emdr criticism
this is from an organization that calls itself scepticism "skepsis" from the netherlands
a group of physicians on a crusade against everything that is not purely scientific
I tried to translate it so it is not in perfect english
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Author: Rob Nanninga source: Skepter 17 (1), March 2004 A
THORN IN THE FLESH
the controversial success of EMDR
EMDR is a new psychotherapy for people who suffer from traumatic memories. The method has become rapidly very popular under psychologists. But according to critics there is nothing new under the sun.
He, who has experienced a shocking or life-threatening event, can develop posttraumatic stress disorder (ptsd). The unpleasant memories continue to force themselves upon the person, in the presence of flashbacks and nightmares. The victims frequently develop strong avoidance behaviour: they go out of the way of everything that can remind them of the traumatic experience. Some other symptoms that can appear are: raised excitability, concentrations problem, listlessness, feelings of alienation, anxiety attacks, hyper vigilance, startling reflex and insomnia. Ptsd has been in the diagnostic manual of psychiatric diseases (DSM) since 1980.
A common treatment is cognitive behaviour therapy. An important component of it is imaginary confrontation (exposure). The patient is encouraged to describe the shocking memories multiple times in all its details. As an assignment he often must listen daily for an hour to a recording of his own story. He must, purposeful and prolonged, expose himself to the unpleasant memories and the situations that he always tried to avoid. That appears often an effective manner to subside the intense emotions, come to terms with the experiences and eliminate PTSD-symptoms. A disadvantage is that it demands sometimes too much of the patients, as a result of which they pull out prematurely.
Fifteen years ago the American psychologist Francine Shapiro (1989) published a scientific article in which she presented a new and rather remarkable therapy for PTSD. She called it EMDR, Eye Movement Desensitization and Reprocessing (the R was added in 1991). As a first step she gave the patient the task to create a clear picture for himself of the nastiest moment to think back of. He or she had also to be conscious of an associated physical sensation and of a negative idea that would evoke the picture, for example 'I am powerless'. Whereas the patient concentrated on this, Shapiro kept two fingers on three decimetres distance in front of his face and commissioned him to follow her fingers with his eyes. She moved her hand about twenty times rapidly back and forth-in horizontal or diagonal line. After this eye exercise the patient was allowed to put the picture out of his head and Shapiro let him take a deep sigh.
Then he had to recall the nasty memory and on a scale of 0 to 10 indicate how much fear and tension he still felt. When other pictures or experiences rose, they were treated in the same manner. The eye movements were repeated as long as the tension had not yet fallen to the zero point. As last step the patient had once again recall the nasty moment whereas he thought of something positive concerning himself, for example 'I can handle this'. The credibility of this pronouncement was assessed on a scale of 1 to 7. As long as the patient was not fully persuaded, Shapiro let him carry out the eye movements again.
EMDR seemed much more effective than the common methods. Shapiro reported that she could make every traumatic memory harmless within an hour. For her research she treated 22 persons, among them some Vietnam veterans and different victims of sexually violence. Thanks to the eye movements all patients could in no time think back to their traumas without tension, and three months later they could to that still. The majority told that their main complaints had disappeared entirely, and the rest said that the complaints had diminished. For example there was a Vietnam veteran who had daily anxiety attacks. Planes flying over provided flashbacks and he had had no erection in three years. Extra long EMDR-sessions of 90 minutes, in which three different memories were treated, appeared sufficient to solve these problems. A part of the patients, among them were alleged victims of ritual abuse, several sessions were necessary to dissipate all symptoms, but on average no more than five or so.
Mission work
Shapiro (1989) wrote that she was convinced that her article offered sufficient information for the readers to enable them to desensitize 75% of all traumatic memories within 50 minutes. However shortly after she reached the insight that a two-day course was necessary, which was extended a year later up to four days. Shapiro founded the EMDR Institute and in 1995, already had supplied 10,000 certificates to psychologists who completed her training. On the document sat a nice seal with her name. Three years later there were 25,000 registered Emdr-therapists and meanwhile their number have increased to approximately 45.000. They form a strong network and have been well organised. The costs of an EMDR-training nowadays are over a thousand dollars.
