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EMDR debate

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by cara susanna, Mar 19, 2012.

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  1. cara susanna

    cara susanna Predoctoral Intern

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    I figure people might be interested to read these articles on NY Times concerning EMDR, featuring Shapiro as the guest consultant.

    They first posted this article: http://consults.blogs.nytimes.com/2012/03/16/expert-answers-on-e-m-d-r/?src=recg

    Then comments started bringing up what a lot of us think (exposure with bells and whistles), so they had a follow-up, yet again with Shapiro:

    http://consults.blogs.nytimes.com/2012/03/02/the-evidence-on-e-m-d-r/

    She claims that that the studies finding EMDR to have poor relapse rates etc are seriously flawed and cites the studies supporting its efficacy.

    Thoughts?
  2. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    Until there are replicated peer-reviewed studies that can successfully tease out the 'exposure' aspect of the treatment from the eye movement...I will continue to believe it is a junk treatment. A few years ago I had a good discussion with a former mentor about the nuerological underpinnings associated with eye movement, though that is still leaps and bounds away from viewing EMDR as anything other than repackaged exposure therapy.
  3. futureapppsy2

    futureapppsy2 Ed Psych PhD student Moderator

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    Has anyone done an RCT of exposure therapy versus EMDR yet? If not, I'm kind of surprised, as it seems like a logical step.

    I was sort of bugged by the random "Harvard research" name drop in the Shapiro article, because clearly Harvard is this only institution that conducts meaningful research. /sarcasm

    But my anti-EMDR bias may be showing. ;) The process of tacking random stuff onto EBT happens a ton in schools, and it's aggravating.
    Last edited: Mar 19, 2012
  4. ClinicalABA

    ClinicalABA

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    Some meta-analyses (e.g.: Davidson, Paul R.; Parker, Kevin C. H. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, Vol 69(2), Apr, pp. 305-316.; Devilly, Grant J.(2002). Eye Movement Desensitization and Reprocessing: A Chronology of Its Development and Scientific Standing. The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, Vol 1(2), pp. 113-138.) have not supported EMDR as being more effective that exposure, and have not supported the eye-movement component as an important factor in clinical change. As pointed out by Devilly, it can be difficult to scientifically examine EMDR, as there are some unfalsifiable claims regarding its theoretical basis and the specific definition of what constitutes EMDR therapy has changed over time.
  5. cara susanna

    cara susanna Predoctoral Intern

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    Apparently they have, according to Shapiro, and it found no difference. But it doesn't sound like anyone's done a component analysis of EMDR, and that to me sounds like the logical next step.
  6. Psychadelic2012

    Psychadelic2012 PhD Student

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    I went to a conference on childhood sexual abuse and attended the (sparsely populated) session on evidence-based care. The speaker was great--and funny. He kept saying how the literature shows no difference in outcomes between EMDR and trauma-focused CBT, which supports what many of you are saying here. The thing that cracked me up is that he said the only difference is "This..." and started waving his hand back and forth in EMDR-fashion. In conclusion, he said, "Now you all can just stop doing all of this!"--again, waving his hand back and forth. It was funny.

    At my practicum site, my supervisor doesn't even use the eye movements. A suitable substitute, apparently, is using these electronic "tappers" that the client holds in their hands and an electrical sensation alternates from right to left hand with variable speeds. The practitioner can also tap the client's hands right-to-left in the same way. It really seems that EMDR appeals to this desire for this deep-seated biological mystery that appeals to clients and practitioners alike. Bah!
  7. ClinicalABA

    ClinicalABA

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    Component analyses have been done, with the general conclusion that the eye movements aren't crucial (citations in my post above).
  8. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    Well, honestly, the way I see it is that if a particular aspect of a particular treatment appeals to clients, we might as well make use of it (when possible and ethical). Given how significant the placebo effect and "buying into" treatment can be, we'd be selling ourselves short by not taking advantage of them when such opportunities present themselves.
  9. cara susanna

    cara susanna Predoctoral Intern

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    Haha, awesome. I can't remember if I've read that article or not, we read a lot about EMDR in one of my classes so I may already be familiar with it.
  10. Psychadelic2012

