EMDR debate

[sarahbutler]

Could you recommend some citations, as I'm curious to read about what they found.

I am a little hesitant to join the discussion as I am a therapist who, after initial skeptikism, read and continue to read the literature, was trained in EMDR, and have seen many positive effects using EMDR with clients of all ages and various presentations that stem from underlying memories of negative or traumatic life experiences. I was directed to this interesting discussion by a colleague, and would now like to become a part of the discussion myself.

I know of 3 recent peer reviewed articles published in the Journal of Anxiety Disorders that have specifically examined what happens to the autonomic nervous system during EMDR therapy. Also, interestingly these studies have looked at the specific effects the eye movements have on physiological measures such as heart rate, sweating, breathing, body temperature ect during EMDR sessions. The papers I know of are:
1.Elofsson, U.O.E.,vonSchèele,B.,Theorell,T.R.,&Söndergaard,H.P.(2008).Physiological orrelates of eye movementdesensitization and reprocessing. Journal of Anxiety Disorders, 22, 622–634.

2.Sack, M.,Lempa,W.,Steinmetz, A.,Lamprecht, F.,& Hofmann, A.(2008).Alterations in autonomic tone during trauma exposure using eyemovement Desensitisation. Journal of AnxietyDisorders, 22, 1264–1271.
3.Schubert, S. J., Lee, C. W., & Drummond, P. (2011). The efficacy and psychophysiological correlates of dual-attention tasks in eye movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 25(1), 1-11.
There were also comments earlier questioning the necessity of the eye movements in EMDR. The 3rd pape listed above looked at the effectiveness of EMDR when the eye moveemtns were taken out of the procedure compared to when they are used in the therapy. Although EMDR-without eye movements still reduced the distress and vividness of the traumatic memories targeted, EMDR-with eye movements reduced the distress and vividness significantly more. Also, what was interesting to see in this study was that EMDR-with eye movements produced different changes in physiology compared when the eye movements were taken out (and people just were exposed to the memory with their eyes closed instead). The eye movements created a relaxation response in the body during treatment. It shows, along with many other studies that have been mentioned in the discussion so far (i.e. Christman and colleague's body of research, Barrowcliffet al., 2004, van den Hout 's papers etc.), that the eye movements do have a specific role to play in EMDR in helping with the processing of trauma memories.

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[sarahbutler]

It is the primary component of the intervention, so that is important. It isn't like we are singling out a particular skill building exercise from a specific module within a manualized CBT treatment program.

I haven't had time to read through the citations that have shown "positive effects", though I'm curious if this means a statistically significant effect that is not better accounted for by placebo or another factor?

As for the anatomical concomitants...the theory can't claim that a major tenet of the intervention involves changes at the neuronal level, and then not back it up with hard science. The underlying theory quoted from the EMDRIA asserts there are factors at the anatomical level that contribute to the treatment, so it is fair game.

My understanding is that although the therapy is called EMDR, the eye movemetns are not the primary component of treatment. The therapy is a structured protocol with 8 phases that draw on many components of other evidence based therapies. The therapy is a structured, but integrative therapy that contains many elements/ components of effective psychodynamic, cognitive behavioural (i.e. identifying and installing positive thoughts over negative cognitions), experential, and physiological/sensorymotor therapeutic techniques.

I have read in the past that many within the field would like the name to change, posibly just to just reprocessing and desensitisation therapy, so as the eye movement component is not seen as the primary component of treatment (as in my opinion it is not!). However, the therapy has been around for over 20years and I guess its too late for a name change now! However, the eye movement component is in the therapy, and it is unique, and it interests us all!!

In response to one of your above comments though - Over the past 20years EMDR was initially compared to waitlist conditions in randomised treatment trials, then it has been compared to other non-evidence based therapies and treatment as usual conditions, and it has also been compared to other effective/evidence-based trauma treatments such as PE. Over the past decade the research is primarily focussing on examining not whether it works, beccause this has been deomnstrated, but why and how it works. My understanding is this:
1. that there is strong peer-reviewed evidence that EMDR was consistently statistically superior (greater effect sizes) to waitlist or delayed treatment controls.
2. EMDR was consistently more effective in treating adult PTSD than other nonspecific treatmentsor treatment as usual.
3. as mentioned in discussions already, that average effect sizes for EMDR and other trauma-focused treatments (i.e. PE) are similar, but that EMDR achieve its results withouth the use of homework. - and when working with complex populations it is important for a therapist to take into account whether their clients are able to do tasks outside of session.