Since 1995 there is an international professional organisation (EMDRIA) and even a humanitarian aid organisation (EMDR-HAP). When there has been a calamity somewhere - for example a earthquake, terrorist attack or a mass assassination - then a professional team of volunteers can be set in used that learns the local care workers how the traumatised victims must be treated. Training missions are also sent to ghettos, slums, developing countries and other problem areas. EMDR-HAP sets its objectives to “break the cycle of violence ' by training people within a local community who can perform EMDR techniques, so-called ' ambassadors of healing '. In the previous years the psychotherapeutic mission workers were among others active in Bosnia, Bangladesh, Turkey, Northern Ireland and the gazastrip.
Also in the Netherlands, where the method has already been taught since 1993, the number of Emdr-therapists grows. Meanwhile there are over 500. Psychologists, psychiatrists and psychotherapists whom follow a three-day elementary course at a registered EMDR-trainer, can become a candidate member at the EMDR association in the Netherlands. For the full membership a follow-up course is necessary. He who wants become registered officially as a practitioner, must have acquired the necessary experience and much works for some time under supervision of a registered supervisor. One must also regular follow continuous schooling and training. Last year there was a Dutch handbook published in which all the steps of the EMDR-basis protocol are described (the Jongh & at Broeke, 2003).
More and more scientific organisations recognise EMDR as an effective treatment for patients with PTSD. Meanwhile there is also the necessary empirical support available. There already appeared about twenty or so controlled studies. Other therapies for PTSD were never that often researched and examined this way. The Dutch Trimbos-institute, which spreads scientific knowledge in the field of the mental health care, brought out a report recently with directives for the treatment of anxiety disorders (Van der Velde, 2003). EMDR is called as 'one of the intervention to take most into account for PTSD'. Also newest mental health care directions mention that PTSD can be the best treated with EMDR or with imaginary exposure. EMDR is moving fast in conquering the market. It seldom happens for a new psychotherapeutic movement to win terrain under professionals that fast.
100% success
But there are also critics. They are annoyed with the marketing - and recruitment methods which (especially in the US) were used to spread EMDR. In the illustrated magazine Clinical Psychology Review (Herbert et already, 2000) even appeared a long article in which EMDR is plain labelled as pseudo-science. The authors were seven clinically psychologists, among which Jeffrey Lohr, Scott Lilienfeld and David Tolin. This last triad also published some critical evaluations of the study into the effects of EMDR (among other Lohr et al, 1998).
The renowned psychologist Richard McNally (see Skepter, December 2003) pulled even more registers open. He surprised the Journal or Anxiety Disorders with a 'comparative historical research'. He described 'the striking resemblances between the history of mesmerism and the history of EMDR ' in a cynical manner. McNally (1999) mentioned only one important difference: animal magnetism was unmasked in 1784, by a scientific commission, as the power of suggestion. EMDR on the other end was recommended in 1997, as ' probably effective' by a commission of the American Psychological Association. This recognition was based on two controlled studies from which it seemed that EMDR had better result than being on a waiting list.
But according to McNally mesmerism could probably also have met this criterion.
We cannot assume that all positive results of a therapy are a consequence of the special techniques, which are applied. They could also be a result of general factors, which can make a success of each therapy. Some of it is: the enthusiasm and the strong persuasiveness of the therapist, the credibility of the method, the attention for the patient and the positive expectations, which are being raised. If you compare patients whom got EMDR-treatment, with patients who got no treatment, then you perhaps only measure a placebo effect.
Criticism is aimed partly at the origin of EMDR-movement. Francine Shapiro is no well-qualified psychologist. She instructed initial English literature and intended to write a dissertation concerning the poems of Thomas Hardy. But after she got cancer, she got interested in the connections between body and spirit and in all kinds of manners to fight stress. She moved to California and started to study at the somewhat alternative and meanwhile raised professional school for Psychological studies in San Diego. In 1987, she walked one day in a park when she noticed that the nasty thoughts, which appeared all the time suddenly, had disappeared. Self-research revealed that this phenomenon happened when she moved her eyes automatically fast back and forth. Critics doubt however if she could really be aware of such involuntary saccadic eye movements.
Shapiro discovered that the method was also effective when she moved her eyes willingly back and forth. She started to test this on others and decided to conduct a research experiment. For that she received in 1988 a not commonly acknowledged doctorate. A year later she published her research report in the second volume of the Journal or Traumatic stress. Thus she arrived according to the critics by means of a backdoor on the psychological podium. In her research she compared the results of EMDR with a control condition. The patients who were present in the control group, had to describe their ghastly experiences aloud, whereas Shapiro interrupted their tale seven times in a row after a minute to ask how much tension they still felt. This was measured on the Subjective Units or Disturbance (SUD)-scale, which run of 0 to 10. In the control group the tension rose from 7 to 8, whereas those in EMDR-group fell to 0.
