goal. Subjective anxiety and a belief in a positive
cognition related to war trauma were also assessed. Second,
EMDR subjects were then seen for one history-taking session and
two treatment sessions. Approximately 17 days after the initial
assessment, repeat assessments of PTSD symptomatology, goal
attainment, subjective anxiety, and belief in desired positive
cognitions were conducted. Overall, EMDR showed little effectiveness in this study. Although effective in reducing in-session
subjective anxiety, EMDR was not effective in improving other
PTSD symptoms, in contributing to goal attainment, or in increasing subjects' beliefs in their desired positive cognition. The results
imply that EMDR may not be successful in treating Vietnam
combat veterans with PTSD.
LOHR, J.M., TOLIN, D.F., & LILIENFELD, S.O. (1998).
Efficacy of eye movement desensitization and reprocessing: Im plications for behavior therapy. Behavior Therapy, 29, 123-156. The
commitment of behavior therapy to empiricism has led it to a prominent
position in the development of validated methods
of treatment. The recent development and rapid expansion of
EMDR, a treatment that bears a resemblance to behavioral
techniques and that has been proposed as an alternative to such
techniques for numerous psychological disorders, raises important questions for the field of behavior therapy. In this article,
we examine 17 recent studies on the effectiveness of EMDR and the
conceptual analysis of its mechanisms of action. The research
we review shows that (a) the effects of EMDR are limited largely
or entirely to verbal report indices, (b) eye movements appear to
be unnecessary for improvement, and (c) reported effects are
consistent with non-specific procedural artifacts. Moreover, the
conceptual analysis of EMDR is inconsistent with scientific
findings concerning the role of eye movements. Implications of
the empirical and theoretical literature on EMDR for behavior
therapy are discussed.
MARCUS, S.V., MARQUIS, P., & SAKAI, C. (1997). Controlled study of treatment of PTSD using EMDR in an HMO setting.
Psychotherapy, 34, 307-315. Sixty-seven individuals diagnosed with
PTSD were randomly assigned to either EMDR treatment or Standard
Care (SC) treatment. Participants were assessed pretreatment, after 3 sessions, and at the completion of treatment
using the Symptom Checklist-90, Beck Depression Inventory,
Impact of Events Scale, Modified PTSD Scale, Spielberger StateTrait Anxiety Inventory, and Subjective Units of Disturbance. In
addition, an independent evaluator assessed participants using
DSM-III-R criteria for PTSD including Global Assessment of
Functioning at the 3 data points. The individuals in the EMDR
treatment group showed significantly greater improvement with
greater rapidity than those in the SC treatment group on measures of PTSD, depression, anxiety, and general symptoms. Participants who received EMDR treatment used fewer medication
appointments for their psychological symptoms and needed
fewer psychotherapy appointments.
MCNALLY, R.J. (in press-b). EMDR and mesmerism: A comparative historical analysis. Journal of Anxiety Disorders. EMDR is among
the fastest growing interventions in the annals of psychotherapy.
Although many psychologists have commented on its
presumably unusual origins and dissemination, history reveals
its many parallels with Mesmerism, a previous therapy that
spread rapidly throughout 18th century Europe and America.
The purpose of this article is to document the many striking
similarities between the history of Mesmerism and the history of
EMDR.
PITMAN, R.K., ORR, S.P., ALTMAN, B., LONGPRE, R.E.,
POIRE, R.E., & MACKLIN, M.L. (1996). Emotional processing during
eye movement desensitization and reprocessing therapy
of Vietnam veterans with chronic posttraumatic stress disor der. Comprehensive Psychiatry, 37, 419-429. This study examined emotional
processing and outcome in 27 Vietnam veterans with chronic PTSD
who underwent EMDR therapy, with and without
the eye movement component, in a crossover design. Results
supported the occurrence of partial emotional processing, but
there were no differences in its extent in the eye-movement
versus eyes-fixed conditions. Therapy produced a modest to
moderate overall improvement, mostly on the Impact of Event
Scale. There was slightly more improvement in the eyes-fixed
than eye-movement condition. There was little association between the extent of emotional processing and therapeutic outcome. In our hands, EMDR was at least as efficacious for combatrelated PTSD as imaginal flooding proved to be in a previous
study, and was better tolerated by subjects. However, results
suggest that eye movements do not play a significant role in
processing of traumatic information in EMDR and that factors
other than eye movements are responsible for EMDR's therapeutic
effect.