Now, in terms of why it works, there are four main theories that are accumulating lots of emperical data and support: 1. the theory of inter-hemispheric comunication; 2. working memory theroies; 3. physiological theories such as orienting response theories;, and 4. REM-like mechanisms. And, as mentioned earlier also, there is evidence that distraction also plays a role in why EMDR may work. I know of a good peer-reviewed paper that puts forward an intigrative model of EMDR that refers to all theories (Gunter & Bodner, 2009, titled EMDR Works . . . But How? Recent Progress in the Search for Treatment Mechanisms). It makes sense that because EMDR involves many elements/components in treatment, that it does not just work through one mechanism, but many mechanisms that work in complex ways to produce the positive effects seen in EMDR treatment.

I am not familiar enough to comment on the neurological underpinings of EMDR - or any therapy - but I know that in terms of the eye movements there has been a great deal of research that has examined their effects on memory and cognitive processes. Eye movements have been shown to reduce the vividness and distress associated with autobiographical memoreis (i.e Andrade et al, 1997; Barrowcliff et al. 2004; Kavanagh et al 2001; Maxfield et al 2008), enhance people's ability to recall or retrieve episodic memories (Christman et al 2003), and increase cognitive flexibility (Kuiken et al 2001–2002). Much of the cognitive, labratory research on the effects of eye movements on memory has been done outside the EMDR treatment/research field.

 

[Psychadelic2012]

3. as mentioned in discussions already, that average effect sizes for EMDR and other trauma-focused treatments (i.e. PE) are similar, but that EMDR achieve its results withouth the use of homework. - and when working with complex populations it is important for a therapist to take into account whether their clients are able to do tasks outside of session.

Others have mentioned this, too, and it brings up an obvious question: Have any studies been done that compare the outcomes of EMDR and PE/TF-CBT where neither group is assigned homework? Anyone know?

Also, I'm just thinking out loud here, but what about the short- versus long-term effects of these therapies? It seems to me that EMDR has a built-in protocol for asking about the short-term effects of the intervention, but I'm not clear on the other therapies' protocols for this. In other words, I see a lot of EMDR therapists here saying that they see good results with EMDR, but I don't see the same for PE/TF-CBT--why is that? Why does EMDR produce this anecdotal result when the literature does not show more of an effect?

 

[Canid]

Could you recommend some citations, as I'm curious to read about what they found.

Some of these have shown up in other comments on research but here are the full citations.
Bossini L. ***iolini, A. & Castrogiovanni, P. (2008) Neuroanatomical changes after EMDR in PTSD. Journal of Neuropsychiatry and Clinical Neuroscience. 19,457-458.
Harper, M.L., Rasolkhani-Kalhorn, T., & Drozd, J.F. (2009) On the neural basis of EMDR therapy: Insights from qeeg studies. Traumatology, 15 , 81-95.
Kowal, J. A. (2005). QEEG analysis of treating PTSD and bulimia nervosa using EMDR. Journal of Neurotherapy, 9 (Part 4), 114-115.
Lamprecht, F., Kohnke, C., Lempa, W., Sack, M., Matzke, M., & Munte, T. (2004). Event-related potentials and EMDR treatment of post-traumatic stress disorder. Neuroscience Research, 49, 267-272.
Lansing, K., Amen, D.G., Hanks, C. & Rudy, L. (2005). High resolution brain SPECT imaging and EMDR in police officers with PTSD. Journal of Neuropsychiatry and Clinical Neurosciences.
Levin, P., Lazrove, S., & van der Kolk, B. A. (1999). What psychological testing and neuroimaging tell us about the treatment of posttraumatic stress disorder PTSD) by eye movement desensitization and reprocessing (EMDR). Journal of Anxiety Disorders, 13, 159-172.
Nardo, D., et al. (2009, in press). Gray matter density in limbic and paralimbic cortices is associated with trauma load and EMDR outcome in PTSD patients. Journal of Psychiatric Research. doi:10.1016/j.jpsychires.2009.10.014
Oh, D.-H., & Choi, J. (2004). Changes in the regional cerebral perfusion after Eye Movement Desensitization and Reprocessing: A SPECT study of two cases . Journal of EMDR Practice and Research, 1,1, 24-30.
Ohta ni, T., Matsuo, K., Kasai, K., Kato, T., & Kato, N.(2009). Hemodynamic responses of eye movement desensitization and reprocessing in posttraumatic stress disorder. Neuroscience Research, 65, 375-383.
Pagani, M. et al. (2007). Effects of EMDR psychotherapy on 99mTc-HMPAO distribution in occupation-related post-traumatic stress disorder. Nuclear Medicine Communications, 28, 757–765.
Pagani, M. et al. (2011). Pretreatment, intratreatment, and posttreatment EEG imaging of EMDR Methodology and preliminary results from a single case. Journal of EMDR Practice and Research, 5, 42-56.
Propper, R., Pierce, J.P., Geisler, M.W., Christman, S.D., & Bellorado, N.(2007). Effect of bilateral eye movements on frontal interhemispheric gamma EEG coherence: Implications for EMDR therapy. Journal of Nervous and Mental Disease, 195, 785-788.
Richardson, R., Williams, S.R., Hepenstall, S., Gregory, L., McKie, S. & Corrigan, F.(2009). A single-case fMRI study: EMDR treatment of a patient with posttraumatic stress disorder. Journal of EMDR Practice and Research, 3, 10-23.
Sack, M., Lempa, W., & Lemprecht, W. (2007). Assessment of psychophysiological stress reactions during a traumatic reminder in patients treated with EMDR. Journal of EMDR Practice and Research, 1, 15-23.
Sack, M., Nickel, L., Lempa, W., Lamprecht, F. (2003) Psychophysiological regulation in patients suffering from PTSD: Changes after EMDR treatment. Journal of Psychotraumatology and Psychological Medicine, 1, 47 -57. (German)
van der Kolk, B., Burbridge, J., & Suzuki, J. (1997). The psychobiology of traumatic memory: Clinical implications of neuroimaging studies. Annals of the New York Academy of Sciences, 821, 99-113.