There is much comment to make on this experiment. First it does not seem astonishing that the EMDR-group ended up on a SUD-score of 0, because EMDR-sessions were only stopped when the patients indicated that they felt no more tension. As long as that was not yet the case, they had to continue to move their eyes. It is possible that they adapted their appraisal at the expectations of Shapiro, who did the complete research on her own. Besides the fact that it is difficult to concentrate on a memory picture when you must follow a rapidly moving finger at the same time. The eye movements reduce the vividness of the picture; as a result it therefore recalls less emotions. This doesn’t only apply to negative memories but also to positive, as appeared to be from an experiment of the psychologist Marcel van den Hout (2001), nowadays professor in Utrecht. Shapiro gave the control group afterwards an EMDR-session, because she didn’t want to withhold her therapy for anybody. As a result, she could not compare the results with anything. All patients told her three months later that they improved. A standardised questionnaire was not used.
The critics blamed Shapiro that she started to promote her therapy as revolutionary with such a miserable experiment. She spoke of a '100% success score' and provided herself with a considerable income with her EMDR. Her students had to sign a declaration in which they promised not to teach the method to others. Shapiro and her followers claimed that EMDR was much more effective than the common therapies, but they didn’t had scientific proof for that. They offered mainly case-stories, anecdotes and personal experiences. There were several psychologists who carried out controlled studies, but that provided initially little evidence (just as from 1997 it went a little better). Nevertheless EMDR was recommended for more and more psychiatric disorders. EMDR-therapists acted also in several American tv-shows. Disappointing experimental results were attributed to all kinds of research flaws: the patients had been traumatised too severe, they got too few sessions or the therapists stuck not strictly to the rules of EMDR-protocol. The therapeutic effect of EMDR could not be shown that easily apparently in the way such as Shapiro suggested initially. She has herself never again carried out a new research.
Stationary finger
Thousands of psychotherapists started swaying with their fingers. Did they however have a good reason for that? The critics doubt that. According to Shapiro the rhythmic, bilateral stimulation ensure that the traumatic experiences surfaces and are conducted in the correct way. The eye movements accelerate the information processing. Shapiro compared it with the fast and automatic eye movements which we make during our dreams. But it did not become clear how a purposeful way of looking at something could influence unconscious processing in the brain. Was the swaying finger more than a gimmick, a trick to distract attention or a ritual to make an impression?
In six years time (1993-1998) largely a dozen controlled studies appeared which examined to what extent the eye movements made a contribution to the success of EMDR. Patients, who were in the control group, got EMDR-treatment in which they did not move their eyes. Generally they got the task to stare at a certain point, aim at a stationary finger or a blinking light. There were also experiments where the control group had closed their eyes or rhythmically had to tap with the fingers. From the results became clear that that made little difference: the complaints of the patients could be dealt with even without moving their eyes (Cahill et already, 1999; Davidson and Parker, 2001). Only the subjective SUD-scores were often better. The advocacy of EMDR had a lot of comment on these studies. They indicate for example that Boudewyns and Hyer (1996) offered only 5 to 7 therapy sessions, whereas there was two times as much necessary because they worked with heavily traumatised war veterans. Such criticism cannot however show that the eye movements are necessary.
Cusack and Spates (1999) compared EMDR with an alternative where another important component was omitted, 'the installation of a positive cognition' such as 'I am okay'. PTSD-patients got each three therapy sessions. Two months later their symptoms had considerably decreased. That also applied to the group in which no positive cognition had been installed. This element was therefore apparently as well as the eye movements not essential.
Shapiro stated that all forms of bilateral stimulation, among the rhythmically tapping on two sides of the body, could be effective. In the Netherlands one frequently uses an earphone as a result of which the patient alternatively left and right hears clicking sounds. We cannot even exclude that bilateral stimulation can also act when the patient keep his eyes aimed at a fixed-point. Shapiro wrote this in an email to a group of colleagues, but according to the critics she tried to make her theory irrefutable in this way. She emphasised that the eye movements are only one component of the therapy, which has much more to offer. When one element is omitted, still sufficient remains that have an impact. Shapiro told that she would want the eye movements removed from the name of her therapy, but that she did not do that because the term EMDR had already established itself. According to the critic’s finger swings were purely a gimmick, that she used for her therapy to distinguish it from other methods. Perhaps she could have let the patients stand on one leg for all that matter.