ROSEN, G.M. (in press). Treatment fidelity
and research on eye movement desensitization and reprocessing
(EMDR). Journal of Anxiety Disorders. EMDR was introduced
by F. Shapiro (1989)
as a treatment for PTSD. When controlled studies failed to
support the extraordinarily positive findings and claims made by
Shapiro, proponents of EMDR raised the issue of treatment
fidelity and criticized researchers for being inadequately
trained.
This paper considers the issues raised by EMDR proponents.
It is concluded that treatment fidelity has been used as a specious,
distracting issue that permits the continued promotion of EMDR
in the face of negative empirical findings. Clinical psychologists
are urged to remember the basic tenets of science when evaluating extraordinary claims made for novel techniques.
ROTHBAUM, B.O. (1997). A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims. Bulletin of the
Menninger Clinic, 61, 317-334. EMDR is a new method developed
to treat PTSD. This study evaluated the efficacy of EMDR compared to a no-treatment wait-list control in the treatment of PTSD
in adult female sexual assault victims. 21 subjects were entered
and 18 completed. Treatment was delivered in 4 weekly individual sessions. Assessments were conducted preand posttreatment and 3 months following treatment termination by an independent assessor kept blind to treatment condition. Measures
included standard clinicianand self-administered PTSD and
related psychopathology scales. Results indicated that subjects
treated with EMDR improved significantly more on PTSD and
depression from preto posttreatment than control subjects,
leading to the conclusion that EMDR was effective in alleviating
PTSD in this study.
SCHECK, M.M., SCHAEFFER, J.A., & GILLETTE, C. (1998).
Brief psychological intervention with traumatized young
women: The efficacy of eye movement desensitization and
reprocessing. Journal of Traumatic Stress, 11, 25-44. To study the efficacy
of EMDR with traumatized young women, 60 women between the ages of
16 and 25 were randomly assigned to 2
sessions of either EMDR or an active listening (AL) control.
Factorial ANOVA interaction effects and simple main effects for
measures (Beck Depression Inventory, State-Trait Anxiety Inventory,
Penn Inventory for PTSD, Impact of Event Scale, Tennessee Self-Concept
Scale) indicated significant improvement for both
groups and significantly greater pre-post change for EMDRtreated participants.
Pre-post effect sizes for the EMDR group averaged 1.56 compared to
0.65 for the AL group. Despite treatment brevity, the posttreatment
outcome variable means of EMDRtreated participants compared favorably
with nonpatient or successfully treated norm groups on all measures.
SHAPIRO, F. (1989). Efficacy of the Eye Movement Desensitization procedure in the treatment of traumatic memories.
Journal of Traumatic Stress, 2, 199-223. The aim of the study was to determine
the effectiveness of the recently developed Eye Movement Desensitization
(EMD) procedure on traumatic memory symptomatology. 22 subjects suffering
from symptoms related to
traumatic memories were used in the study. All had been victims
of traumatic incidents concerning the Vietnam War, childhood
sexual molestation, sexual or physical assault, or emotional abuse.