Hope this is helpful.

 

[Canid]

Others have mentioned this, too, and it brings up an obvious question: Have any studies been done that compare the outcomes of EMDR and PE/TF-CBT where neither group is assigned homework? Anyone know?

Also, I'm just thinking out loud here, but what about the short- versus long-term effects of these therapies? It seems to me that EMDR has a built-in protocol for asking about the short-term effects of the intervention, but I'm not clear on the other therapies' protocols for this. In other words, I see a lot of EMDR therapists here saying that they see good results with EMDR, but I don't see the same for PE/TF-CBT--why is that? Why does EMDR produce this anecdotal result when the literature does not show more of an effect?

I'm probably misunderstanding your statement but there are numerous long-term outcome studies on EMDR (and the exposure therapies as well). Here's just a sample from the randomized studies in case this is what you are looking for:
Abbasnejad, M. Mahani, K. N. & Zamyad, A. (2007). Efficacy of "eye movement desensitization and reprocessing" in reducing anxiety and unpleasant feelings due to earthquake experience. Psychological Research, 9, 104-117 (1 month follow-up)
Edmond & Rubin, A. (2004). Assessing the long-term effects of EMDR: Results from an 18-month follow up study with adult female survivors of CSA. Journal of Child Sexual Abuse, 13, 69-86. (18 month follow-up, obviously)
Hogberg, G. et al., (2008). Treatment of post-traumatic stress disorder with eye movement desensitization and reprocessing: Outcome is stable in 35-month follow-up: Psychiatry Research, 159, 101-108. (35-month)
Jarero, I., Artigas, L., & Luber, M.(2011). The EMDR protocol for recent critical incidents: Application in a disaster mental health continuum of care context. Journal of EMDR Practice and Research, 5, 82-94. (3-month follow-up)
Lee, C., Gavriel, H., Drummond, P., Richards, J. & Greenwald, R. (2002). Treatment of post-traumatic stress disorder: A comparison of stress inoculation training with prolonged exposure and eye movement desensitization and reprocessing. Journal of Clinical Psychology, 58, 1071-1089. (3-month follow-up)
Marcus, S., Marquis, P. & Sakai, C. (2004). Three- and 6-month follow-up of EMDR treatment of PTSD in an HMO setting. International Journal of Stress Management, 11, 195-208.
Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies, 2, 199–223. (3-month follow-up and the study that introduced EMD, as it was then called)
Wilson, S., Becker, L.A., & Tinker, R.H. (1997). Fifteen-month follow-up of eye movement desensitization and reprocessing (EMDR) treatment of post-traumatic stress disorder and psychological trauma. Journal of Consulting and Clinical Psychology, 65, 1047-1056.