Competitor
Is EMDR purely a placebo therapy? Probably not. There have been some studies in which EMDR was compared to non-specific treatments, among them biofeedback, relaxationtraining, group therapy and patient oriented listening. On average these methods provided less good results than EMDR. An exception was writing therapy, which seemed to work as well. Moreover EMDR was not really effective for the treatment of fear of speaking in public, phobias and panic disorders.
The latter became clear from a study of Goldstein et al. (2000). In this study 45 people who suffered from agora phobia (fear for open spaces, squares etc.) and panic attacks had six therapy sessions of an hour and a half. Approximately half of the group was treated with EMDR, whereas the rest got a credible placebo therapy. The persons in the placebo group started first with a long lasting relaxation exercise and evoked a mental picture afterwards that recalled a lot of anxiety. Then they had to examine which associations were linked with that anxiety. The therapist told them that such a process of free association could help to understand the meaning of the panic attacks. He encouraged the patients with sentences such as ' Let come up whatever comes up”. This association therapy was just as effective as EMDR.
McNally noticed that: ' what works at EMDR, is not new, and what is new, does not work.' The critics assume that EMDR worked because it resembles imaginary exposure, in contrast to treatment methods, which do not confront the patient directly with his fears. The proponents counter argument was that in EMDR one is only exposed for a short time period to unpleasant memories. A series of eye movement lasts no longer then a half a minute. According to the common theory desensitization only occurs when someone is confronted over an extended period of time with something he is afraid of.
It is especially interesting to compare the results of EMDR with the nearest competitor, cognitive behaviour therapy with long-term exposure. Three studies have been published (all in 2002) from which one could conclude that PTSD-patients with EMDR improve somewhat more or quicker then with exposure. The best investigation was conducted by Power et al (2002). The Jongh & Ten Broeke (2003) wrote the following about this: “Both treatments were more effective in comparison with being on a waiting list”. EMDR was more effective than E (exposure) + CR (cognitive restructuring) concerning reduction of depression and the number of treatment sessions (EMDR: 4.2 meetings and E+CR: 6.4 meetings). The EMDR-group felt themselves indeed less depressive, but other measurements did not show significant differences. It was according to Power also not certain if EMDR demanded fewer meetings, because there were no criteria agreed upon to when the therapists had to conclude their treatment.
Two studies reported that EMDR is less effective than long-term exposure. Taylor et al (2003) carried out a research, which was of better quality better than all the previous. They compared three methods with each other: relaxation, EMDR and exposure. The 60 patients got eight treatments of an hour and a half. In all groups progress was achieved, but the patients in the exposuregroup suffered clearly less from flashbacks and avoidance behaviour. The percentage 'healed' patients, who no longer met the criteria for PTSD, after measurements, was in this group also the highest (almost 90%). In the EMDR-group the percentage was over 20 percent lower, although the difference was not statistically significant. The therapists used not only imaginary exposure, but also confronted the patients with real life situations that recalled unpleasant memories. They went, for example, together with a woman whom had been violated to a fitness centre where men were working out at that time. The patients in the exposuregroup were also encouraged to expose themselves daily for an hour to terrifying circumstances. This method therefore required thus more effort than EMDR.
Brain hemispheres
EMDR is no Breakthrough Therapy, the subtitle of a popular book in which Shapiro (1997) extols her therapy. But the method is not as inept as the critics claims it to be, because for the treatment of PTSD the therapy seems to be approximately equally effective as imaginary exposure. Added to that EMDR is often experienced as less difficult, hard to undergo, both by the patient and by the therapist. The traumatic memories do not need to be described exhaustively. That can also be an advantage when the patient doesn’t speak the language well and takes possibly also less time. In vivo exposure probably yields more, as appeared to be from a Dutch research of Muris and Meckelbach (1999), who treated spider phobias. A live spider can however be put on an table easier than a traumatic memory.
The critics admitted that their resistance would not have been that strong, if Shapiro had presented her method as an alternative on the already existing cognitive behaviour therapy (Lohr et already 1998). She postulated on the other hand a unique functioning mechanism. That created, according to the critics, the obligation to prove convincingly that 'bilateral stimulation' is really contributing something and that the effectiveness was not solely a result of already well-known mechanism. It is still uncertain if they will succeed, although there are a couple of experiments, which has been recently carried out, that gave the EMDR-theoretics some hope.