Memories of the traumatic incident were pivotal to the presenting
complaints which included intrusive thoughts, flashbacks, sleep
disturbances, low self-esteem, and relationship problems. Dependent
variables were (1) anxiety level, (2) validity of a positive self-statement/assessment
of the traumatic incident, and (3) presenting complaints. These measures
were obtained at the initial
session and at 1and 3-month follow-up sessions. The results of
the study indicated that a single session of the EMD procedure
successfully desensitized the subjects' traumatic memories and
dramatically altered their cognitive assessments of the situation,
effects that were maintained through the 3-month follow-up
check. This therapeutic benefit was accompanied by behavioral
shifts which included the alleviation of the subjects' primary
presenting complaints.
SHAPIRO, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford
Press. This book reviews research and development; discusses theoretical
constructs and possible underlying mechanisms; and presents protocols
and procedures for treatment of
adults and children with a range of complaints. Among the
many clinical populations for whom the material in this volume
is applicable are victims of sexual abuse, violence, combat, grief,
and phobias. To assist the learning process, detailed descriptions
transcripts guide the clinician through every stage of therapeutic
treatment, ranging from the safety issues necessary
for appropriate client selection through the administration of
EMDR and its integration within a comprehensive treatment
plan. Only licensed mental health professionals, or those under
direct supervision of licensed clinicians, should use the procedures
and protocols in this book. The book has been written with four kinds
of readers in mind: academicians, researchers,
clinicians, and clinical graduate students. [Adapted from Text]
VAUGHAN, K., ARMSTRONG, M.S., GOLD, R., O'CONNOR,
N., JENNEKE, W., & TARRIER, N. (1994). A trial of eye movement desensitization compared to image habituation training
and applied muscle relaxation in post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 25, 283-291.
36 patients with PTSD were randomly allocated to individual treatment
with imaginal exposure (image habituation
training IHT), or applied muscle relaxation (AMR) or eye
movement desensitization (EMD). Assessment by a blind independent rater
and self-report instrument applied pre and posttreatment and at 3-month
follow-up indicated that all groups improved significantly compared
with a waiting list and that
treatment benefits were maintained at follow-up. Despite a failure
to demonstrate differences among groups, there was some suggestion
that immediately after treatment EMD was superior
for intrusive memories.
WILSON, D.L., SILVER, S.M., COVI, W.G., & FOSTER, S.
(1996). Eye movement desensitization and reprocessing: Effectiveness and autonomic correlates. Journal of Behavior Therapy
and Experimental Psychiatry, 27, 219-229. 18 subjects distressed by memories
of a specific traumatic event were randomly assigned to a single session
of 1 of 3 conditions: EMDR, a Time Interval
Condition (TIC), or Tapping Alternate Phalanges (TAP). All
subjects treated in the EMDR group showed desensitization as
monitored by SUDs, which correlated with the physiological
data and cessation of pronounced symptomatology. Only 1
subject in a control group showed desensitization. Compared to
TIC and TAP, autonomic measures showed distinct changes
during EMDR: (1) respiration synchronized with the rhythm of
the eye movements in a shallow, regular pattern; (2) heart rate
slowed significantly overall; (3) systolic blood pressure increased
during early sets, invariably declined during abreactions, and
decreased overall; (4) fingertip skin temperature consistently
increased; and (5) the galvanic skin response consistently decreased
in a clear "relaxation response." This relaxing effect of
the eye movements suggests that at least one of the mechanisms
operating during EMDR is desensitization by reciprocal inhibition, by pairing emotional distress with an unlearned or "compelled" relaxation response.
WILSON, S.A., BECKER, L.A., & TINKER, R.H. (1995). Eye
movement desensitization and reprocessing (EMDR) treatment
for psychologically traumatized individuals. Journal of Consulting and Clinical Psychology, 63, 928-937. The effects of 3 90-minute EMDR
treatment sessions on traumatic memories of 80 participants were studied.
Participants were randomly assigned to treatment or delayed-treatment
conditions and to 1 of 5 licensed
therapists trained in EMDR. Participants receiving EMDR showed
decreases in presenting complaints and in anxiety and increases in positive
cognition. Participants in the delayed-treatment condition showed no
improvement on any of these measures across the 30 days before treatment,
but after treatment participants in
the delayed-treatment condition showed similar effects on all
measures. The effects were maintained at 90-day follow-up.