 

[Psychadelic2012]

I'm probably misunderstanding your statement but there are numerous long-term outcome studies on EMDR (and the exposure therapies as well). Here's just a sample from the randomized studies in case this is what you are looking for:

Lee, C., Gavriel, H., Drummond, P., Richards, J. & Greenwald, R. (2002). Treatment of post-traumatic stress disorder: A comparison of stress inoculation training with prolonged exposure and eye movement desensitization and reprocessing. Journal of Clinical Psychology, 58, 1071-1089. (3-month follow-up)

Well, only sort-of what I was getting at, and this one is the only study you cited that compares two of the therapies in question. All of the others are EMDR and control only, and I won't even look at a study by Shapiro or that is published in a journal that includes "EMDR" in the title (sorry)! Now, with this one, I can only see the abstract but there appears to be similar results immediately post-treatment and I can't see what the follow up result is. Also, what I really want to see is the detail about whether homework is given, and I can't tell that from the abstract. Also, this is a very small sample, hardly conclusive.

What else is there that compares EMDR to PE or CBT? Anything? In a good journal, with a good sample size, with a control group, etc.?

Also, regarding the short-term effect, I was just trying to say that there isn't this enormous response from CBT or PE therapists saying that they see great results in their practice, the way EMDR therapists have done here. This is curious to me. Obviously CBT works. But isn't it strange that CBT/PE therapists aren't going around advertising it? I just find this very curious.

 

[Canid]

Hey, some psychologists degrade psychoanalysis. Some abhor behaviorism. Some dislike the biologically-oriented "sell-outs."

I don't see why a treatment as potentially controversial as EMDR would be exempt from criticism, warranted or not. At least the dialogue is meant to serve a purpose (protect victims of trauma from iatrogenic effects, etc). Obviously our society allows some treatments to happen without understanding how they work. Personally, I think that interventions targeting victims of trauma deserve more scrutiny than most given how vulnerable the patients are. This isn't some side effect of a blood pressure pill. We're talking serious implications for memory systems, hormones, and how these folks will live after this is all over.

I would not recommend EMDR to a traumatized family member because of these unknowns. With more research validation and longitudinal data, my mind could be changed. It's just my own professional opinion given the population and the risk/benefit ratio in my head.

I appreciate your caution about recommending EMDR to a family member. The question would remain, that if you don't believe there's enough research to support the use of EMDR, then what therapy would you refer someone to? How many publications does it take for a therapy to be declared empirically valid? (The answer of the US military and Veterans Administration is two, the number supporting CPT.) To put it another way, what is it that we base our clinical decisions on? In my case, I refused to use EMDR even though I was on the editorial board of the journal that published Shapiro's first research, had a trusted peer share his experiences with it (including data), went through the training (I was looking for CEs to be honest) that was offered by the medical school of my Ph.D. alma matter and had it work on some small stuff of my own. My reluctance to use it was not based on the science but because I could not get it to fit any of my models (yeah, yeah, I know: I should have read Kuhn - I had. I ignored him.) I was lucky. A patient asked about the training and then expressed a willingness to try - I have always been impressed by my client's courage if not my own. We did and resolved a major combat trauma. Had that not happened I don't know when or if I'd finally given it a try. Figuring out "what it takes" to investigate something that doesn't fit is, at least for me, an intensely personal and sometimes difficult undertaking.

 

[Canid]

Well, only sort-of what I was getting at, and this one is the only study you cited that compares two of the therapies in question. All of the others are EMDR and control only, and I won't even look at a study by Shapiro or that is published in a journal that includes "EMDR" in the title (sorry)! Now, with this one, I can only see the abstract but there appears to be similar results immediately post-treatment and I can't see what the follow up result is. Also, what I really want to see is the detail about whether homework is given, and I can't tell that from the abstract. Also, this is a very small sample, hardly conclusive.

What else is there that compares EMDR to PE or CBT? Anything? In a good journal, with a good sample size, with a control group, etc.?

Also, regarding the short-term effect, I was just trying to say that there isn't this enormous response from CBT or PE therapists saying that they see great results in their practice, the way EMDR therapists have done here. This is curious to me. Obviously CBT works. But isn't it strange that CBT/PE therapists aren't going around advertising it? I just find this very curious.