Christman et al (2003) gave 40 students a dairy in which they, during six days, had to write down ten striking events. Two weeks after they had handed in the notebook, they got the assignment to describe each event in a couple of sentences. Half of the students looked in advance first, half a minute to a black dot, which jumped two times per second from one side of a screen to the other. The other half looked at a stationary circle, which frequently changed from colour. That seemed to make a difference. The first group could remember slightly more and made especially fewer errors than those who had not moved their eyes (p=0,046). The research workers assume that fast, horizontal eye movements can improve the episodic memory because they activate the brain cortex and promote the interaction between the two brain hemispheres. It is however still unclear how this can be of any importance for the treatment of PTSD. The traumatic flashbacks of PTSD-patients don’t always resembles the exact facts and can in the course of time change. One imagines it sometimes much worse than it was in reality. (?)
The critics’ will continue to frown their eyebrows as long as the 'mystery' remains unsolved of the bilateral stimulation. EMDR-therapists prefer not to think too much about that. In their experience EMDR is an efficient method, which produces good results. They can also join an enthusiastic and active movement, which offers professional support. To win the competition battle, the supporters of the cognitive behaviour therapy, perhaps also need to put up their sleeves more.
Postscript: frauds
Those who want to follow an EMDR-training have to be a health care psychologist. A system of supervision and on going education offers the guarantee that EMDR-therapists stick to obligatory protocols. Because of the increasing popularity of the method there are however more and more frauds who ask fast amounts of money for their EMDR-therapy without having followed an official training or being accepted by the Netherlands Association of EMDR. Visit such therapists on own risk and spend not too much money on them!
Literature
Boudewyns, P. & Hyer, L. (1996). Eye movement desensitization and reprocessing (EMDR) ash treatment for post-traumatic stress disorder (PTSD). Clinical Psychology and Psychotherapy, 3 (3), 185-195.
Cahill, S. et al (1999). Does EMDR work? And if so, why?: a critical review or controlled outcome and dismantling research. Journal or Anxiety Disorders, 13 (1-2), 5-33.
Christman, SD et al (2003). Bilateral eye movements enhance the retrieval or episodic memories. Neuropsychology, 17, 221-229.
Cusack, K. & Spates, R. (1999). The cognitive dismantling or eye movement desensitization and reprocessing (EMDR) treatment or mail traumatism tic stress disorder (PTSD). Journal or Anxiety Disorders, 13 (1-2), 87-99.
Davidson, P. & Parker, K. (2001). Eye movement desensitization and reprocessing (EMDR): a meta-analysis. Journal or Consulting and Clinical Psychology, 69 (2), 305-316.
Goldstein, A.J. et al (2000). EMDR for panic disorder with agoraphobia: comparison with waiting trick and credible attention placebo control conditions. Journal or Consulting & Clinical Psychology, 68 (6), 947-956.
Herbert, J. et al (2000). Science and pseudoscience in the development or eye movement desensitization and reprocessing: implications for clinical psychology. Clinical Psychological Review, 20 (8), 945-971.
Hout, M. van den, et al (2001). Autobiographical memories become less vivid and emotional after eye movements. British Journal or Clinical Psychology, 40 (2), 121-130.
Jong, A. & at Broeke, E. (2003). Handbook EMDR. Lisse: Swets & Zeitlinger.
Lohr, J. et al (1998). Efficacy or eye movement desensitization and reprocessing: implications for behaviour therapy. Behaviour Therapy, 29 (1), 123-156.
McNally, R. (1999). EMDR and Mesmerism: a comparative historical analysis. Journal or Anxiety Disorders, 13 (1-2), 225-236.
Muris, p & Merkelbach, H. (1999). traumatism memories, eye movements, phobia, and panic: a critical note on the proliferation or EMDR. Journal or Anxiety Disorders, 13 (1-2), 209-223.
Perkins, B. & Rouanzoin, C. (2002). A critical evaluation or current views regarding eye movement desensitization and reprocessing (EMDR): clarifying points or confusion. Journal or Clinical Psychology, 58 (1), 77-97.
Shapiro, F. (1989). Efficacy or the eye movement desensitization procedure in the treatment or traumatism tic memories. Journal or Traumatic stress, 2, 199-223.
Taylor, S. et already (2003). Comparative efficacy, speed, and adverse impact or three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal or Consulting and Clinical Psychology, 71 (2), 330-338.
Rob Nanninga is head editor of Skepter. © foundation Skepsis. It has not been permitted take over Article from Skepter on other Internet sites. (oh ;-)
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