ADDITIONAL CITATIONS
Annotated by the Editors
FESKE, U. (1998). Eye movement desensitization and reprocessing treatment for posttraumatic stress disorder. Clinical
Psychology: Science and Practice, 5, 171-181.
Critically reviews the empirical evaluations of EMDR and concludes that more research is needed. Attention to several issues
is suggested: control conditions, dose, treatment fidelity and
quality, and long-term follow-up. Further research into the
mechanisms underlying the efficacy of EMDR is suggested.
FESKE, U. & GOLDSTEIN, A.J. (1997). Eye movement desensitization and reprocessing treatment for panic disorder: A
controlled outcome and partial dismantling study. Journal of
Consulting and Clinical Psychology, 65, 1026-1035. Randomly
assigned 43 panic disorder patients to 6 sessions of EMDR, EMDR without
eye movements, or a waiting list. At
posttreatment, the EMDR group differed from the wait list
participants on all primary outcomes, and from the EMDR
without eye movements group on 2 of 5 primary outcomes. The
two EMDR groups did not differ at 3-month follow-up.
FOA, E.B. & MEADOWS, E.A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual
Review of Psychology, 48, 449-480. Critically reviews the empirical
literature on PTSD treatment. The authors provide information about
assessment and methods
for treatment outcome research, along with information about
crisis intervention, hypnotherapy, psychodynamic treatment,
and cognitive-behavioral treatment, including EMDR. Considerations
for special populations are included.
FORBES, D., CREAMER, M., & RYCROFT, P. (1994). Eye movement desensitization and reprocessing in posttraumatic
stress disorder: A pilot study using assessment measures.
Journal of Behavior Therapy and Experimental Psychiatry, 25, 113120.
Administered EMDR to 5 men and 3 women who had PTSD.
PTSD and other symptoms improved from pretreatment to posttreatment
and remained low at follow-up. Four patients no longer met criteria
for PTSD at follow-up, and improvement was
associated with decreases in muscle tension.
GOSSELIN, P. & MATTHEWS, W.J. (1995). Eye movement
desensitization and reprocessing in the treatment of test
anxiety: A study of the effects of expectancy and eye movement.
Journal of Behavior Therapy and Experimental, 26, 331-337. Randomly
assigned 41 undergraduates with test anxiety to receive EMDR with or
without eye movements under conditions of either high or low expectancy.
Improvement in anxiety
was observed for both EMDR conditions, and there were no
effects of expectancy.
GREENWALD, R. (1996). The information gap in the EMDR controversy. Professional
Psychology: Research and Practice, 27, 67-72.
Argues that the pronounced differences in the EMDR literature
between favorable and unfavorable positions can be traced to an
information gap between those with and those without formal
EMDR training. Treatment fidelity is presented as a critical
factor, and suggestions are presented for publication standards,
research, and training.
GREENWALD, R. (in press). The power of suggestion: Comment on "EMDR and Mesmerism: A comparative historical
analysis." Journal of Anxiety Disorders. Critiques McNally's
(in press-b) comparative analysis of EMDR and mesmerism. Among the
criticisms offered are an unstated
anti-EMDR agenda and a lack of references favorable to EMDR.
Suggestions for future research are provided.
MCNALLY, R.J. (in press-a). On eye movements and animal magnetism: A reply to Greenwald's defense of EMDR.
Journal of Anxiety Disorders. McNally (in press-b) responds
to a criticism by Greenwald (in press) of the paper by McNally (in
press-b). The author refutes
Greenwald's claims that his purpose was to debunk EMDR.
MURIS, P., MERCKELBACH, H., HOLDRINET, I., &
SIJSENAAR, M. (1998). Treating phobic children: Effects of
EMDR versus exposure. Journal of Consulting and Clinical
Psychology, 66, 193-198. Randomly
assigned 26 spider-phobic children to receive either EMDR, in vivo
exposure, or an exposure control treatment.