Good place to find references: Check the website for the EMDR Humanitarian Assistance Programs (emdrhap.org), a registered nonprofit outfit that does pro bono work in teaching and clinical intervention around the world. (Caveat: I have worked with them on several projects.) Their "Research Findings" tab gives a lot of information, though it is not totally up to date. EMDR does not use homework. I spot 7 studies comparing EMDR with exposure under the Randomized heading - EMDR does as well in outcome measures and is generally faster. I think only one of those studies was in the J. of EMDR, etc. Shapiro, other than her first publication, has not published research pretty much because she knows it would be discounted, though she continues to encourage it. (Interesting that Dr. Foa's CBT/PE research is not; this is not an anti-Foa statement [she's a hero of mine]. The "interesting" part I refer to is the decision-making process about how to regard research published in refereed journals. While a sizable portion of CBT/PE research is authored/coauthored by Foa, virtually all of the research on EMDR after 1989 has been done independently of Shapiro.) The research to one side, what I preferred about EMDR over the behavioral/exposure therapy I had used for treating chronic, complex PTSD was the great reduction in the discomfort my clients had to go through. Yes, the speed was great, especially given the clinical demands of an increasing case load. But it wasn't the research that moved my clinical emphasis over to EMDR (wasn't a whole heck of a lot of it back in 1990) but rather the response of my clients. Their reactions were my research (yep, I have multi-year "follow-ups" lol). I suspect that is what a lot of therapists (as opposed to researchers) ultimately rely on.

 

[Psychadelic2012]

Good place to find references: Check the website for the EMDR Humanitarian Assistance Programs (emdrhap.org), a registered nonprofit outfit that does pro bono work in teaching and clinical intervention around the world. (Caveat: I have worked with them on several projects.) Their "Research Findings" tab gives a lot of information, though it is not totally up to date. EMDR does not use homework. I spot 7 studies comparing EMDR with exposure under the Randomized heading - EMDR does as well in outcome measures and is generally faster. I think only one of those studies was in the J. of EMDR, etc. Shapiro, other than her first publication, has not published research pretty much because she knows it would be discounted, though she continues to encourage it. (Interesting that Dr. Foa's CBT/PE research is not; this is not an anti-Foa statement [she's a hero of mine]. The "interesting" part I refer to is the decision-making process about how to regard research published in refereed journals. While a sizable portion of CBT/PE research is authored/coauthored by Foa, virtually all of the research on EMDR after 1989 has been done independently of Shapiro.)

One does not need to pay money to an organization to fully utilize and administer CBT or PE, unlike EMDR--that's the difference. Correct me if I'm wrong, but Foa doesn't have an obvious conflict of intere$t regarding PE research. Sorry, but I'm not going to look on an EMDR website for references to EMDR studies.

The research to one side, what I preferred about EMDR over the behavioral/exposure therapy I had used for treating chronic, complex PTSD was the great reduction in the discomfort my clients had to go through. Yes, the speed was great, especially given the clinical demands of an increasing case load. But it wasn't the research that moved my clinical emphasis over to EMDR (wasn't a whole heck of a lot of it back in 1990) but rather the response of my clients. Their reactions were my research (yep, I have multi-year "follow-ups" lol). I suspect that is what a lot of therapists (as opposed to researchers) ultimately rely on.

The point is, this doesn't say anything about EMDR's effectiveness specifically. Clinicians sometimes do this--they emphasize their anecdotal experience over research. "Bah, I don't care what the research says! I've seen it work!" The problem with this is that you aren't the best judge of what is working. Okay, so it worked. It's nice to see clients get better and improve, I'm not discounting that. But you don't know if that's due to iatrogenic factors (as mentioned by another poster), placebo effect, or any particular part of the actual therapy. That's what research is for. But I have a feeling what I'm saying won't be heard, so I'll stop, because what's the point?

 

[sarahbutler]

Well, only sort-of what I was getting at, and this one is the only study you cited that compares two of the therapies in question. All of the others are EMDR and control only, and I won't even look at a study by Shapiro or that is published in a journal that includes "EMDR" in the title (sorry)! Now, with this one, I can only see the abstract but there appears to be similar results immediately post-treatment and I can't see what the follow up result is. Also, what I really want to see is the detail about whether homework is given, and I can't tell that from the abstract. Also, this is a very small sample, hardly conclusive.

What else is there that compares EMDR to PE or CBT? Anything? In a good journal, with a good sample size, with a control group, etc.?

The point is, this doesn't say anything about EMDR's effectiveness specifically. Clinicians sometimes do this--they emphasize their anecdotal experience over research. "Bah, I don't care what the research says! I've seen it work!" The problem with this is that you aren't the best judge of what is working. Okay, so it worked. It's nice to see clients get better and improve, I'm not discounting that. But you don't know if that's due to iatrogenic factors (as mentioned by another poster), placebo effect, or any particular part of the actual therapy. That's what research is for. But I have a feeling what I'm saying won't be heard, so I'll stop, because what's the point?

You have asked if anyone knows of research that has compared EMDR to PE/CBT based trauma therapies that are independant from Shapiro and The EMDR journal. Here are some references, and overall reviews/meta-analyses have shown that these studies show equivalent effect sizes for traditional exposure based treatment and EMDR.