    Psychadelic2012 PhD Student

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    Yeah, good point. Although I definitely prefer to err on the side of evidence-based treatment, it is true that we are marketing treatments to a large extent and CBT isn't exactly very romantic, is it? :laugh:
  11. cara susanna

    cara susanna Predoctoral Intern

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    But to me the issue is that it makes therapy sound more floofy to outside people who may not buy into that eye movement stuff.
  12. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    Really? How could it be ethical? How would we be any different than the snake oil salesman or the psychic who sell their services for hundreds/thousands of dollars to compromised people? What is almost as bad is that there are clinicians out there willing to pay $$$ to get EMDR certified. It is really half a step above moodbeam therapy and rebirthing therapy.

    Do they support it in your program? I know some VAs have practitioners who use it (I'm still scratching my head at that one). EMDR caught on in the eating disorder world a number of years ago, and private practice clinicans charged boatloads of money for something behaviorists have known for a long time. What really irks me about EMDR is that I've had patients who have sought treatment from EMDR providers, and they were all indoctrinated into believing it would cure them of their PTSD, eating disorder, etc. EMDR seems to target some of the most vulnerable patients, which may or may not be coincidence. I am wary of any treatment that seems to require a dogmatic following, despite poor research findings. Trust in data, not dogma.
  13. js1221

    js1221

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    I can attest to the fact that at least for me, EMDR was extremely effective. I had the therapy, as a client.
  14. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    Haha exactly. If research suggests, for example, that EMDR and exposure have similar outcomes (owing in large part to suspected similar mechanisms), the client really wants to receive EMDR, the clinician feels competent administering it, and there's no demonstrated harm in the whole rapid eye movement "fluff," then I could potentially see it being appropriate. Anything that's going to keep a client engaged in (and even excited about) treatment and will encourage them to consistently attend sessions should at least be given some consideration, within reason.
  15. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    The difference would be in the demonstrated efficacy. Although I agree that if there's much of a cost difference (monetary or otherwise) to the client, then the treatment should be avoided. If, after education by the therapist, the client decides that they're still fully set on receiving the alternative treatment and wants to get it elsewhere, then that's his/her decision.
  16. ClinicalABA

    ClinicalABA

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    Does the client understand that they are paying for a lot of components that may not be necessary when "choosing" EMDR over exposure? Has the clinician explained that there are really administering a placebo?

    As to the clinician, has she/he knowing and with full support paid the $1500 for presumably specialized training in administering a placebo?
  17. ClinicalABA

    ClinicalABA

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    The argument is not that is doesn't work (evidence shows that it does), but rather does it work for the reasons it's advocates say it does, and does it represent anything different (e.g. more effective/efficient) than other effective therapies, such as exposure.
  18. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    I understand where you are coming from, but I really feel like we need to be very careful with the interventions we choose to provide to our patients because use of a treatment is at the least a passive endorsement of its effectiveness. One of the biggest hurdles I faced treating former EMDR patients was navigating the dogma associated with the treatment. They had mixed results from treatment, but they all believed that if they worked hard enough with it, that they could be "cured". Btw, I don't mean to come across combative, this topic just hits a nerve because some of the worst clinicians I've met were disciples of EMDR.

    Again, we need to be careful about what actually worked. This is no different than a "Made for TV" infomercial that advertises a product to help a person get back in to shape....with the fine print specifying that regular exercise is necessary, the results shown are not typical, and it may not work for all people. The similarities include:

    -Vague references to research studies from "top universities", which are usually on loosely related factors that are not the actual supplement/intervention.
    -An indoctrination into the awesomeness that is XYZ.
    -One or more fringe 'experts' that swear by the treatment
    -An 'anti-establishment'/'anti-medicine' slant that tries to take advantage of prior failures by the person to achieve their goal.