After evaluating the effectiveness of these interventions, the
investigators delivered in vivo exposure to all children. Only
exposure showed effectiveness on all outcome measures after
the initial treatment; EMDR showed effectiveness on self-reported phobia
but not on behavioral avoidance.
MURIS, P., MERCKELBACH, H., VAN HAAFTEN,
H., &
MAYER, B. (1997). Eye movement desensitization and reprocessing versus exposure in vivo: A single-session crossover
study of spider-phobic children. British Journal of Psychiatry,
171, 82-86. Randomly assigned 22 spider-phobic children to receive
EMDR and in vivo exposure in a cross-over design. The treatments
were comparable in terms of their effects on self-reports. Although
both treatments had effects on behavioral avoidance, exposure was relatively
more effective.
RENFREY, G. & SPATES, C.R. (1994). Eye movement desensitization: A partial dismantling study. Journal
of Behavior Therapy
and Experimental Psychiatry, 25, 231-239. Randomly assigned
23 participants to one of 3 conditions: EMDR; EMDR with eyes fixed;
and EMDR in which eye movement was
stimulated by a light tracking task. All groups improved at
posttest and were comparable in the amount of treatment gains,
which were maintained at 1-3 month follow-up.
ROSEN, G.M. & LOHR, J. (1997). Can eye movements cure
mental ailments? NCAHF [National Council Against Health Fraud]
Newsletter: Quality in the Health Marketplace, 20, 1. Critically comments
on the development of EMDR and on the
acceptance of the technique by professionals before the value of
eye movements was empirically evaluated.
ROSEN, G.M., LOHR, J.M., MCNALLY, R.J., & HERBERT,
J.D. (1998). Power Therapies, miraculous claims, and the
cures that fail. Behavioural and Cognitive Psychotherapy, 26, 99101.
Comments on a class of new therapeutic techniques that have
been promoted as rapid treatments for PTSD and other disorders,
with EMDR described as the most widely known of these techniques.
Questions about the theoretical foundations for these techniques are
raised.
ROSEN, G.M., MCNALLY, R.J., LOHR, J.M., DEVILLY, G.J.,
HERBERT, J.D., & LILIENFELD, S.O. (1998). A realistic appraisal
of EMDR. California Psychologist, 31, 25, 27. Critically comments
on several issues related to the interpretation of the efficacy data
from EMDR: the comparable efficacy observed with
eyes-fixed control conditions, the other components of EMDR, and the
question of treatment fidelity in studies
that failed to find support for EMDR.
SHAPIRO, F. (1994). Alternative stimuli in the use of EMD(R) [letter]. Journal of Behavior Therapy and Experimental Psychiatry,
25, 89. Notes that EMDR training includes instruction on the
use of hand taps and auditory signals as alternative to eye movements
in
EMDR. Suggestions for future research are offered.
SHAPIRO, F. (1996). Eye Movement Desensitization and Reprocessing
(EMDR): Evaluation of controlled PTSD research.
Journal of Behavior Therapy and Experimental Psychiatry,
27, 209-218. Critically reviews the controlled studies of EMDR
for treating PTSD and concludes that the bulk of the evidence supports
EMDR as an empirically-validated treatment. The author argues
that some studies have been clinically inadequate and suggests
standards for future research including fidelity checks, the use of
appropriate measures, and assessment of comorbid conditions.
VAN ETTEN, M.L. & TAYLOR, S. (1998). Comparative efficacy
of treatments for posttraumatic stress disorder: A metaanalysis.