Devilly, G. J., & Spence, S. H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal of Anxiety Disorders, 13 (1–2), 131–157.
Ironson, G., Freund, B., Strauss, J. L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58, 113–128.
Lee, C., Gavriel, H., Drummond, P., Richards, J., & Greewald, R. (2002). Treatment of PTSD: Stress inoculation training with prolonged exposure compared to EMDR. Journal of Clinical Psychology, 58, 1071–1089.
Power, K., McGoldrick, T., Brown, K., Buchanan, R., Sharp, D., Swanson, V., et al. (2002). A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of post-traumatic stress disorder. Clinical Psychology and Psychotherapy, 9, 299–318.
Rogers, S., Silver, S., Goss, J., Obenchain, J., Willis, A., & Whitney, R. (1999). A single session, group study of exposure and eye movement desensitization and reprocessing in treating posttraumatic stress disorder among Vietnam War Veterans: Preliminary data. Journal of Anxiety Disorders, 13, 119–130.
Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18, 607–616.
Taylor, S., Thordarson, D. S., Maxfi eld, L., Fedoroff, I. C., Lovell, K., & Ogrodnicuk, J. (2003). Comparative efficacy, speed, and adverse affects of three PTSD treatments: Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71, 330–338.
Vaughan, K., Armstrong, M. S., Rold, 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, 2, 283–291.
van der Kolk, B. A., Spinazzola, J., Blaustein, M. E., Hopper, J. H., Hopper, E. K., Korn, D. L., et al. (2007). A randomized clinical trial of eye movement desensitization and reprocessing (EMDR), fluoxetine, and pill placebo in the treatment of posttraumatic stress disorder: Treatment effects ad long-term maintenance. Journal of Clinical Psychiatry, 6, 37–46.

Significant effects within these, and other randomised controlled studies indicate that statistically differences between groups are due to more than just chance - ie that they are not just placebo effects.

You are right in that there are 2 very different and distinclty seperate questions being discussed here.
Firstly, is EMDR effective? Research clearly shows that it is effective in treating PTSD, and that its just effective as other evidence-based trauma treatments.

Secondly, why does a treatment work? Research now is examining this question, and others have mentioned previously, there have been a large number of component, labratory studies that have teased out and examined further the relative contribution of different aspects of the EMDR procedure, including what effect the eye movements have on overall treatment effectiveness. This research is ongoing, its difficult to do, but the evidence appears to be accumulating more in the EMDR field that for any other therapy I know of or use. As a therapist I would love to know at a neurological level what changes with all evidence-based therapy used - but we simply do not know this yet. With advances in science maybe we can know this in the future?​

But, I think what is important to remember is that just because we do not know the specifics of why a treatment works, does not detract at all from the first question about its efficacy. The questions are 2 seperate issues. Like others have pointed out, we do not know specifically how any therapy works, especially at a neurological level. Science has not yet answered the questions about this for any therapy, or even pharmoctherapies for that matter. What I like though is that the heated discussions and skepticism towards EMDR has fuelled a great deal of research into this second question of why it works. And research findings so far in the field is helping us all further understand trauma and the mechanisms underlying why people become unwell, and through what underlying mechanisms do they best recover. Not an eloquent sentence, but I hope my point is somewhat clear!

I am not aware of any research that has compared EMDR to PE that has taken the homework component out of the PE condition - as homework is part of the PE treatment protocol. I will ask around. I am aware that there is some researchers in Australia that are currently doing a study in which the homework component is being removed or made equivalent in both treatment conditions.

 

[sarahbutler]

... I was just trying to say that there isn't this enormous response from CBT or PE therapists saying that they see great results in their practice, the way EMDR therapists have done here. This is curious to me. Obviously CBT works. But isn't it strange that CBT/PE therapists aren't going around advertising it? I just find this very curious.

I am thinking that the reason I, and possibly others haven't posted on the effectiveness of PE is that no one is questioning the effectiveness of PE here. This discussion is about EMDR, and why EMDR works. I am, however, just as interested in the underlying mechanims, at the physiological and neuronal level, as to why PE (i.e. habituation) works also, and the specific contributions each aspect of the PE protocol make to its overall effectiviness. But, this is a seperate question for a seperate discussion!

 

[Researcher900]

One does not need to pay money to an organization to fully utilize and administer CBT or PE, unlike EMDR--that's the difference. Correct me if I'm wrong, but Foa doesn't have an obvious conflict of intere$t regarding PE research.