    I just don't see how someone who understands the research would be able to ethically provide EMDR as an intervention to a patient. Plain ol' Exposure Therapy can accomplish the same thing. I'm admittedly a strong supporter of EBTs, but I believe that any support of fringe science is damaging to the field's reputation.
  19. Psychadelic2012

    Psychadelic2012 PhD Student

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    These two things. I do sense that EMDR (like other modalities that are first developed, then tested for effectiveness) tends to attract clients who are looking for someone to fill the emptiness created by a lack of answers/results in conventional care and therapists who don't understand research (and who, therefore, find it boring and not worthwhile).

    Unfortunately, we live in a commercialized world where the average person/client/therapist would rather believe they are on the "cutting edge" with something that science may not have latched onto yet. We are emotional beings--therapies like this reward our emotional nature.
  20. nitemagi

    nitemagi Senior Member

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  21. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    I understand your points, and agree with all of them; EMDR may not be the best example to illustrate my point. I'm a proponent of EBTs as well, and personally would not use EMDR. But I do feel we do ourselves and our clients a disservice if we automatically discount/reject everything that falls outside the realm of current EBTs, even if it's just to examine why a particular "fringe" treatment might be effective and how we can then use that to better inform more reputable and established treatments.

    Edit: Although let me be clear in also saying that we, as psychologists (and future psychologists), also have an obligation to serve as experts and interpreters of research for our clients, and to keep them fully informed of the efficacies (as far as we know them) of various treatments. I think in that respect, there are some differences when wearing the "hat" of a clinician vs. a scientist.
    Last edited: Mar 19, 2012
  22. penguinbean

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    I've been to a training on it, and as PP stated, she focused more on the tapping instead of eye movements. I guess (?) its become more commen to use the alternating buzzers in your hands or tapping on either side of your body. I am at work and dont have any of the citations or sources or whatnot, but She emphasized a lot that it was more about the bi-lateral integration of the movements, stimulating either side of your brain rather than moving your eyes doing anything specific. She also talked about how the tapping keeps you grounded in the here and now when you are re-hashing out the traumatic experience so you dont completely immerse yourself back into the traumatic event. (thats not very good technical terminology, but its been a long day already, so the words aren't coming to me, lol)

    The bi-lateral integration stuff she was talking about made a lot of sense, and she was talking about integrating logical parts of your brain along with the emotional parts of your brain, because when you are experiencing or re-experiencing trauma, your brain shifts away from the logical, rational part to the emotional fight or flight type responses.

    If anyone would like I can try to dig out the resources I have on it when I get home. She was really interesting and made it sound a lot less "fluffy" or hokey.

    ETA: I should add that I am a MA level therapist right now, and I have never used it with a client, and doubt that I would. I dont really know anyone practicing that actually uses it.
    Last edited: Mar 19, 2012
  23. Ollie123

    Ollie123

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    ?

    Not sure how that's relevant, its just a comparison of tx outcomes (which no one is denying) - not mechanisms. Unless your point was just about the often-ignored limitations of RCTs and how we need to move away from relying on them as a gold-standard for anything beyond internal validity.
  24. nitemagi

    nitemagi Senior Member

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    There was discussion about long term efficacy, and people throwing around meta-analyses. My point was to look at what is considered the gold standard of meta-analyses rather than scraping from various sources. But take from it what you will.
  25. cara susanna

    cara susanna Predoctoral Intern

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    No, thank God! When we studied it, it was basically looking at how the data suggests it's the same as exposure. But there are some placements around here that love it.
  26. Doctor Eliza

    Doctor Eliza

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    Frankly, I have been shocked how common EMDR is in the private practice world. In grad school it was dismissed as bunk and suggested that no one who is logical/reasonable/ethical would use it. I assumed that only quacks would be out there using it. I was shocked to find that many intelligent clinicians do use it. I was also shocked to find out what a demand there is for EMDR therapists.

    I personally,don't believe in it, but I think it is really interesting how many clinicans do. What is this all about? Not reading the literature? Being drawn in by something new and sexy? Patient demand? Do they know something I don't know? I also think it would be interesting to know the demographics of clinicans using it (early/late career, specialty, approach, degree). Food for thought.