Clinical Psychology and Psychotherapy, 5, 126-144. Conducted
a meta-analysis of 61 studies of treatment for PTSD. Psychological
therapies were more effective than drug therapies. EMDR and behavior
therapy were the most effective
psychological therapies and were comparable in terms of their
effectiveness across outcomes.WILSON, S.A., BECKER, L.A., & TINKER,
R.H. (1997). Fifteenmonth
follow-up of eye movement desensitization and reprocessing (EMDR)
treatment for posttraumatic stress disorder and psychological
trauma. Journal of Consulting and Clinical
Psychology, 65, 1047-1056. Conducted a 15-month follow-up of
66 patients who were previously treated with EMDR. Treatment gains
were comparable among the 32 patients with PTSD and the 34 who did
not have
PTSD. Substantial treatment effects remained at follow-up, with
an average treatment effect size of 1.59.
The PILOTS database can be used to find many kinds of
information on treatments for PTSD. The PILOTS Thesaurus contains descriptors
for recognized therapies, and new ones are added when it becomes apparent
that the literature warrants them. The descriptor "eye movement desensitization" is
applied to all publications on EMDR, so it is easy to locate papers
on this subject. If you are using the
Web interface to the PILOTS database, just pull down the PILOTS
UPDATE list
of search indexes, select "descriptor" and type "eye
movement desensitization" into the box. There are more
than 40 descriptors for the various psychotherapies, as
well as 18 for drug therapies and several for other forms of
treatment.
What if you are searching for literature on a very new or
a very specialized treatment, and you can find no appropriate descriptor
in the PILOTS Thesaurus? Then you should use natural language searching.
Select "topic" from
the list of search indexes, and type in the word or phrase
that best describes what you are looking for. For example,
if you were looking for literature on dimensional therapy,
you would type in those two words. If they appeared in
either the title or the abstract of one or more documents
indexed in the database, your search would retrieve those
publications. (As this is written, that phrase occurs in
neither PILOTS nor PSYCINFO, but there is no telling
when somebody will apply it to a newly conceived treatment.)
You can use the PILOTS database to refine the search
further by focusing on a particular approach to a treatment.
The descriptor "treatment effectiveness" is applied to all
papers that attempt to evaluate the efficacy of a treatment,
and when appropriate "clinical trial" or "randomized clinical trial" is
used to show how that evaluation was reached. Or perhaps your concern
is with the mechanics of administering a treatment. The descriptor "psychotherapeutic
processes" is applied to those publications that examine
the interaction between therapist and patient. Specific
aspects of that interaction are indexed under "countertransference" or "transference," and "manual-based
treatments" is used when the paper discusses the use of a
treatment manual.
As with any kind of literature searching, there is a tradeoff between
simplicity and power. The Web interface to the PILOTS database permits
quick, easy searching of the
literature, but does not support the complex combination
of terms and result sets that the more robust but less userfriendly
textual interface allows. The Web interface offers an "expert search" option
that contains some of the advanced features found in the textual interface.
It is a good idea to regard literature searching as an area
of expertise comparable to statistical methodology. If you
suspect that your research requires more familiarity with
the techniques of bibliographical database searching than
you possess, you would be well advised to consult an
expert: a reference librarian or an experienced literature
searcher. In designing the PILOTS database, we have tried
to follow the adage that "things should be made as simple
as possible-but no simpler." The traumatic stress literature is international,
interdisciplinary-and complex. The PILOTS database is a powerful tool
for finding your way
through this literature. As with any tool, the skill with
which it is used has a lot to do with the results you will
obtain.
CONTROL
GROUPS IN PSYCHOTHERAPY RESEARCH Paula P. Schnurr, Ph.D.
A good understanding
of the role of control groups in psychotherapy research is necessary
for interpreting the results of studies designed to evaluate the
efficacy of EMDR or other psychological interventions. The goal in
a true experiment is to hold all irrelevant variables constant while
manipulating the variable(s) of interest. Accomplishing this level
of control in a drug study is relatively straightforward given that
excellent control can be provided by administration of a placebo
that appears identical to the drug under investigation. In a psychotherapy
study, it is not possible to achieve this level of control
even with randomization, blinding, and other methodological features
designed to enhance validity.