I'm not sure I understand your statement. There are many organizations that conduct trainings in CBT and in EMDR. Beck, Foa and Shapiro originally were "sole source" for their respective therapies. However, at this point no one person or organization profits from the proliferation of cognitive therapy, PE or EMDR. APA codes mandate training before clinical procedures are administered or researched. Therapists desirous of using CPT, PE or EMDR would either pay someone for training or be part of an organization where they could receive free training. For instance, the Department of Defense is offering trainings in CPT, PE and EMDR to their clinicians.

 

[Researcher900]

Others have mentioned this, too, and it brings up an obvious question: Have any studies been done that compare the outcomes of EMDR and PE/TF-CBT where neither group is assigned homework? Anyone know?

There is only one study that I am aware of that compared EMDR to PE without homework:

Arabia, E., Manca, M.L. & Solomon, R.M. (2011). EMDR for survivors of life-threatening cardiac events: Results of a pilot study. Journal of EMDR Practice and Research, 5, 2-13.

However, other studies have tested PE without homework. It is referred to as imaginal exposure (IE). I'm aware of one study that tested it in combination with CT and one in isolation:

Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B. R., Reynolds, M., Graham, E., et al. (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Counseling and Clinical Psychology, 67, 13–18.

Abstract
A randomized trial was performed in which imaginal exposure (IE) and cognitive therapy (CT) were compared in the treatment of chronic posttraumatic stress disorder (PTSD). Patients who continued to meet PTSD caseness at the end of a 4-week symptom-monitoring baseline period (n = 72) were randomly allocated to either IE or CT. There was a significant improvement in all measures over treatment and at follow-up, although there were no significant differences between the 2 treatments at any assessment. A significantly greater number of patients who showed worsening over treatment received IE, although this effect was not found at follow-up. Patients who worsened showed a greater tendency to miss treatment sessions, rated therapy as less credible, and were rated as less motivated by the therapist. It was concluded that either exposure or a challenge to cognition can result in symptom reduction, although neither resulted in complete improvement.


The use of imaginal exposure alone has been criticized, because homework is considered mandatory to achieve clinically significant effects in PE.

Foa, E. B., & Jaycox, L. H. (1999). Cognitive-behavioral theory and treatment of post-traumatic stress disorder. In D. S. Spiegel (Ed.), Effi cacy and cost-eff ectiveness of
psychotherapy (pp. 23–61). Washington, DC: American Psychiatric.

 

[Uri]

There is no brief way to answer a question on EMDR's neuroanatomical underpinnings. I would refer those who are intersted to the following review article: Bergmann, U. (2010). EMDR's neurobiological mechanisms of action: A review of 20 years of searching. Journal of EMDR Practice and Research, 4(1), 22-42.

 

[Uri]

How about this.....

Like many fringe treatments....the devil is in the details. I don't trust fluffy pseudo-neuro terminology.

It is not possible to comment, briefly, on the neuroanatomic substrates of EMDR. Please refer to the following review article: Bergmann, U. (2010). EMDR's neurobiological mechanisms of action: A survey of 20 years of searching. Journal of EMDR Practice and Research, 4(1), 22-42.

 

[Researcher900]

Now, with this one, I can only see the abstract but there appears to be similar results immediately post-treatment and I can't see what the follow up result is. Also, what I really want to see is the detail about whether homework is given, and I can't tell that from the abstract.

To answer your questions about the Lee et al., 2002 study:

"The session was audiotaped and following exposure the client's reaction was discussed. The homework assignment was to listen daily for the next week to the taped scenario from the session" (p. 1076).

"The SITPE condition included a substantial homework component where, from the third session, participants were given tasks that encouraged them to face stimuli that they had previously avoided. These tasks occupied seven hours of the participant's week and thus represent a very intensive aspect of the intervention. However, there were no significant differences between the two treatments on any of the avoidance measures at post-treatment or follow-up." (p. 1085-86)

EMDR appears to be a more efficient treatment than SITPE. In the current SITPE protocol each person was set approximately seven hours of homework between each treatment session (totaling 42 hours). Although compliance was less than optimal, therapists administering SITPE estimated from the participants' homework diaries that the average person completed 28 hours of homework. This was a similar compliance rate to that reported in other studies that formally assessed the degree to which homework tasks were completed with this type of intervention (Marks, Lovell, Noshirvani, Livanou, &Thrasher, 1998; Scott & Stradling, 1997). This compares to an estimated three hours of homework
for EMDR. (p.1086)