    Dr. E
  27. KillerDiller

    KillerDiller

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    Huh. Are people using it to treat the eating disorder itself, or are we talking about people suffering from comorbid eating disorders and PTSD? If the former, what exactly are they reprocessing? Sorry, this just makes me really curious.

    I'm not a neuropsychologist and will never claim to be one, but this sounds like pseudoscience to me. The areas involved in emotional memories (e.g. the amygdala) are bilateral structures. The emotional limbic system is subcortical, and does not fall into the right brain vs. left brain dichotomy (which, in my opinion, is wayyyy overblown as it is). Someone with more of a neuroscience background correct me if I'm wrong, please. I just can't come up with any reason why bilateral stimulation would help with memory processing unless it is simply creating another stimulus/context to re-encode with the memory.

    Edit: Penguinbean, that is nothing personal against you, I know you were just repeating what you learned from the person teaching your seminar.
  28. ClinicalABA

    ClinicalABA

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    I believe you are referring to one of my earlier posts. I wasn't "throwing around meta analyses" (I was citing two, prefaced by "e.g." which identifies what follows as only some examples), and they weren't "scraped from various sources". The first is from JCCP- a rather well-thought-of peer reviewed journal (This article is also cited in the NYT article linked in the OP). The second is from SRMHP- another peer reviewed journal focused on evaluation of controversial therapeutic claims. I retrieved both references from PSCINFO- a university based online academic search tool. I was directly responding to the previous post in the thread, and feel I did so relatively thoughtfully with more than the due level of scholarship required in such an activity (heck, i gave full citations to peer reviewed journal articles, rather than just my opinions)
  29. wigflip

    wigflip

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    I wonder if EMDR's popularity with clinicians is regional? I usually roll my eyes when people characterize CA as "wacky" or "out there," but it seems that a number of goofy therapies take hold out here.

    I do know one social worker and one psychologist who use it. Neither or them keep up with the empirical literature.
  30. paramour

    paramour

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    I attended a supposed evidence-based treatment workshop/seminar for PTSD toward the end of the final semester of my master's program (one of our prof's paid for it as part of our class). They ranted about the wonders of EMDR for hours. I was looking forward to pursuing my doctorate in clinical psych at the time, and I started questioning whether I wanted to go that route if they were going to teach me this "crap" (excuse my bias, please)--perhaps fluff would be a better word?--and this was the only thing anyone was using out there. And, in a room full of local mental health practitioners of varying levels (in the South), they all seemed to be proponents of EMDR; the few who did not had a strong desire to learn all they could about this "evidence-based cognitive treatment" to "cure all evils." :rolleyes:

    If this was what cognitive therapy or CBT was all about (per them), I wanted no part of it.

    Seriously . . . I almost rescinded my acceptance.
  31. PETRAN

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    Yeah this "connect-your-logical-brain-to-your-emotional-brain" is pseudoscience. Apparently no mechanism seems to make sense. The only thing i can think of, is, because mental imagery (from top-down/memory processes) seems to arise from the same visual brain areas that we use for normal vision (and apparently seems to use the same "neural machinery"see also "embodied theories of cognition"), maybe the actual eye movements assist in over-writting the visual memory? (in combination with exposure?). Or maybe by dividing attention between the eye movement and the mental image reduces the associated stress? (in combination to the exposure that occurs). Whatever is it, it doesn't seem to add much (to normal exposure). Maybe there are responders and not-responsers though? Don't know.
  32. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    I wish I had attended one of the EMDR trainings way back when, as it probably would have been an interesting experience. A quick consult with Dr. Google (as we call it here) came up with:

    The EMDR International Association's definition of EMDR for clinicians: http://www.emdria.org/associations/12049/files/EMDRIA%20Definition%20of%20EMDR.pdf

    Here is a synopsis of Shapiro's 'The Adaptive Information Processing Model', which is the basis of EMDR: http://www.ellenfarrell.com/PDF/what_is/general/emdr_information_proc.pdf

    The neuroanatomical basis of their EMDR is uhm....fuzzy science in the most generous sense of the term. Here is what the EMDRIA say about how trauma is experienced at a neuroanatomical level:

    Traumatic events and/or disturbing adverse life experiences can be encoded maladaptively in memory resulting in inadequate or impaired linkage with memory networks containing more adaptive information. Pathology is thought to result when adaptive information processing is impaired by these experiences which are inadequately processed. Information is maladaptively encoded and linked dysfunctionally within emotional, cognitive, somatosensory, and temporal systems. Memories thereby become susceptible to dysfunctional recall with respect to time, place, and context and may be experienced in fragmented form. Accordingly, new information, positive experiences and affects are unable to functionally connect with the disturbing memory. This impairment in linkage and the resultant inadequate integration contribute to a continuation of symptoms.