Thus, the question is not "What is an appropriate control
group for evaluating a new psychotherapy?" but rather,
"What inferences can be drawn given the type of therapy
control group that is used?" A number of authors have
discussed this issue, but Borkovec (1993) provides an
especially helpful framework. He distinguishes psychotherapy research
designs based on the nature of the comparison group. In a no-treatment comparison
design, participants in a
comparison group are assigned to a wait-list. This type of
design is extremely useful in the early stages of investigation on
a given treatment because it rules out numerous threats to internal validity.
It is a very efficient way to
determine whether a treatment is effective. The major
drawback is that it provides no basis for inferring why that
treatment is effective. A nonspecific comparison design provides somewhat
more information about the mechanism behind a given therapy's effectiveness
by attempting to
control for the nonspecific effects of psychotherapy. If the
therapy is shown to be effective relative to a placebo-like
therapy or care as usual, there is greater certainty that the
effectiveness is not merely due to factors that all therapies
have in common, such as therapist contact and the expectancy of improvement.
However, Borkovec (1993) argues that a dismantling design is the optimal way to control for nonspecific factors and
to generate data that provide more certainty about the mechanism of
action behind any type of psychotherapy. In
this design, an investigator systematically varies the active
elements of a technique, usually including all elements in
one condition. Sometimes the distinction between nonspecific designs
and dismantling designs can be blurry, e.g., a "supportive" counseling
condition can be used in either, depending on the extent of comparability
between the
supportive and active conditions. Lastly, Borkovec discusses comparative
designs, in which active treatments are compared with one another.
His view of such designs is
quite negative, because active-active comparisons in practice often
include inadequate control for differences in the quality with which
each therapy is delivered. Nevertheless, these designs are widely used
and can provide data of
great practical significance if the different therapies can be
equated for nonspecific factors and therapist quality, e.g.,
to compare treatments that vary greatly in cost.
So, what inferences can be drawn given the types of
control groups that have been used in EMDR research? The
studies that have compared EMDR to a wait-list control
provided the first building block in establishing efficacy,
but they did not yield any information about the mechanism behind the
observed efficacy. The next evidence came from nonspecific comparison
designs, which helped somewhat to rule out a placebo explanation for
the effects
observed in the wait-list comparison studies. Further information about
the efficacy of EMDR has come from studies that have compared EMDR
with and without eye movements, which are classic examples of a dismantling
design.
These studies raise serious questions about the role of eye
movements in the efficacy of EMDR, but it is important to
remember that they do not invalidate the efficacy findings-they merely
indicate that the mechanism of action is unlikely to involve the hypothesized
relationship between
eye movements and brain activity. Whether it is the imaginal exposure
component is hard to say at present. Dismantling designs need to go
further in order to disentangle the role of imaginal exposure relative
to other elements of
EMDR. EMDR appears to compare favorably to cognitivebehavioral treatment,
but the amount of evidence from comparative studies is too limited
to support a firm conclusion. Additional comparative research, with
strict quality
and fidelity controls, is needed in order generate information about
the efficacy of EMDR relative to other active treatments for PTSD.
REFERENCE
Borkovec, T.D. (1993). Between-group therapy outcome research: Design and methodology. NIDA Research Monographs,
137, 249-289.
Source: http://www.ncptsd.org/publications/rq/rqhtml/V10N1.html
The information on this Web site is presented
for educational purposes only. It is not a substitute for informed
medical advice or training. Do not use this information to diagnose
or treat a mental health problem without consulting a qualified health
or mental health care provider.
All information contained on these pages is in
the public domain unless explicit notice is given to the contrary,
and may be copied and distributed without restriction.
For more information call the PTSD Information
Line at (802) 296-6300 or send email to ncptsd@ncptsd.org.
This page was last updated on Mon Nov 20 16:39:06 2000.
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