"There were no significant differences between groups on any of the global measures immediately after treatment. However, small but statistically significant differences were found at treatment follow-up on measures of trauma symptomatology and distress. The
comparatively greater improvement over the follow-up period after EMDR treatment is consistent with the results of Van Etten and Taylor (1998). . . . There was no significant difference between the two treatments according to the number of people meeting PTSD diagnosis at post-treatment or follow-up. Using the criterion of clinically significant improvement defined as symptom reduction of at least two standard deviations below the pretreatment score, there was no difference between the treatments at post-treatment but at follow-up almost twice as many EMDR participants had reached this criterion than participants in SITPE." (p. 1084)

 

[Researcher900]

A new study evaluating the eye movement component of EMDR therapy with PTSD patients has just been published:

van den Hout et al. (2012). Tones inferior to eye movements in the EMDR treatment of PTSD. Behaviour Research and Therapy 50, 275-79.

A b s t r a c t
Eye Movement Desensitization and Reprocessing (EMDR) is an effective treatment for posttraumatic stress disorder (PTSD). During EMDR, patients make eye movements (EMs) while recalling traumatic memories, but recently therapists have replaced EMs by alternating beep tones. There are no outcome studies on the effects of tones. In an earlier analogue study, tones were inferior to EMs in the reduction of vividness of aversive memories. In a first EMDR session, 12 PTSD patients recalled trauma memories in three conditions: recall only, recall + tones, and recall + EMs. Three competing hypotheses were tested: 1) EMs are as effective as tones and better than recall only, 2) EMs are better than tones and tones are as effective as recall only, and 3) EMs are better than tones and tones are better than recall only. The order of conditions was balanced, each condition was delivered twice, and decline in memory vividness and emotionality served as outcome measures. The data strongly support hypothesis 2 and 3 over 1: EMs outperformed tones while it remained unclear if tones add to recall only. The findings add to earlier considerations and earlier analogue findings suggesting that EMs are superior to tones and that replacing the former by the latter was premature.

 

[Canid]

One does not need to pay money to an organization to fully utilize and administer CBT or PE, unlike EMDR--that's the difference. Correct me if I'm wrong, but Foa doesn't have an obvious conflict of intere$t regarding PE research. Sorry, but I'm not going to look on an EMDR website for references to EMDR studies.



The point is, this doesn't say anything about EMDR's effectiveness specifically. Clinicians sometimes do this--they emphasize their anecdotal experience over research. "Bah, I don't care what the research says! I've seen it work!" The problem with this is that you aren't the best judge of what is working. Okay, so it worked. It's nice to see clients get better and improve, I'm not discounting that. But you don't know if that's due to iatrogenic factors (as mentioned by another poster), placebo effect, or any particular part of the actual therapy. That's what research is for. But I have a feeling what I'm saying won't be heard, so I'll stop, because what's the point?

Sorry, you are wrong in your first comment: Dr. Foa does charge for her training in CBT and PE. Most originators do. There are programs whereby individual clinicians can get the training for no cost to them (examples would include the VA's roll-out of CPT and PE, the Army's trauma treatment training program that includes PE, CPT, and EMDR, and organizations like EMDR-HAP [pro bono EMDR training around the world] and so on) though at some point someone does shell out for the costs. My suggestion of checking out a place where the research on EMDR can be found was simply for the sake of efficiency - if you had bothered, you would have found the site includes negative as well as positive research. And a reference is a reference - you could always examine it yourself to determine its value. Or you could use PubMed or PsychInfo (though such databases, as you know, are seldom complete). Or the online library at Northern Kentucky University which permits searching through pretty much everything presented on EMDR and purported mechanisms of action, including non-English sources.
As for your second point, the issue of alternative explanations for EMDR effects, they have been investigated (its in the research), dismantling studies have been done, and neurophysiological studies have begun (more than on any other psychotherapy, so it is amusing to see someone write that they'll consider EMDR when there are larger Ns while continuing to do whatever it is they do that has no Ns). Are you under the impression your cautions have not been expressed during the twenty years EMDR has been available? What you are saying has been heard and responded to quite some time ago - this is because your thoughts are fundamental to the scientific process and naturally were raised almost from "Day One." Researching EMDR, though slow in the beginning, hit high gear in the mid-'90s and has continued to accelerate (it is not accidental, then, that all those national and international agencies that have recognized EMDR as efficacious in the treatment of EMDR began doing from around 1995 onward and not before). Your frustration of not being heard comes from the reality that you were heard, it was just fifteen years ago. Mine comes from people saying the evidence is not strong enough after expressing an unwillingness to look at the evidence. I suppose that is our common ground.