    :eek:

    So...maladaptive encoding of memory is disruptive to adequately encoded information, and the maladaptive memories are then dysfunctionally linked to the systems that handle emotion, cognition, somatosensory information, etc...? God forbid they actual talk about the actual anatomical basis of their theories, as they imply there is a connection.


    If any finds any studies/published articles on the actual neuroanatomical underpinnings of EMDR, I'd love to read it. Somehow I'm picturing, "The scary memory is not remembered right, and then people (like alligators) become ornery because of their Medulla Oblangada!"
  33. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    Sounds like someone read a bit of the neural networks literature in neuroscience and then just ran with it. The "dysfunctional" linkage makes a little sense on a very general level, I suppose, at least in terms of facilitating and strengthening connections between the memories and physiological arousal processes, and I guess you could throw generalization and spreading activation in there somewhere. But where the actual eye movements/tapping fit into all that in a way that would affect the system uniquely above and beyond mechanisms in PE and CPT, I just don't see it (bad quasi-pun intended).

    Completely unrelated aside: has anyone else here noticed that because of your years in psychology, you now find that anytime you write the word "affect" as a verb, it causes a knee-jerk response of being gramatically incorrect?
  34. StellaB

    StellaB

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    To be fair, psychiatrists have been using electroconvulsive therapy and psycho-pharmaceuticals for decades now without being compelled to explain *how* they work - simply explaining *that* they work is fine. Here's an article from just yesterday about new information on how ECT possibly works: http://www.latimes.com/health/boost...k-therapy-depression-20120319,0,5132405.story

    I agree that the logic behind EMDR is hocus pocus, but I want to add my n-1 potential placebo effect experience into the discussion. Years ago I was in therapy and experienced a traumatic dog attack. I had already been working with the therapist for a while when the dog attack happened, and we decided why not try EMDR. We gave it a go with her tapping my knees while I talked, and it was a pretty incredible experience, even for someone who had already done therapy for a while. We never did it again - I wasn't in therapy for trauma, the dog attack was just a random occurrence. Would this work for long-standing childhood traumas? I don't know. Would it work for everyone? Probably not. Might it have just been a willingness to believe on my part and the part of my therapist? For sure, but I'm not positive that matters all that much if the results are positive.

    All I'm saying is, I wouldn't necessarily turn my nose up at it just because we don't know how it supposedly works. Shapiro herself is nauseating, as are a number of other out-there theories (Levine is another one who comes to mind), but I don't think we should necessarily attack an approach that might work just because the idea behind how it works is junk and the person schilling it is obnoxious.

    We have much lower standards of proof for pharmaceuticals, which have far more money behind them and equally more side effects.
  35. nitemagi

    nitemagi Senior Member

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    Very little of medicine begins with understanding mechanism. Penicillin was discovered because we noticed it worked (by accident). The how is discovered later, then perhaps extrapolated and used to design even better treatments. But refuting based on lack of theory presumes that the theory is actually what makes it work. Do we really know (or believe) that working within the cognitive model is what makes CBT work?
  36. SingingCow

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    Thankfully, no. I still use the word "affect" as a verb ALL THE TIME with ease. It is when I see the word "effect" being used as a verb that I start to scream.
  37. KillerDiller

    KillerDiller

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    This would be my best guess as to the mechanism of action. If this is the case, we don't need to complete expensive training in EMDR. We can simply get trained in PE and give the clients a word search or a maze to do while recalling their trauma.
  38. Psychadelic2012

    Psychadelic2012 PhD Student

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    If EMDR is no more effective than CBT or PE, there is no reason to find out the mechanism through which it works, because the conclusion is that it's not the eye movements (or 'bilateral' whatevers) and works in the same way as the CBT or PE. Moot point. Right?
  39. nitemagi

    nitemagi Senior Member

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    With the presumption that it works the same for the same people, meaning for the individual that doesn't respond to CBT, they also won't respond to EMDR. I don't think we have crossover studies to show that.

    And I'm not a proponent of EMDR, just sayin'.
  40. KillerDiller

    KillerDiller

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    Well, one argument from the EMDR proponents is that it works in fewer sessions than traditional PE/CBT. This may mean that there is an additional mechanism of action (e.g. divided attention), or it may simply mean that PE could accomplish the same thing in fewer sessions than what was previously assumed.
  41. ClinicalABA

    ClinicalABA

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    I know you were being tongue in cheek, but there is actually some pretty solid evidence against such an approach (strongest in the animal research, but some support in human/clinical research as well). Any potentially distracting or "soothing" stimuli that are present during exposure may act as conditioned inhibitors, interfering with the effects of the exposure (exposure therapy is basically classical extinction).
  42. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    While anxiety treatment isn't my area of specialty, I'd always heard/read this was the reason clients were discouraged from taking their anxiety meds (at least the PRN ones) during exposure.
  43. ClinicalABA

    ClinicalABA

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    It's certainly one reason. You might not even want them to have the anxiety meds with them, as even that kind of "safety signal" can be a conditioned inhibitor for extinction. Same thing goes for lucky rabbit's feet, special coin, cell phone with "escape" number on speed dial and open on the screen, etc.
  44. cara susanna

    cara susanna Predoctoral Intern

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    It's also why you don't want them to dissociate during PE.
  45. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    Yeah, I'd thought of that right after making my post--a mix of not wanting to dull the anxious experience so that it's less-intense than that typically experienced, as well as having a safety signal and attributing the success to the external factor rather than fully taking "ownership" of it themselves.
  46. ClinicalABA

    ClinicalABA

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    Caution- behavioral diatribe to follow...

    While I think that assumed (or even client-reported) private events (e.g. "anxious experience"; "attributing the success", "fully taking 'ownership'") can be helpful for trying to to understand what's going, you need to be very careful with them. I'm not sure that your explanations are valid (or even falsifiable). Exposure techniques were developed based on some of the basic behavioral literature. The conditioned inhibiting effect is easily demonstrated in non-humans, where things like "attributing success" and "fully taking ownership" are much harder to imagine, let alone define in any objective, measurable manner. Once we jump to humans, with our truly amazing verbal behavior, we tend to attribute a lot of basic, neuronal level conditioning effects to there their associated or inferred cognitive states. In the case of conditioned inhibitors and classical extinction (i.e. exposure), these things are really explanatory fictions- treatment effects can be consistently explained through a description of the observed relationship between environmental variables and the behavior of the client.

    ...end behavioral diatribe
  47. Therapist4Chnge

    Therapist4Chnge Neuropsych Ninja Faculty Moderator Emeritus

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    ClinicalABA..you are my new best friend! :laugh: I think many other schools of thought rely too heavily on overly involved theories and ignore the underlying behavioral components that are more likely at play.
  48. ClinicalABA

    ClinicalABA

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    Thanks- one can never have too many best friends, i think? I want to be clear- I wasn't criticizing acronymallergy's theories. Theories are good, when they lead to more rigorous examination. I was just pointing out the need for caution with such theorizing.
  49. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

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    Duly noted, and agreed (this and your previous post). I do occasionally need re-grounding in my behavioral roots.
  50. KillerDiller

    KillerDiller

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    Yeah, I agree (I'm a behaviorist as well). Divided attention would serve to create a new context to encode with the memory. However, so does recalling the memory in any new environment. No reason eye movement or bilateral stimulation would work any differently. I guess occam's razor indicates the eye movements add...well, nothing. If clients were interpreting it as a soothing behavior, you're right, EMDR would not work as well as prolonged exposure.

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